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Pharmacology > Diabetes Type 2 > Flashcards

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
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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%)

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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
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4
Q

T2DM: How many diagnosed at first cardiac event?

A

50% !

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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
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6
Q

3 Risk Fx for DM

A
  • genetics
  • activity
  • weight
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7
Q

Insulin resistance: what are the “post-binding effects?”

A

Occurs in hepatic and muscle tissue; decreased glucose transport, decreased glycogensynthesis

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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
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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
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10
Q

Labs needed to Dx T2DM

A
  • glucose
  • A1C
  • renal, liver functions
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11
Q

Plan:

A
  • MUTUAL est. goals
  • glucose goals/ A1C goals
  • weight/meal plan/ activity plan
  • med options!
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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

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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

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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

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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
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16
Q

Labs needed to Dx T2DM

A
  • glucose
  • A1C
  • renal, liver functions
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17
Q

Plan:

A
  • MUTUAL est. goals
  • glucose goals/ A1C goals
  • weight/meal plan/ activity plan
  • med options!
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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

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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

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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

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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

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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
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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

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24
Q

Name the “Insulin Sensitizers”

A

BIGUANIDES: Metformin (Glucophage); Metformin XR
TZDs: Avandia and Actos

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25
Q

BIGUANIDES:
when indicated
MOA
Notable items

A

=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
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26
Q

Metformin: RISK of-

and how to prevent

A

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

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27
Q

Metformins:
DOSAGE & ADMIN
SE

A 
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
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28
Q 
TZDs: 
Indications
MOA
Notable SE
C/I for WHOM?
A
  • 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
Q

ACTOS is C/I in these pts:

A

-pts with increased risk for bladder CA/ active or Hx bladder CA

30
Q

Metformin VS TZD:

A
  • Metformin: GI upset
  • $$$
  • Weight loss/ gain
  • Renal status
  • Edema issues
31
Q

Insulin Secretogues:

Name 3 types

A

1) Meglitinides (Prandin)
2) Amino-acid derivatives (Starlix)
3) Sulfonylureas: LONG AND SHORT-acting

32
Q

Insulin Secretogues:
Indications
MOA
C/I

A

= 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
Q

Risk with Insulin Secretogues?

A

Hypoglycemia

34
Q

Long-Acting Sulfonylureas: names

A

1) Glyburide /Micronase
2) Glynase
3) Glimepiride/ Amaryl
4) Glipizide ext rel / Glucotrol XL

35
Q

Short-Acting Sulfonyureas: Name

A

1) Glipizide / Glucotrol

36
Q

Meglitinides:
Name
MOA
Admin instructions/ notable

A

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
Q

Meglitidines: C/I

A
  • NOT for use with NPH insulin R/T risk of MI

- C/I with Gemfibrozil (R/T PROTRACTED HYPOGLYCEMIA)

38
Q

Amino-acide Derivatives:
Name
MOA
Admin instructions/ notable

A

Starlix (Nateglinide)

  • unrelated to sulfonylureas
  • stimulates release of insulin from B cells
  • take 1-30 min AC TID (skip meal/ skip dose)
39
Q

Prandin VS Starlix VS Sulfonylureas

A
  • Risk hypoglycemia
  • meal flexibilty
  • potency
  • Sulfa allergy considerations
  • $$$
40
Q

What to use for PP glucose elevations

(newer / milder DM):

A

Alpha-glucosidase inhibitors:

Precose and Glyset

41
Q

Alpha-Glucosidase Inhibitors:
Name
MOA
Admin instructions/ notable

A

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
Q

A-Glucosidase Inhibitors:

Precose and Glyset: C/I

A

C/I in

  • chronic intestinal DZ
  • Acarbose C/I in liver DZ
  • AVOID in renal dysfunction
43
Q

DPP-4 Inhibitors: Names

A

Januvia, Onglyza, Tradgenta, Nesina

44
Q

Incretins and the role of DPP-4 Inhibitors:

A

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
Q

DPP-4 Inhibitors:

do they cause hypoglycemia?

A

When used as monotherapy DPP-4 Inhibitors do not cause hypoglycemia

46
Q

DPP-4 Inhibitors:

C/I:

A

Increased risk for pancreatitis??

47
Q

DPP-4 Inhibitors:

Use as monotherapy or with…

A

Metformin, TZDs; Onglyza, Tradgenta and Januvia can be used with Sulfonylureas too

48
Q

DPP-4 Inhibitors- adjust dosing for….

A

RENAL, of course!!! ;)

Also might have to consider CYP inducers/ inhibitors also on board.

49
Q

Postmarketing research for Nesina indicates…

A

HEPATIC failure, sometimes fatal :(

50
Q

SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors: Names

A

Invokana, Farxiga, Jardiance

51
Q

SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors:

MOA

A

Blocks REabsorption of glucose by kidney and increase excretion of glucose in urine by inhibiting SGLT2

52
Q

SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors:

SEs

A
  • 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
Q

SGLT-2 (Sodium Glucose Co-Transporter 2) Inhibitors:

Dose-adjust for…

A

GFR

54
Q

Invokana- interacts with…

A

These may decrease effectiveness of Invokana:
-Rifampin
-Phenytoin
-Phenobarb
INVOKANA CAN ALSO INCREASE CONC OF DIG! (yikes!)

55
Q

Farxgia: Do not use if….

hint: “Bexiga” is bladder in Portugese

A

Pts with BLADDER CA or HX of bladder CA

56
Q

Welchol: Use in T2DM

A

= an ADJUNCT RX in T2DM (how creative!:)

57
Q

Welchol:
SEs
C/I
Interactions

A

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
Q

Cylcoset (Bromocryptine Mesylate):
MOA
SE

A 
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
Q

Cylcoset (Bromocryptine Mesylate):
USE WITH CAUTION
and C/I

A

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
Q

COMBO RX: how/ why

A
  • can be prescribed at DX onset or later
  • targets different defects
  • lower doses each med may&raquo_space; less SEs!!
61
Q

Glycovance: Glyburide + Metformin

Precautions and Admin instruction

A
  • same precautions as sulfonlynureas only
  • same liver/ kidney issues as metformin
  • take with food
62
Q

Non-insulin injectables, GLP-1 Receptor Agonists:

Names

A

Bynetta, Victoza, Bydureon, Tanzeum, Trulicity

63
Q

GLP-1 (Glucagon-like peptide-1)=

MOA

A

Incretin-mimetic;

  • enhances glucose dependent insulin secretion
  • decreases gastric motility
  • decreases hepatic glucose production
  • increases satiety (ie» modest ongoing weight loss)
64
Q

GLP-1 Agonists can be used with…

A

Metformin (or as monoRx)

65
Q

Bynetta:

SEs

A
  • pancreatitis
  • nausea
  • renal failure
66
Q

Bydureon, Victoza, Tanzeum, Trulicity
Cautions
SEs

A

-caused thryroid CA in rats
-decrease sulfonlyurea dose to prevent hypoglycemia
SEs:
-nausea
-pancreatitis

67
Q

How to advance therapy:

A

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
Q

Oral RX and insulin:
MOA
types of insulin

A
  • correction of FPG by PM insulin may improve OA action

- NPH at HS; Lantus or Levemir at HS; Aspart at PM meal

69
Q

Oral RX and insulin:

options

A
  • sulfonylurea + insulin
  • Metformin + insulin
  • Precose + insulin
  • Actos + insulin

Pharmacology (17 decks)

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