Diabetez pt 2 (injectables) Flashcards by Jimmy Hayden

How to GLP-1 agonists work?

Analogs of incretin hormone GLP-1 which increases glucose-dependent insulin secretion and decreases glucagon secretion

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Exenatide brand, dose, renal dosing

Byetta
5 mcg SC BID for 1 month, then 10 mg SC BID

CrCL < 30 mL/min not recommended (underlined)

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Exenatide extended release brand, dose, renal dosing

Bydureon
2 mg SC once ~~~weeeeekly~~~
CrCL < 30 mL/min not recommended (underlined)

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Liraglutide brand, dose, renal dosing

Victoza
Start 0.6 mg SC daily x 1 week, then 1.2 mg SC daily
Can increase to 1.8 mg SC daily if needed
No renal dosing

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Dulaglutide brand, dose, renal dosing

Trulicity
0.75 mg SC once weekly, can increase to 1.5 mg SC once weekly

~~weeeekly~~

No renal dosing

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Lixisenatide brand, dose, renal dosing

Adlyxin

10 mcg SC daily x 14 days, then increase to 20 mcg aily

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GLP-1 agonist boxed warnings, contraindications, warnings, side effects, counseling points

Boxed warnings: All except Byetta (exenatide) and Adlyxin (lixisenatide) risk of thyroid C-cell carcinomas, seen in rats, unknown if applied to humans

Contraindications: all except Byetta and Adlyxin - personal or family history of medullary thyroid carcinoma

Warnings: Pancreatitis, not recommended in patients with severe GI disease

side effects: nausea, wt loss (slowed gastric emptying)

Counseling: dose Byetta and Adlyxin within 60 minutes of meals, all others can be given without regard to meals

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Which class of drugs can cause pancreatitis?

GLP-1 agonists

(Byetta, Bydureon, Trulicity, Victoza, Adlyxin

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How are GLP-1 agonists administered?

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True or false: Give Byetta within 60 minutes after a meal?

False - within 60 mins before a meal

After can cause hypoglycemia

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Bydureon vial counseling points

Single-dose vial/tray - once mixed, must inject immediately or else clumps will form

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Once weekly GLP-1 agonists

Bydureon, Trulicity, Tanzeum

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Symlin MOA, dosing, boxed warning, contraindications, warnings, side effects

Pramlintide is an analog of amylin which controls postprandial glucose by slowing gastric emptying, suppressing glucagon secretion following a meal, and increasing satiety

Type 1: 15 mcg/dose increase in 15 mcg increments every 3 days
Type 2: 60 mcg/dose, up to 120 mcg/dose after 3 days
Give prior to each major meal (> 30 g/carbs)

Boxed warning: severe hypoglycemia if used with insulin
Contraindications: gastroparesis
Warnings: hypoglycemia - reduce mealtime insulin by 50% when starting

Side effects: n/v, anorexia, headache, wt loss

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Name the rapid acting insulins

Aspart (Novolog)
Glulisine (Apidra,)
Lispro (Humalog)
Afrezza (powder)

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Warnings w rapid acting insulin

Hypoglycemia, hypokalemia (shifts K from intracellular space to the intracellular space)

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Counseling, boxed warnings, contraindications w Afrezza

Rapid acting insulin inhalation powder
Replace inhaler every 15 days

Boxed warnings: Acute bronchospasm in asthma or COPD
Contraindications: Asthma, COPD

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Name the short acting regular insulins

Humulin R
Novolin R
Comes as 100 units/mL or 500 units/mL

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When is concentrated (500 units/mL) insulin recommended?

In patients where > 200 units/day of insulin is required

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Counseling for U-500 uinsulin?

Must use a U-500 syringe to avoid dosing errors

Each marking represents 5 units - no dose conversion needed

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True or false: Insulin is available without a prescription

Yes - Humulin R, Novolin R, Humulin N, Novolin N, Humulin 70/30, and Novolin 70/30 are available without a prescription

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Name the intermediate acting insulins

NPH Insulin

Humulin N, Novolin N

Counseling for Novolin N, Humulin N

Solution is cloudy when mixed
Can mix with rapid or short-acting insulins but draw up rapid or short acting first and then add NPH bc NPH is cloudy whereas rapid/short are not

Name the long-acting insulins

Detemir (Levemir)
Glargine (Lantus, Basaglar, Toujeo)
Degludec (Tresiba)

Insulin pumps should be limited to what kind of insulin?

Short acting or regular insulin

How to initiate basal-bolus insulin (calculations)

Step 1: Calculate TDD (0.6 units/kg/day using ABW) Step 2: Divide TDD into 50% basal, 50% bolus Step 3: Divide bolus into 3 meals 0.6 units/kg/day x 70 kg = 42 units = 21 units Lantus and 21 units Humalog = 21 units lantus + 7 units humalog TIDAC

What is the Rule of 500?

500 divided by the total daily dose of RAPID ACTING insulin = grams of carbs covered by 1 unit of rapid acting insulin Rapid acting insulins: Aspart (novolog), glulisine (apidra), lispro (humalog)

What is the rule of 450?

450 divided by the total daily dose of REGULAR insulin = grams of carbs covered by 1 unit of rapid acting insulin Regular insulin: Humulin R, Novolin R

What is the 1800 rule?

Used to determine amount of RAPID ACTING insulin needed to return their blood glucose to a normal range 1800/TDD = correction factor for 1 unit of rapid-acting insulin Blood glucose now - target blood glucose divided by correction factor = correction dose

What is the 1500 rule?

Used to determine amount of REGULAR insulin needed to return their blood glucose to a normal range 1500/TDD = correction factor for 1 unit of rapid-acting insulin Blood glucose now - target blood glucose divided by correction factor = correction dose

Initiation of insulin for type 2 DM dosing guidance

0.1-0.2 unitskg/day (using ABW) or 10 units/day | Titrate by 10-15% or 2-4 units once or twice weekly to reach fasting glucose goal

Dosing conversion among insulins

Most 1:1 unit-to-unit dose conversion Converting from twice daily NPH to once daily insulin glargine (Lantus, Toujeo, Basaglar) - use 80% of the total daily NPH dose as the initial dose of insulin glargine

Insulin injection counseling points

Roll vial if a suspension, do not shake Abdomen pref'd injection site Draw up clear before cloudy if mixing insulin (NPH cloudy) Rotate injection site along the abdomen

Expiration date of insulin

If refrigerated and unopened, stable until expiration date on the label Stability at room temperature varies, most are 28 days

Syringe/needle recommendations

Smaller syringe barrel = easier it is to read scale markings in order to draw up an accurate dose

Define HHS

Hyperglycemia hyperosmolar state, often occurs in T2DM Serum ketones are negligible or not present because patient with type 2 diabetes has enough insulin to suppress ketogenesis ``` BG > 600 High serum osmolality > 320 Extreme dehydration Altered consciousness pH > 7.3, bicarbonate > 15 mEq/L ```

Define DKA

Diabetic ketoacidosis Occurs in type 1 diabetes often due to insulin non-compliance Ketones are present BG > 250 Ketones in urine and serum or fruity breath Anion gap (arterial pH < 7.35 and anion gap > 12)

Do not use if eGFR or CrCL < 30

Metformin SGLT2 inhibitors (Canagliflozin (invokana), Dapagliflozin (Farxiga), and empagliflozin (Jardiance)) Exenatide (GLP-1, Byetta) Glyburide

Do not use in heart failure

TZD's (Pioglitazone (actos), rosiglitazone (avandia)) | alogliptin, saxagliptin

Do not use in peripheral neuropathy, PAD, or diabetic foot ulcers

Canagliflozin (SGLT-2)

Do not use in gastroparesis or other GI disorders

GLP-1 agonists, (Exenatide (Byetta, Bydureon), Liraglutide (Victoza), Dulaglutide (Trulicity), Albiglutide (Tanzeum), Lixisenatide (Adlyxin) pramlintide

Do not use in sulfa allergy

Sulfonylureas

Do not use in G6PD deficiency

Sulfonylureas

Agents w risk of lactic acidosis

Metformin

Agents w risk of hepatotoxicity

TZD's (Pioglitazone (actos), rosiglitazone (avandia)) | alogliptin

Agents w risk of hypotension/dehydration

SGLT-2 inhibitors (Canagliflozin (invokana), Dapagliflozin (Farxiga), and empagliflozin (Jardiance))

Agents w risk of UTI/genital infections

SGLT-2 inhibitors (Canagliflozin (invokana), Dapagliflozin (Farxiga), and empagliflozin (Jardiance))

Agents w risk of potassium abnormalities

Canagliflozin (hyperkalemia) (SGLT-2) | Insulin (hypokalemia)

Agents w risk of pancreatitis

DPP-4 inhibitors (Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), Alogliptin (Nesina)) GLP-1 agonists (Exenatide (Byetta, Bydureon), Liraglutide (Victoza), Dulaglutide (Trulicity), Albiglutide (Tanzeum), Lixisenatide (Adlyxin)

Agents w risk of hypersensitivity rxns

Sulfonylureas | DPP-4 inhibitors (Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), Alogliptin (Nesina))

Agents w risk of ketoacidosis

SGLT-2 inhibitors (when BG < 250 mg/dL) | Canagliflozin (invokana), Dapagliflozin (Farxiga), and empagliflozin (Jardiance)

Agents w risk of cancer

Pioglitazone, dapagliflozin (bladder cancer) GLP-1 agonists (thyroid cancer) (Exenatide (Byetta, Bydureon), Liraglutide (Victoza), Dulaglutide (Trulicity), Albiglutide (Tanzeum), Lixisenatide (Adlyxin)