Diabetes Type 2 Therapeutics Flashcards
1
Q
prediabetes involves impaired ____ and or impaired ___
A
fasting glucose (IFG); glucose tolerance (IGT)
2
Q
t/f prediabetes puts you at higher risk for developing Type 2 diabetes
A
t
3
Q
what is impaired fasting glucose?
A
elevated fasting blood glucose but normal post-meal levels
4
Q
what is impaired glucose tolerance?
A
elevated post-meal glucose but normal fasting glucose
5
Q
what FPG give a prediabetes diagnosis?
A
6.1-6.9 mmol/L (IFG)
6
Q
what 2hPG after a 75g OGTT would give a diagnosis of prediabetes?
A
7.8-11.0 mmol/L (IGT)
7
Q
what A1C would give a diagnosis of prediabetes?
A
6.0-6.4%
8
Q
what is the goal of therapy for prediabetes?
A
to prevent or delay the progression to type 2 diabetes
9
Q
what is used to manage prediabetes?
A
- intensive lifestyle modifications
2. medications may be considered
10
Q
what medications and doses may be used in prediabetes?
A
- metformin 250-850mg BID
- orlistat 120mg TID
- acarbose 100mg TID
11
Q
women are typically screened for gestational diabetes between weeks ___ and ___ of pregnancy
A
24 and 28; if other clinical factors, they may be screened sooner
12
Q
how is gestational diabetes screened for?
A
usually a 50g OGTT with a 1 hour post glucose reading and then may do a 75g test depending on the result
13
Q
how is gestational diabetes managed?
A
can sometimes be managed with diet, but usually requires insulin (most data with NPH, but long-acting also appears safe)
14
Q
what is the FBG target for gestational diabetes?
A
<5.3 mmol/L
15
Q
what is the target 1 hr post meal glucose in gestational diabetes?
A
<7.8 mmol/L
16
Q
what is the target 2 hr post meal glucose for gestational diabetes?
A
<6.7 mmol?l
17
Q
what is the diabetes diagnostic value for FPG?
A
7.0 mmol/L or greater
18
Q
what is the diabetes diagnostic value for A1C?
A
6.5% or greater in adults
19
Q
what is the diabetes diagnostic value for 2hPG in a 75g OGTT?
A
11.1 mmol/L or more
20
Q
what is the diabetes diagnostic value for random PG?
A
11.1mmol/L or more
21
Q
if a patient has one test value in diabetic range, but is asymptomatic, what do you do?
A
repeat the test on another day
22
Q
what is the simplified pathology of Type 2 diabetes?
A
insulin resistance and Beta cell dysfunction
23
Q
t/f in type 2 diabetes, the symptoms can be mild or even absent
A
t
24
Q
t/f obesity is common in type 2 diabetes
A
t
25
in a hyperosmolar hyperglycemic state (HHS), there may be enough insulin to prevent ____, but not enough to prevent ___ or allow ____
lipolysis; gluconeogenesis; glucose uptake into tissues
26
there is typically an underlying cause to HHS, what is an example of an underlying cause?
infection
27
what are the symptoms of HHS?
volume depletion, dehydration, decreased GFR, electrolyte depletion
28
are ketones present in HHS?
may be minimal, or no ketones present
29
is there usually acidosis involved in HHS?
no
30
what is the typical target A1c for patients with type 1 and type 2 diabetes
7.0 or less
31
what is the A1c target of patients with type 2 to reduce risk of CKD and retinopathy if patient is at low risk for hypoglycemia?
6.5% or less
32
what is the goal A1c for patients who are functionally dependent?
7.1-8.0
33
what is teh goal A1c for patients with recurrent severe hypoglycemia and or hypoglycemia unawareness?
7.1-8.5%
34
what is the A1c target for patients with limited life-expectancy?
7.1-8.5%
35
what is the target A1c for patients who are frail, elderly or who have dementia?
7.1-8.5%
36
you should not target an A1c higher than ___
8.5
37
what is the target pre-meal FPG?
4.0-7.0
38
what is the target 2hr post-meal BG?
5.0-10.0 (5-8 if A1c targets not met)
39
what is the goal LDL?
2.0 mmol/L or less
40
what is the goal blood pressure?
<130/80 mmHg
41
what are the ABCDESSS of diabetes care?
1. A1c targets
2. BP targets
3. cholesterol drugs
4. drugs for CVD risk reduction
5. exercise goals & healthy eating
6. screening for complications
7. smoking cessation
8. self-management, stress
42
what medications make up the SADMANS list of medications to be held when sick?
```
Sulfonylureas
ACE inhibitors
Diuretics & direct renin inhibitors
Metformin
ARBs
NSAIDs
SGLT2 inhibitors
```
43
metformin belongs to what class of drugs?
biguanides
44
what is the name brand of metformin>
glucophage
45
how much does metformin reduce A1c?
1.0-1.5%
46
what is the general MOA of metformin?
decrease hepatic glucose production and increase insulin sensitivity
47
metformin has what effect on lipid levels?
positive effects (decrease LDL and TG and increase HDL)
48
what is the effect of metformin on weight?
neutral or loss
49
what is the risk of hypoglycemia with metformin?
rare
50
aside from diabetes, what is a nother use of metformin?
can improve ovulation in PCOS patients
51
metformin can cause malabsortion of what vitamin?
B12
52
metformin needs to be stopped if patient is getting contrast dye, how soon after can it be restarted?
2-3 days
53
what are the ADRs of metformin?
diarrhea and nausea (start low and go slow to avoid)
54
what is a rare ADR of metformin? Who is most likely to experience?
lactic acidosis; patients with renal or liver Dx
55
when is metformin C/i?
1. renal or liver impairment
2. alcohol abuse
3. severe infection or septicemia
4. shock
5. hypoxic states
6. CHF
56
what is the typical starting dose of metformin?
500mg BID
57
when can the initial effects of metformin be seen? When can we see max effect?
3-5 days; 1-2 weeks
58
special administration instruction for metformin
take with food
59
what is the max daily dose of metformin?
2550mg/day
60
what is the extended release formulation of metformin that can be dosed UID?
Glumetza
61
if a patient has ASCVD and MACE, what are the diabetis drugs of choice?
GLP-1 RA or SGLT2 inhibitor s
62
if a patient has ASCVD and HHF, what is the diabetic drug of choice?
SGLT2 inhibitor
63
if a patient has ASCVD and progression of nephropathy, what is the diabetic drug of choice?
SGLT2 inhibitor
64
is a patient has CKD and MACE, what is the diabetic drug of choice?
SGLT2 inhibitor or GLP-1 RA
65
if patient has CKD and HHF, what is the drug of choice?
SGLT2 inhibitor
66
if a patient has CKD and progression of nephropathy, what is the drug of choice??
SGLT2 inhibitor
67
if a patient has HF and HHF, what is the drug of choice?
SGLT2 inhibitors
68
if a patient is over 60 with CV risk factors and MACE, what is the drug of choice?
GLP-1 RA
69
if a patient is over 60 with CV risk factors and HHF, what is the drug of choice?
SGLT2 inhibitor
70
if a patient is over 60 with CV risk factors and progression of nephropathy, what is the drug of choice?
SGLT2 inhobitor (only initiate if eGFR <30mL/min)
71
give 3 examples of sulphonylurea secretagogues
glyburide, gliclazide, glimepiride
72
what is the name brand of glyburide?
Diabets
73
what is the name brand of gliclazide?
Diamicron
74
what is the name brand of glimerpiride?
amaryl
75
how much do sulphonylureas decrease A1c?
1.0-1.5%
76
what is the general MOA of sulphonylurea secretagogues?
increase the insulin secretion from beta cells
77
what is the risk for hypoglycemia in sulphonylureas
higher (no on/off switch, just always trying to squeeze out as much insulin from beta cells as possible)
78
what is the effect of sulphonylureas on weight
weight gain
79
sulphonylureas may have a small chance of having a cross allergy with what class of medications?
sulphonamide
80
what is the starting dose of glyburide?
1.25--2.5mg UID
81
what is the max dose of glyburide?
20mg/day (10mg BID)
82
how should the glyburide dose by titrated?
every 1-2 weeks
83
t/f glyburide may have more hypoglycemia risk than gliclazide
t
84
gliclazide comes in what 2 formulations?
1. regular release (80mg tabs)
| 2. modified release tablets (30 or 60mg tablets)
85
what is the initial dosing of gliclazide?
40mg reg release or 30mg modified release
86
one 80mg regular release tablet = one ___mg MR tablet of gliclazide
30
87
what is the max dose of gliclazide?
160mg BID reg release or 120mg MR daily
88
how should gliclazide be titrated?
every 1-2 weeks
89
gliclazide is safe in what level of renal impairment?
mild to moderate
90
what is the starting dose of glimepiride?
1mg daily
91
what is the max dose of glimepiride?
8mg daily
92
how should glimepiride be titrated?
every 1-2 weeks
93
t/f glimepiride may have lower rates of hypoglycemia compared to gliclazide
t
94
Give an example of a Meglitinide
Repaglinide
95
what is the name brand for repaglinide?
Gluconorm
96
t/f repaglinide has a rapid onset and short half life
t
97
when should repalglinide (special admin instructions)
taken shortly before a meal
98
what do you do with you repaglinide dose if you skip your meal?
skip the repaglinide dose
99
what is the risk of hypoglycemia with repaglinide?
associated with less hypoglycemia
100
what is the effect of repaglinide on weight?
associated with less weight gain
101
what BG reading will repaglinide lower?
the postprandial BG
102
what is the starting dose of repaglinide?
0.5mg TID
103
what is the max dose of repaglinide?
4mg QID
104
how much does repaglinide lower A1c?
1.0-1.5%
105
how should repaglinide be titrated?
weekly; slowly in renal and hepatic impairment
106
repaglinide has a significant interaction with what drug?
gemfibrozil
107
hypoglycemia is a BG reading usually below ____mmol/L
4.0
108
what are the Sx of mild hypoglycemia?
tremors, palpitations, sweating, anxiety, tingling, anxiety, nausea, excessive hunger
109
what are the Sx of moderate hypoglycemia?
headache, mood changes, irritability, visual changes, dizziness
110
what are the Sx of severe hypoglycemia?
unresponsive, unconsciousness, seizures, coma
111
what is the treatment for hypoglycemia?
15g of carbs
112
give some examples of 15g of carbs
```
glucose tabs
3/4 cup of juice or soft drink
6 lifesavers
15ml honey
15ml or 3 packs of table sugar dissolved in water
```
113
give 4 examples of DPP-4 inhibitors
1. sitagliptan
2. saxagliptan
3. linagliptan
4. alogliptan
114
brnad name of sitagliptan
Januvia
115
Brand name of saxagliptan
Onglyza
116
brand name of linagliptan
Trajenta
117
brand name of alogliptan
Nesina
118
general MOA of DPP-4 inhibitors
inhibits the enzyme DPP-4 that causes the degradation of GLP-1
119
how much do DPP-4 inhibitors lower the A1c?
by 0.6-1.0%
120
what is the effect of DPP-4 inhibitors on weight?
weight neutral
121
what is the risk of hypoglycemia with DPP-4 inhibitors?
no risk for hypoglycemia
122
DPP-4 inhibitors effect typically has an oset within ___ weeks, with a max effect at ____ weeks
4; 18
123
what are the ADRs of DPP-4 inhibitors?
joint pain, muscle pain, muscle spasms, increased risk for HF, concerns about risk of pancreatitis
124
t/f longterm safety data for DPP-4 inhibitors has not been established yet
true
125
what is the dose of sitagliptan (Januvia)?
100mg UID
126
dose adjustments are required for sitagliptan in what level of renal impx?
moderate to severe
127
sitagliptan has fewer ___ interactions than saxagliptan
CYP3A4
128
sitagliptan should be avoided in what chronic condition?
heart failure
129
what is the dose of saxagliptan (Onglyza)
2.5-5.0mg UID
130
what are the ADR of saxagliptan?
anemia, increased risk for upper respiratory infections, hypersensitivity rxn
131
saxagliptan has interactions with what CYP enzyme?
3A4
132
saxagliptan should be avoided in what chronic condition?
heart failure
133
what is the dose of linagliptan (Trajenta)?
5mg UID
134
which DPP-4 inhibitor does not require dose adjustment in renal or hepatic impairment?
linagliptan
135
linagliptan has interactions with what enzyme/transporter
CYP3A4 and PgP
136
Linagliptan should be avoided in what chronic condition?
heart failure
137
the A1c decrease from linagliptan will be seen withing ____ weeks
4-6
138
what is the dose of alogliptan (Nesina)?
6.25-25mg daily
139
what are the ADRs of alogliptan (Nesina)?
upper respiratory infections, hypersensitivity reactions
140
what are the drug interactions of alogliptan?
minimal CYP3A4
141
what should be especially monitored when on alogliptan?
LFTs
142
alogliptan should be avoided in what chronic condition?
heart failure
143
what is the MOA of SGLT2 inhibitors in diabetes care?
decreases the renal absorption of glucose and decreases the renal threshold for glucose
144
how long does it take for SGLT2 inhibitors to lower A1c?
3-6 months
145
what are the ADRs of SGLT2-inhibitors?
increased yeast infections, UTI, urinary frequency, increased BUN and SCr, decreased BP, hypovolemia
146
what is the effect of SGLT2 inhibitors on weight?
weight loss
147
what is the risk of hypoglycemia of SGLT2 inhibitors?
low (only peeing out the extra glucose)
148
how much can SGLT2 inhibitors decrease A1c?
0.5-0.8%
149
what factors increase patient risk for experiencing DKA while taking an SGLT2 inhibitor?
1. low carb intake/fasting
2. acute serious illness
3. elderly
4. surgery
5. decreased insulin dose
6. type 1 diabetes
7. excessive alcohol intake
150
what is the starting dose of canagliflozin (invokana)?
100mg/day in AM
151
what is the max dose of canagliflozin (invokana)?
300mg/day
152
what is the brand name for canagliflozin?
invokana
153
what are the drug interactions with canagliflozin?
UGT inducers may decrease the effectiveness (rifampin, carbemazepine, phenytoin), can increase digoxin levels
154
the amputation risk with canagliflozin was higher in the ___ trial and neutral in the ____ trial
CANVAS; CREDENCE
155
canagliflozin decreases ___ in patients with established CVD or CV risk factors
MACE
156
what is the effect of canaglifozin on CKD and HF hospitalizations?
benefit in CKD and decrease HF hospitalizations
157
what is the brand name for dapagliflozin?
Forixga
158
what is the starting dose of dapaglifozin?
5mg daily AM
159
what is the max dose of dapagliflozin (forixga)?
10mg/day
160
dapagliflozin is c/i in patients with an eGFR of ____
30-45mL/min
161
what is the effect of dapagliflozin on MACE?
neutral
162
what is the effect of dapagliflozin on CKD?
beneficial
163
what is the effect of dapagliflozin on CV mortality, all cause mortality and HF hospitalization?
decrease
164
what is the brand name of empagliflozin?
Jardiance
165
what is the dose of empagliflozin?
10-25mg daily
166
empagliflozin is C/i when eGFR is less than ___ ml/min
30
167
what are the beneficial effects of empagliflozin?
1. decreased mortality
2. decreased MACE
3. decreased HF hospitalization
4. decreased progression of CKD
168
GLP-1 receptor agonists are mostly delivered by what route?
injection
169
what is the MOA of GLP-1 RA?
binds to GLP-1 receptor resulting in increased insulin secretion
170
GLP-1 RA reduce ___ glucagon release
post-meal
171
what is the effect of GLP-1 on gastric emptying?
slows, which decreases food intake and lead to weight loss
172
what is the effect of GLP-1 on weight?
weight loss of 1.5-4kg
173
how much do GLP-1 lower A1c?
by 1-2%
174
what is the risk level for hypoglycemia with GLP-1 RA?
no risk
175
GLP-1 are C/i in what patients?
Hx or family Hx of medullary thryoid cancer or multiple endocrine neoplasia syndrome type 2 (MENS2)
176
what are the rare ADRs of GLP-1 RAs?
gallbladder Dx, retinopathy with semaglutide injectable, possibly pancreatitis
177
what are the common ADRs of GLP-1 RA?
GI (esp nausea), decreased appeitie, increased HR and increased PR interval
178
use of GLP-1 should be done with caution in what conditions?
gastroparesis and GERD
179
what are 5 GLP-1 RAs?
1. Exenatide
2. Liraglutide (Victoza)
3. Semaglutide injectable and PO
4. Dulaglutide
5. Lixisenatide
180
what is the dosing of regular release exenatide (Byetta)?
initial: 5mcg SQ BID and increase to 10mcg SQ bID after 1 month if tolerated
181
what is the dose of extended exenatide (Bydureon)?
2mg once weekly
182
does bydureon require reconstitution?
yes
183
exenatide is c/i when eGFR is less than ____ and caution when its less than ____
30 ml/min; 50ml/min
184
exenatide is stable at room temp for ___ days
30
185
what are the CVD outcomes for exenatide?
neutral
186
what is the brand name of liraglutide?
victoza
187
what is the initial dose of liraglutide?
0.6mg SQ UID
188
what is the max dose of liraglutide?
1.8mg SQ UID
189
the dose of liraglutide should be titrated every ____
1-2 weeks
190
liraglutide is stable at room temp for ___ days
30
191
liraglutide is C/i in patients if eGFR is less than ____
15-30mL/min
192
what is the effect of liraglutide in CVD?
decrease CVD mortality and decrease MACE
193
what is the brand name of semaglutide?
ozempic
194
what is the dsoing of semaglutide?
once weekly 0.25mg for 4 weeks then 0.5mg weekly
195
what is the max dosing of semaglutide?
1mg SQ weekily
196
semaglutide is c/i in eGFR less than ___
30mL/min
197
semaglutide is stable at room temp for ___ days
56
198
what are the effects of semaglutide on CVD?
decrease MACE in patients with established CVD
199
what is the brand name for the oral semaglutide?
Rybelsus
200
what is the dosing of Rybelsus (oral semaglutide)?
3mg daily for 30 days then 7mg daily
201
what is the max dose of Rybelsus?
14mg daily
202
how should rybelsus (oral semaglutide) be taken?
take 30 min AC with <120ml water
203
rybelsus should be used with caution if the eGFR is less than ____
30mL/min
204
what is the effect of rybelsus on CVD outcomes?
neutral
205
what is the brand name of dulaglutide?
Trulicity
206
what is the dose dulaglutide?
0.75mg once weekly; max 1.5mg weekly
207
dulaglutide should be used in caution when eGFR is less than ____
15 mL/min
208
dulaglutide is stable at room temp for ___ days
14
209
what is the effect of dulaglutide on CVD?
decrease MACE in patients with established CVD
210
what is the brand name of lixisenatide?
Adlyxine
211
what is the dose of lixisenatide (including max dose)?
10mcg daily AC then increase to 20mcg daily after 2 or more weeks. Max: 20mcg daily
212
lixisenatide is stable at room temp for __ days
14
213
what are the CVD outcomes for lixisenatide?
neutral
214
give an example of an alpha-glucosidase inhibitor
Acarbose
215
what is teh brand name of acarbose?
Glucobay
216
what is the MOA of acarbose?
delays digestion of carbs and absorption of glucose in the small intestine
217
what glucose reading does acarbose decrease?
post-meal
218
what is the initial dose of acarbose?
25mg UID
219
what is the max dose of acarbose?
100mg TID
220
what are the A1C lowering effects of acarbose?
0.4-0.9%
221
what is the effect of acarbose on weight?
neutral
222
what is the risk of hypoglycemia with acarbose?
rare
223
what is the impact of acarbose on renal impairment?
can be used in mild renal impairment
224
how should acarbose be taken?
with the first bite of food
225
how should acarbose be titrated?
start low and go slow (titrate every 2-4 weeks)
226
what are some ADRs of acarbose?
flatulence and diarrhea
227
when will acarbose reach its max efficiacy?
8 weeks
228
if you do get hypoglycemia while on acarbose, what is special about the way it has to be treated?
must be treated with pure glucose such as milk, honey or dextrose tabs
229
acarbose is C/i in what conditions?
IBD, intestinal ulcers, cirrhosis and severe renal impx
230
what are 2 examples of thiazolidinediones?
1. pioglitazone (Actos)
| 2. rosiglitazone (Avandia)
231
why are thiazolidinediones not recommended as first line therapy?
increased risk for edema, weight gain, CHF, fractures in women and concerns w/ CV outcomes
232
what is the general MOA of thiazolidinediones?
increase insulin sensitivity and decrease hepatic glucose production
233
what are the A1C lowering effects of thiazolidinediones?
1.0-1.5%
234
what is the rissk of hypoglcemia with TZDs?
no risk
235
TZDs start to work after ___ weeks and reach max effects after ____ weeks?
2; 6-12
236
in what levels of renal impairment can TZDs be used?
mild to severe
237
TZDs cannot be combined with ____
insulin
238
aside from diabetes, what is another use for TZDs?
may cause ovulation in women w/ PCOS and premenopausal women
239
what specific lab is required when starting a TZD?
LFTs
240
what are the initial and max doses of rosiglitazone (Avandia)?
initial: 4mg UID
Max: 4mg BID
241
what is the effect of rosiglitazone (Avandia) on lipids?
increase LDL and HDL (not ideal for pts with ASCVD)
242
rosiglitazone is c/i in what condition?
NYHA classes (all)
243
can rosiglitazone be used as monotherapy?
no, it is no longer approved for this
244
is rosiglitazone approved for use in triple therapy?
no
245
rosiglitazone has concerns that it may increase the rate of what heart condition?
MI
246
what are the initial and max doses of pioglitazone (Actos)?
initial: 15mg UID
max: 45mg UID
247
what are the effects of pioglitazone on lipids?
increase HDL and decrease TG
248
pioglitazone (Actose) is c/i in what NYHA HF classes?
2, 3, 4
249
there are concerns that pioglitazone (Actos) may increase risk for ___ cancer
bladder
250
what dose is insulin typically started in type 2?
0.1-0.2 u/kg or 10u at bedtime
251
how is the dose of insulin titrated in type 2?
adjust by 1-2 units every 2-3 days
252
t/f consistent food intake and physical activity contribute to success in DMT2
true
253
when possible, what medication should always be maintained in type 2 diabetes?
metformin
254
when starting mealtime insulin, how should the oral meds be adjusted?
dose reduced or d/c with the exception of metformin
255
how many times a day should a pregnant person monitor BG?
4 or more times a day
256
how many times a day should a patient test their BG if they are starting a new med that is known to cause hyperglycemia (ex; steroids) or experiencing illness?
will be individualized, but likely at least 2 or more times/day
257
which SGLT2 have been shown to improve outcomes in patients with HFrEF, even w/o diabetes?
dapagliflozin and empaglifozin
258
what HF outcomes were seen in the DAPA-HF trial?
dapagliflozin reduced hospitalization and CV death
259
what was shown by the EMPEROR reduced trial?
empagliflozin reduced hospitalization
260
diabetes is pregnancy is almost always treated with ___
insulin (usually NPH)
261
the diabetes targets in pregnancy are ___ (higher/lower)
lower
262
what is the typcal treatment for HHS?
IV insulin, fluids and K depending on levels
263
diabetics over 40 years old should be on what cardio med?
statin
264
what meal do you typically start with when adding metformin to meals?
supper (bc it is usually the largest meal of the day)
265
how often should B12 be checked in metformin patients?
yearly
266
patients with what factors make lactic acidosis with metformin more likely?
liver or kidney impairment, meal insufficiency, heart failure
267
metformin should be held during what type of diagnostic testing?
anything with contrast dye (increases risk for AKi)
268
how much weight is it typical to gain when taking a sulphonylurea?
1-2 pounds
269
1 80mg tablet of regular gliclazide is equal to 1 __mg modified release gliclazide tablet
30
270
t/f DPP-4 only work in the presence of high BG
t
271
which DPP-4 has been associated with poor outcomes in HF and should be avoided in this Dx?
saxagliptan
272
why may SGLT2 not be a great option for elderly patients?
more risk for dehydration and falls when needing to get up to use the bathroom
273
if SCr goes up by ___%, you should stop SGLT2
20-30%
274
how does oral semaglutide need to be taken?
30min before any meal and with no more than 120ml of water
275
metformin can be used in renal impairment as long as the eGFR is greater than ___
30ml/min
