Diabetez pt 2 (injectables) Flashcards
How to GLP-1 agonists work?
Analogs of incretin hormone GLP-1 which increases glucose-dependent insulin secretion and decreases glucagon secretion
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)
Exenatide extended release brand, dose, renal dosing
Bydureon
2 mg SC once ~~~weeeeekly~~~
CrCL < 30 mL/min not recommended (underlined)
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
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
Lixisenatide brand, dose, renal dosing
Adlyxin
10 mcg SC daily x 14 days, then increase to 20 mcg aily
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
Which class of drugs can cause pancreatitis?
GLP-1 agonists
(Byetta, Bydureon, Trulicity, Victoza, Adlyxin
How are GLP-1 agonists administered?
SC
True or false: Give Byetta within 60 minutes after a meal?
False - within 60 mins before a meal
After can cause hypoglycemia
Bydureon vial counseling points
Single-dose vial/tray - once mixed, must inject immediately or else clumps will form
Once weekly GLP-1 agonists
Bydureon, Trulicity, Tanzeum
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
Name the rapid acting insulins
Aspart (Novolog)
Glulisine (Apidra,)
Lispro (Humalog)
Afrezza (powder)
Warnings w rapid acting insulin
Hypoglycemia, hypokalemia (shifts K from intracellular space to the intracellular space)
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
Name the short acting regular insulins
Humulin R
Novolin R
Comes as 100 units/mL or 500 units/mL
When is concentrated (500 units/mL) insulin recommended?
In patients where > 200 units/day of insulin is required
Counseling for U-500 uinsulin?
Must use a U-500 syringe to avoid dosing errors
Each marking represents 5 units - no dose conversion needed
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
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)
