Diabetez pt 1 (basics, oral meds)

Question 1

When do we treat prediabetes with pharm therapy and what do we use? How often do we monitor?

Answer 1

When BMI is greater than 35, age < 60, or women with history of gestational diabetes

Use metformin

Monitor annually

Question 2

Gestational diabetes - goals? Treatment?

Answer 2

Fasting < 95, 1-hour post meal < 140, 2-hours post meal < 120

Insulin is preferred treatment

Question 3

When should we test someone for T2DM? How often should we repeat if tests are normal?

Answer 3

Screen adults who are overweight or obese (BMI > 25 or > 23 in Asian Americans) and who have one or more additional risk factor

Test after age 45 regardless of risk factors

Normal test results should be repeated every 3 years

Question 4

Waist circumference goals

Answer 4

< 35 in for females, < 40 in for male

Question 5

Nutritional supplements recommended

Answer 5

Omega-3 fatty acids (EPA and DHA) and omega-3 linolenic acid (ALA)

Question 6

Carbohydrate serving is how many grams?

Answer 6

15

Question 7

Which diabetic agents have been shown to decrease cardiovascular and all-cause mortality when added to standard treatment?

Answer 7

Empagliflozin (Jardiance)

Liraglutide (Victoza)

Question 8

When should aspirin be added to diabetes therapy?

Answer 8

Primary prevention: age > 50 years who have diabetes and at least one additional ASCVD risk factor

Secondary prevention: everyone

Question 9

When are statins recommended with diabetes therapy?

Answer 9

In most patients with diabetes, intensity of dosing is based on ASCVD risk
ACC/AHA: Recommend high intensity in patients age 40-75 who have diabetes plus ASCVD risk

ADA recommends:
Age < 40 years, only if they have ascvd risk factors
Age > 75 years, mod intensity of they have no risk factors or mod/high if they have risk factors

Question 10

Preferred anti-htn in diabetes?

Answer 10

ACEi or ARB preferred in patients with albuminuria (urine albumin > 30 mg/24 hours or UACR > 30 mg/g)

Otherwise any agent from the preferred classes are fine

Question 11

How to monitor for renal disease progression in diabetes?

Answer 11

Annual urine albumin excretion

Question 12

How to monitor for retinopathy in diabetes?

Answer 12

Eye exams every 2 years

Women with preexisting diabetes who become pregnant: higher risk, check each trimester and up to 1 year postpartum

Question 13

How to monitor for neuropathy?

Answer 13

Assess annually using 10-g monofilament and at least one additional test (pinprick, temperature, or vibration sensation)

Question 14

Preferred agents for neuropathy per the ADA?

Answer 14

Duloxetine, pregabalin

Question 15

How to monitor for foot ulcers etc?

Answer 15

Comprehensive foot exams once per year

All patients with diabetes should inspect their feet daily

Question 16

Foot care counseling

Answer 16

Underlined:
Check feet every day
Avoid walking barefoot
Protect feet from hot and cold

Question 17

Vaccinations for patients w diabetes

Answer 17

Annual flu
Pneumococcal (23 x 1 between age 2-64
13 then 23 after age 65, spaced at least 1 year apart and 23 separated by 5 years after previous admin)
Hepatitis B vaccine? approved ages 19-59, per ACIP can be used in age > 60

Question 18

How often should A1C be measured?

Answer 18

Quarterly

Question 19

Drugs that can cause hyperglycemia

Answer 19

Beta blockers (or hypo)
Diuretics (thiazides/loop)
Immunosuppressants (cyclosporine, tacrolimus)
Niacin
Protease inhibitors
Quinolones (or hypo)
Second-gen antipsychotics
Statins
Steroids

Question 20

Janumet

Answer 20

Metformin and sitagliptin

Question 21

Qtern

Answer 21

Saxagliptin and dapagliflozin

DPP-4 inhibitor and SGLT2 inhibitor

Question 22

Xultophy

Answer 22

Liraglutide and insulin degludec

GLP-1 agonist + long acting insulin

Question 23

Soliqua

Answer 23

Lixisenatide and insulin glargine

GLP-1 agonist + long acting insulin

Question 24

Metformin boxed warnings

Answer 24

Lactic acidosis, increased risk with intravascular iodinated contrast, age > 65, hypoxic states, dehydration, alcohol

Underlined: contrast, alcohol, eGFR stuff

Question 25

Renal dosing metformin

Answer 25

based on eGFR
Contraindicated in eGFR < 30
Not recommended to initiate if between 30-45, assess benefit if already taking if eGFR < 45 and already taking

Question 26

Side effects metformin

Answer 26

N/V/D
Flatulence
Abdominal cramping (give w/ meal)
Vitamin B12 deficiency

Question 27

Sulfonylureas and meglitinides MOA

Answer 27

Insuline secretagogues; work by stimulating insulin secretion from the pancreatic cells to decrease postprandial blood glucose

Question 28

Sulfonylureas and meglitinides side effects, counseling

Answer 28

Meglitinides (nateglinide, repaglinide): Take 15-30 mins before meals
Sulfonylureas: once or twice daily

Can cause weight gain, hypoglycemia
Take before meals (sulfonylureas take 30 min before breakfast, except glipizide IR take 30 mins before any meal
Hold doses if NPO!

Question 29

True or false: It’s ok to use sulfonylureas and insulin together

Answer 29

False - high risk of hypoglycemia

Question 30

Thiazolidinediones MOA

Answer 30

Increase peripheral insulin sensitivity by agonizing PPAR-gamma receptors

Question 31

Actos dosing, generic, drug class, contraindications/warnings, side effects

Answer 31

Pioglitazone
Thiazolidinediones
15-30 mg daily
Contraindicated in Class III/IV heart failure
Can cause hepatic failure, edema (including macular edema)
Increased risk of bladder tumors, do not use in patients with active bladder cancer
Can cause peripheral edema, weight gain
Monitor for s/sx of HF

Question 32

SGLT-2 inhibitors MOA

Answer 32

Increases reabsorption of filtered glucose in the proximal renal tubule (underlined)
Increases urinary glucose excretion

Question 33

Invokana generic, MOA, dose

Answer 33

Canagliflozin
100 mg daily but can inc to 300 mg daily
Decrease based on eGFR - if 45-59, dec to 100 mg daily max
Not recommended in 30-44, contraindicated < 30
SGLT-2 inhibitor

Question 34

SGLT2 inhibitor boxed warnings, warnings, side effects, monitoring

Answer 34

Canagliflozin has a boxed warning for increased risk of leg and foot amputations
Contraindicated in eGFR < 30
Warnings of ketoacidosis, genital mycotic infections, urosepsis, and pyelonephritis
Also can cause intravascular volume depletion (hypotension, dehydration) when used with diuretics, RAAS inhibitors, or NSAIDs
Canagliflozin can cause hyperkalemia
Side effects: wt loss, hypoglycemia
Monitor: renal fx

Question 35

Jardiance generic, MOA, dose

Answer 35

Empagliflozin
SGLT-2 inhibitor
10 mg daily, up to 25 mg daily
Not recommended in eGFR 30-44
Contraindicated eGFR < 30

Question 36

DPP-4 inhibitor MOA

Answer 36

Increases insulin release from pancreatic beta cells and decreases glucagon excretion from pancreatic alpha cells

Question 37

Januvia generic, MOA, dose

Answer 37

Sitagliptin
DPP-4
100 mg daily
CrCL 30-49: 50 mg daly
CrCL < 30: 25 mg daily

Question 38

Warnings w DPP-4, side effects, counseling

Answer 38

DPP-4
Acute pancreatitis
Saxagliptin (Onglyza) and alogliptin (Nesina) can inc risk of heart failure

SIde effects: nasopharyngitis, URTI’s, UTI’s

Question 39

Onglyza generic, MOA, dose

Answer 39

Saxagliptin
DPP-4 inhibitor
2.5-5 mg daily
eGFR < 45: 2.5 mg daily

Question 40

Tradjenta generic, MOA, dose

Answer 40

Linagliptin
DPP-4
5 mg daily
No renal dose adjustment!

Question 41

Nesina generic, MOA, dose

Answer 41

Alogliptin
DPP-4
25 mg daily
eGFR 30-59: 12.5 mg daily
< 30: 6.25 mg daily

Question 42

Which drugs require glucose (not sucrose) for tx of hypoglycemia if caused by another drug?

Answer 42

Acarbose (Precose) or miglitol Glyset)
These block metabolism of intestinal sucrose, which delays glucose absorption to reduce BG
Need glucose gel or tablets if pt is on these