Diabetes Type 2 Flashcards
1
Q
Oral DM meds: what types of Rx available?
A
- Monotherapy
- combination oral therapy
- combination therapy: oral + insulin + GLP-1’s
2
Q
A1C is not the ONLY thing to look at - what reasons might cause inaccurate A1Cs?
A
-Fe+ deficiencies
-pregnancy
-hemoglobinopathies
-severe renal and liver DZ
(prediabetes 5.7-6.4%)
3
Q
ADA Criteria for Dx DM
A
1) Sx DM plus random glucose > or = 200mg/dL OR 2) FPG > or = 126 mg/dL OR 3) 2hr GTT > or = 200 mg/dL OR 4) A1C > or = 6.5
4
Q
T2DM: How many diagnosed at first cardiac event?
A
50% !
5
Q
T2DM: Describe resistance to insulin (signs/Sx)
A
- 75% obese at Dx
- Impaired insulin secretion
- increased hepatic glucose production
- increased frequency in peds
6
Q
3 Risk Fx for DM
A
- genetics
- activity
- weight
7
Q
Insulin resistance: what are the “post-binding effects?”
A
Occurs in hepatic and muscle tissue; decreased glucose transport, decreased glycogensynthesis
8
Q
The Ominous Octet:
A
- increased lipolysis
- increased glucagon secretion
- increased glucose reabsorption
- increased HGP
- decreased incretin effect
- decreased insulin secretion
- decreased glucose uptake
- NT dysfunction
9
Q
First steps: Assessment and Exam
A
- complete Hx with emphasis on confirmation of Dx; factors that affect glucose control (lifestyle/ psychosocial/ meds), complications
- complete exam based on complications
10
Q
Labs needed to Dx T2DM
A
- glucose
- A1C
- renal, liver functions
11
Q
Plan:
A
- MUTUAL est. goals
- glucose goals/ A1C goals
- weight/meal plan/ activity plan
- med options!
12
Q
Initiating Tx algorithm:
mild/no sx
neg ketones
A1C
A
1) Start MNT/ activity
2) Consider Metformin
3) 6-8 weeks, if target not met at OA
13
Q
Initiating Tx algorithm: FPG > 150 Random > 250 A1C > 7.0 not mild/ severe
A
1) Start Metformin
2) Choose alternate drug if Metformin contraindicated
3) Continue MNT RX
14
Q
Initiating Tx algorithm: marked hyperglycemia significant weight loss severe SX >2+ ketones DKA hyperosmolar Severe illness Surgery
A
1) Start insulin
2) MNT/ activity
15
Q
First steps: Assessment and Exam
A
- complete Hx with emphasis on confirmation of Dx; factors that affect glucose control (lifestyle/ psychosocial/ meds), complications
- complete exam based on complications
16
Q
Labs needed to Dx T2DM
A
- glucose
- A1C
- renal, liver functions
17
Q
Plan:
A
- MUTUAL est. goals
- glucose goals/ A1C goals
- weight/meal plan/ activity plan
- med options!
18
Q
Initiating Tx algorithm:
mild/no sx
neg ketones
A1C
A
1) Start MNT/ activity
2) Consider Metformin
3) 6-8 weeks, if target not met at OA
19
Q
Initiating Tx algorithm: FPG > 150 Random > 250 A1C > 7.0 not mild/ severe
A
1) Start Metformin
2) Choose alternate drug if Metformin contraindicated
3) Continue MNT RX
20
Q
Initiating Tx algorithm: marked hyperglycemia significant weight loss severe SX >2+ ketones DKA hyperosmolar Severe illness Surgery
A
1) Start insulin
2) MNT/ activity
21
Q
Advancing DM Med RX if A1C > 7 or not at goal within 3 months:
A
1) Initiate oral antidiabetic meds or add an additional oral med of a different class
2) Initiate or add insulin (0.1-0.2 u/kg)
3) Add GLP-1 agonist or insulin to OA med
22
Q
If 2-3 mo after addition of OA med, insulin, GLP-1 agonist, if A1C>7 or at not goal, consider:
A
- combine GLP-1 with basal insulin
- adding premeal rapid/short acting insulin yo HS NPH or long acting insulin
- Adding basal insulin and adjusting rapid/short acting insulin
- changing to multidose insulin Rx
- adding OA if already on insulin
23
Q
First line Rx: List all 9
A
1) Biguinides
2) Insulin secretagogues
3) DPP-4 inhibitors
4) GLP-4 receptor agonist
5) SGLT-2-inhibitors
6) Alpha glucosidase inhibitors
7) Thiazolidinediones
8) Bile Acid Sequestrant
9) Centrally Acting agents
24
Q
Name the “Insulin Sensitizers”
A
BIGUANIDES: Metformin (Glucophage); Metformin XR
TZDs: Avandia and Actos
25
BIGUANIDES:
when indicated
MOA
Notable items
=FIRST line RX, unless C/I
- Decreased hepatic glucose production (inhibits gluconeogenesis)
- stimulates glucose uptake in skeletal muscle and adipocytes (cell receptors, glu transport GLUT 4)
- assoc with 1-2kg WEIGHT LOSS
- USUALLY does not cause hypoglycemia
26
Metformin: RISK of-
| and how to prevent
Lactic Acidosis;
DO NOT USE IN PTS with:
-RENAL dysfunction (Cr 1.4 fem; Cr 1.5 male; Cr Cl abn in >80 yo)
-But can use with GFR > 45
-LIVER dysfunction (ETOH abuse/binge drinking)
-CV collapse/ Acute MI/ CHF
-Undergoing major SURGERY
-CONTRAST STUDY: stop day of study/ recheck Cr within 48 hrs prior to restarting
27
Metformins:
DOSAGE & ADMIN
SE
```
500mg QD /BID> 850mg QD
Max: 2550 mg
* take WITH FOOD: to minimize gas/ diarrhea
Metformin Oral: 500mg= 5ml
Glucophage XR: TAKE WITH PM MEAL!
500mg QD initial dose> 750mg
Max: 2000mg QD
Fortamet/Glumetza:
500-1000mg QD initial dose
Fortamet Max= 2500; Glumetza Max= 2000mg QD
```
28
```
TZDs:
Indications
MOA
Notable SE
C/I for WHOM?
```
- usually for OBESE with NO LIVER OR SEVERE CAD
- BLACK BOX WARNING: CHF (especially do not use Avandia with Insulin)
- C/I in Class III and IV CHF
- improves glucose transport to cells (binds to PPARs; affects insulin sensitivity)
- decreases hepatic glucose production
- USUALLY does not cause hypoglycemia
- Assoc with weight GAIN
- ADV effects: worsening macular edema/ bone Fx risk
29
ACTOS is C/I in these pts:
-pts with increased risk for bladder CA/ active or Hx bladder CA
30
Metformin VS TZD:
- Metformin: GI upset
- $$$
- Weight loss/ gain
- Renal status
- Edema issues
31
Insulin Secretogues:
| Name 3 types
1) Meglitinides (Prandin)
2) Amino-acid derivatives (Starlix)
3) Sulfonylureas: LONG AND SHORT-acting
32
Insulin Secretogues:
Indications
MOA
C/I
= use in T2DM with decreased insulin PRODUCTION,
LONGER duration DM; perhaps a thinner person
-Stimulates release of insulin from B-cells (inhibits K+ efflux> depolarization of B cell)
-decreases hepatic glucose production
-CAUTION/AVOID with: LIVER AND RENAL DZ (R/T prolonged hypoglycemia)
33
Risk with Insulin Secretogues?
Hypoglycemia
34
Long-Acting Sulfonylureas: names
1) Glyburide /Micronase
2) Glynase
3) Glimepiride/ Amaryl
4) Glipizide ext rel / Glucotrol XL
35
Short-Acting Sulfonyureas: Name
1) Glipizide / Glucotrol
36
Meglitinides:
Name
MOA
Admin instructions/ notable
Repaglinide (Prandin)
- Chemically unrelated to Sulfonylureas
- Stimulate release of insulin from B cells
* * risk for hypoglycemia
- take 0-30 minutes AC
- if meal skipped/ added, then skip/ add dose
37
Meglitidines: C/I
- NOT for use with NPH insulin R/T risk of MI
| - C/I with Gemfibrozil (R/T PROTRACTED HYPOGLYCEMIA)
38
Amino-acide Derivatives:
Name
MOA
Admin instructions/ notable
Starlix (Nateglinide)
- unrelated to sulfonylureas
- stimulates release of insulin from B cells
- take 1-30 min AC TID (skip meal/ skip dose)
39
Prandin VS Starlix VS Sulfonylureas
- Risk hypoglycemia
- meal flexibilty
- potency
- Sulfa allergy considerations
- $$$
40
What to use for PP glucose elevations
| (newer / milder DM):
Alpha-glucosidase inhibitors:
| Precose and Glyset
41
Alpha-Glucosidase Inhibitors:
Name
MOA
Admin instructions/ notable
Acarbose (Precose) and Miglitol (Glyset)
- indicated for PP meal elevations; ie., newer/milder DM
- delays absorption of CARBS by inhibiting A-Glucosidase in brush borders of intestines
- check glucose 1 HR PP
- if hypoglycemia, Tx with DEXTROSE not sucrose
- SEs: gas, diarrhea
42
A-Glucosidase Inhibitors:
| Precose and Glyset: C/I
C/I in
- chronic intestinal DZ
- Acarbose C/I in liver DZ
- AVOID in renal dysfunction
43
DPP-4 Inhibitors: Names
Januvia, Onglyza, Tradgenta, Nesina
44
Incretins and the role of DPP-4 Inhibitors:
Incretin-like hormones= GLP-1 and GIP
Incretins = hormones released from small intestine in response to food
Incretins are BROKEN DOWN by DPP-4
DPP-4 INHIBITORS SLOOOOOW the action of incretins
45
DPP-4 Inhibitors:
| do they cause hypoglycemia?
When used as monotherapy DPP-4 Inhibitors do not cause hypoglycemia
46
DPP-4 Inhibitors:
| C/I:
Increased risk for pancreatitis??
47
DPP-4 Inhibitors:
| Use as monotherapy or with...
Metformin, TZDs; Onglyza, Tradgenta and Januvia can be used with Sulfonylureas too
48
DPP-4 Inhibitors- adjust dosing for....
RENAL, of course!!! ;)
| Also might have to consider CYP inducers/ inhibitors also on board.
49
Postmarketing research for Nesina indicates...
HEPATIC failure, sometimes fatal :(
50
SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors: Names
Invokana, Farxiga, Jardiance
51
SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors:
| MOA
Blocks REabsorption of glucose by kidney and increase excretion of glucose in urine by inhibiting SGLT2
52
SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors:
| SEs
- hypotension
- dehydration (esp in OLD FOGIES!)
- hyperkalemia
- decreased RENAL function (duh!)
- genital mycotic infections (GREAT!)
- UTI (ouch)
- increased LDL (Uh-oh!)
- weight loss (might be a good thing;)
53
SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors:
| Dose-adjust for...
GFR
54
Invokana- interacts with...
These may decrease effectiveness of Invokana:
-Rifampin
-Phenytoin
-Phenobarb
INVOKANA CAN ALSO INCREASE CONC OF DIG! (yikes!)
55
Farxgia: Do not use if....
| hint: "Bexiga" is bladder in Portugese
Pts with BLADDER CA or HX of bladder CA
56
Welchol: Use in T2DM
= an ADJUNCT RX in T2DM (how creative!:)
57
Welchol:
SEs
C/I
Interactions
SE: can increase triglycerides when used with sulfonnylureas
C/I:
-Hx/ risk for BOWEL OBSTRXN
-Triglycerides > 500
-Hx hypertriglyceridemia-induced pancreatitis
INTERACTIONS- can reduce absorption of:
-Thyroid, Dilantin, Warfarin, OC's, Sulfonylureas
SO, dose meds 4 hrs before Welchol
58
Cylcoset (Bromocryptine Mesylate):
MOA
SE
```
MOA:
-AM QD admin normalizes hypothalamic NT activities
-Improves PP glycemic control without increasing plasma insulin (WOW!:)
SEs:
-hypotension
-dizziness
-fainting
-nausea
-H/A
```
59
Cylcoset (Bromocryptine Mesylate):
USE WITH CAUTION
and C/I
Use with caution with:
- hypertensive meds
- psychotic disorders (may exacerbate- whoopsies!)
- may alter effectiveness highly-protein bound Rx
- C/I in ERGOTS and SYNCOPAL
- C/I in LIVER DZ
* ue only the quick-release form in DM
60
COMBO RX: how/ why
- can be prescribed at DX onset or later
- targets different defects
* lower doses each med may >> less SEs!!
61
Glycovance: Glyburide + Metformin
| Precautions and Admin instruction
- same precautions as sulfonlynureas only
- same liver/ kidney issues as metformin
- take with food
62
Non-insulin injectables, GLP-1 Receptor Agonists:
| Names
Bynetta, Victoza, Bydureon, Tanzeum, Trulicity
63
GLP-1 (Glucagon-like peptide-1)=
| MOA
Incretin-mimetic;
- enhances glucose dependent insulin secretion
- decreases gastric motility
- decreases hepatic glucose production
- increases satiety (ie>> modest ongoing weight loss)
64
GLP-1 Agonists can be used with...
Metformin (or as monoRx)
65
Bynetta:
| SEs
- pancreatitis
- nausea
- renal failure
66
Bydureon, Victoza, Tanzeum, Trulicity
Cautions
SEs
-caused thryroid CA in rats
-decrease sulfonlyurea dose to prevent hypoglycemia
SEs:
-nausea
-pancreatitis
67
How to advance therapy:
1) MNT, activity, consider Metformin, (and if severe high glucose> insulin)
2) After 6-8 weeks: if MNT only and glucose above target, add ORAL MED
3) Titrate meds over 1-3 months; reinforce MNT and actvity
4) if A1C still > 7% or target, intiate or add OA of different class, insulin, or add GLP-1 inhibitor to OA or insulin
5) Titrate 2-3 months; if still not at goal> GLP-1 + insulin; add basal or PP insuliin, or add OA to insulin
68
Oral RX and insulin:
MOA
types of insulin
- correction of FPG by PM insulin may improve OA action
| - NPH at HS; Lantus or Levemir at HS; Aspart at PM meal
69
Oral RX and insulin:
| options
- sulfonylurea + insulin
- Metformin + insulin
- Precose + insulin
- Actos + insulin
