Diabetes x2 Flashcards
Screening for DM for patient’s <40 with no risk factors
no screening required
Screening for DM for patients > 40 yo
q3y
Screening for DM for patients at high risk
q6-12mon
If a patient is prediabetic, what 3 things would you want to implement
weight loss (5-7% of initial weight)
Physical activity 150min/week as this decreases the risk of progression by 60%
mediterranean diet
DASH diet
Metformin 850 mg PO BID, as it decreases risk of progression by 30%
What are the important pieces of care for DM pt
A1C under good control (<7)
Blood pressure target <130/<80
Cholesterol target - may need a statin
Drugs to reduce risk of CVD (statin, acei/arb, sglt2i, glp1)
exercise - 150min aerobic/week, 2-3 days of resistance training
eating better
screening - feet, eyes, kidneys, heart
smoking cessation
sick day management (for metformin, insulin, SGLT2i)
If pt has an elevated A1C 7.5, what would you do initially for management
trial lifestyle modifications for 3 months, before starting metformin
If a patient has an elevated A1C 10, what you do
start metformin right away
If patient has symptomatic hyperglycemia or metabolic decompensation
insulin +/- metformin
Name all of the SGLT2i
Empagliflozin (jardiance)
Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Bexagliflozin (Brenzavvy)
Ertugliflozin (steglatro)
Sortagliflozin (Inpefa)
Brand name for empagliflozin & class
jardiance & SGLT2i
Brand name for dapagliflozin & class
forxiga & SGLT2i
Brand name for canagliflozin & class
invokana & SGLT2i
Brand name for bexagliflozin & class
brenzavvy & SGLT2i
Brand name for ertugliflozin & class
steglatro & SGLT2i
Brand name for sortiglaflozin & class
inpefa & SGLT2i
Name the GLP1 agonists
Semaglutide (Ozempic)
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Exenatide (Byetta)
Lixisenatide (Adlyxine)
Brand name for semaglutide & its class
ozempic & GLP1 agonist
Brand name for liraglutide & class
Victoza & GLP1 agonist
Brand name for Dulaglutide & class
Trulicity & GLP1 agonist
Brand name for Exenatide & class
Byetta
Brand name for Lixisenatide & class
Adlyxine
Name the DDP (Dipeptidyl peptidase 4 inhibitors)
Alogliptin (Nesina)
Linagliptan (Tradjenta)
Saxagliptin (Onglyza)
Sitagliptin (Januvia)
Brand name and class for linagliptin
tradjenta & DPP4i
Brand name and class for sitagliptin
januvia & DPP4i
Brand name and class for saxagliptin
onglyza & DPP4i
Brand name and class for alogliptin
Nesina & DPP4i
Mechanism of action for SGLT2i & adverse effects
Inhibits the sodium glucose transporter in the proximal renal tubules, reduces the reabsorption of glucose (as SGLT2 is the main site of glucose reabsorption) therefore increasing urinary output of glucose
Increased urinary frequency
Genital mycotic infection
UTI
Euglycemic DKA
AKI
hyperK
What is the mechanism of SGLT2i on sodium in the body
Reduces Na reabsorption, means there is more Na present in the distal renal tubule, which may lower pre and afterload on heat & downregulate sympathetic activity
Mechanism of action for GLP1 agonists & adverse effects
Selectively bind to GLP1 receptor, then increases insulin secretion, decreases inappropriate glucagon secretion, slows gastric emptying, acts in areas of brain involved in regulation of appetite and calorie intake.
Nausea, vomiting, diarrhea
AKI - bc volume contraction
Gallbladder disease (cholelithiasis and/or cholecystitis) [ occur more in pt w/ rapid weight loss, higher doses >1mg, longer duration tx >26 weeks]
increase risk of it pancreatitis (not to be used in pt w/ hx)
?risk of medullary thyroid carcinoma (not to be used in patients w/ fam hx of it OR hx MEN2 [multiple endocrine neoplasia syndrome type 2]
Mechanism of action for DPP4 inhibitors & adverse effects
Inhibits the DDP4 enzyme, which prolongs incretin level, which increases insulin synthesis and release from pancreatic beta cells and decreases glucagon secretion from pancreatic alpha cells (also means decreased glucose production)
Generally well tolerated, does seem to cause arthralgia, pancreatitis, CHF and maybe pancreatic cancer
Diabetic agents that can cause hypoglycemia
Sulfonylurea
- Glyburide > gliclazide
Which diabetic agents are once daily dosing
sulfonylureas (gliclazide, glyburide)
Pioglitazone (thiazolidinedione)
SGLT2i (empagliflozin, dapagliflozin, canagliflozin)
DPP4i (sitagliptin, linagliptin)
Oral GLP1 agonists (semaglutide)
Metformin ER
Janumet (DPP4i/metformin)
Which diabetic agents are once weekly options
semaglutide (ozempic subcut)
dulaglutide (trulicity subcut)
Which diabetic agents have been shown to prevent major complications in patients with cardiovascular disease
SGLT2i (dapagliflozin - Forxiga, empagliflozin - Jardiance, canagliflozin - Invokana)
GLP1 agonists (semaglutide - ozempic, dulaglutide - trulicity, liraglutide - victoza)
Which diabetic agents have been shown to prevent major complications in patients with nephropathy
SGLT2i (canagliflozin - Invokana, dapagliflozin - Forxiga, empagliflosin - Jardiance)
Which diabetic agents have been shown to prevent major complications in patients with HFrEF
SGLT2i (cangliflozin - invokana, empagliflozin - jardiance, dapagliflozin - forxiga)
In pregnancy, what diabetic agents are safe to use
Insulin
Metformin
?glyburide (not initial alternative tx choice, does cross the placenta and no long term safety data available)
BUT gliclazide is contraindicated in pregnancy
What diabetic agents are appropriate to be used in patients who have renal dysfunction?
Insulin
DPP4i (linagliptin - tradjenta, sitagliptin - januvia)
GLP1 agonists (semaglutide - ozempic, dulaglutide - trulicity, liraglutide - victoza)
Which agents also cause weight loss
GLP1 agonists > SGLT2i > metformin >DPP4
Which diabetic agents can cause weight gain
insulin
sulfonylureas
thiazolidinedione
repaglinide
Which is better for people w/ DM, ACEI or ARB
Appear to be equally effective for cardiorenal protection. Have a reduction in the risk and progression of CKD independent of its effect on their BP. Target CV protective doses: ramipril 10 mg, telmisartan 80 mg, perindopril 8 mg
Do all patients w/ DM need an ACEI or ARB
Not all but many. No studies have shown a CV benefit for ACEI/ARBs in patients without HTN or CVD. No evidence for using ACEI/ARBs for primary prevention of nephropathy in patients with normal renal function. However, the majority of pts with DM have additional indications for ACEI/ARBs: clinical CVD, > 55 yo with additional risk factors or end organ damage (ACR > 2, retinopathy, LVH) or microvascular complications. ALL patients with DM and CKD with either HTN or albuminuria ACR >30 mg/g should be on an ACEI/ARB to delay progression of CKD.
Why do ACEI/ARBs protect the kidneys but can also cause acute kidney injury?
During periods of illness (dehydrated), RAAS blockers can reduce kidney function bc interfere w/ kidneys response to intravascular volume depletion by decreasing ability of ANGII to support gfr leading to inadequate perfusion. Monitor serum Cr and K+ at baseline at baseline and 1-2 weeks after starting or increasing dose. A transient increase in serum Cr is normal and should stabilize over time. It is concerning if sCr >30% baseline, should stop the ACEI/ARB. Be aware of sick days to hold these meds when dehydrates and avoid NSAIDs
Do all patients with DM need a statin (primary prevention)
Not all but many. Consider it in all adults w/ T1DM and T2DM, with at least 1 of the following: >40 yo, or 30-40 yo + DM for >15 y, or microvascular complications. Treatment with statin decreases CV risk and CVA events over 4 years, even when the initial LDL was already <3. Best evidence is for moderate doses, atorvastatin 10 mg, simvastatin 40 mg
If not at target or if statin intolerance, are other lipid lowering agents useful?
Ezetimibe has shown benefit but ONLY in combination with a statin. If a pt has familial hypercholesterolemia and unable to reach targets with combo statin + ezetimibe, can use evolocumab (PCSK9i). Fibrates and niacin are NOT recommended generally and the addition of fenofibrate to statin does not decrease risk of CV vs statin alone.
