Diabetic drugs

Question 1

initial therapy for most diabetics

Answer 1

metformin

Question 2

lactic acidosis as a life threatening complication

Answer 2

metformin

Question 3

what is weight neutral and low risk of hypoglycemia

Answer 3

metformin and DPP4 inhibitors (sitagliptin or Januvia)

GLP-1 helps pts lose significant amount of weight.

Question 4

what is added if metformin is not enough

Answer 4

sulfonylureas (as second agent)

if weight loss is desired or at risk for hypoglycemia, can use GLP-1 receptor agonist (exenatide)

Question 5

what are the side effects of sulfonylureas

Answer 5

weight gain and hypoglycemia

Question 6

what can be used if unable to tolerate metformin or sulfonylureas

Answer 6

pioglitazone

Question 7

side effects of pioglitazone

Answer 7

weight gain,

edema,

CHF,

bone fracture,

bladder cancer

Question 8

what is the benefit of pioglitazone

Answer 8

low risk of hypoglycemia when used alone or with metformin and can be used in RENAL insufficiency

Question 9

What are the benefits of using DPP4 inhibitors

Answer 9

low risk of hypoglycemia,

weight neutral

and can be used in renal insufficiency

only modest effective with average lower of 0.5% of A1c.

Question 10

What oral diabetic drugs can be used with renal insufficiency?

Answer 10

DPP4 inhibitors and pioglitazones (TZDs)

Question 11

What is the benefit with GLP-1 receptor agonist (exenatide)

Answer 11

can induce significant weight loss without risk of hypoglycemia (even if metformin is used).

can also be used a second agent if metformin is not enough

lowers A1c down to target

Question 12

exenatide, liraglutide, dulaglutide, semaglutide

Answer 12

GLP_1 receptor agonists - they should not be used with DDP-4 inhibitors.

benefit - loose significant weight

contraindicated against medullary thyroid cancer.

Question 13

Contraindications to starting a GLP-1 receptor agonist?

Answer 13

prior history of MEN2

thyroid cancer (medullary thyroid)

pancreatitis

this drug also can precipitate pancreatitis

Question 14

Diabetic drugs effects on weight:

Answer 14

drugs that cause weight loss: GLP-1 and metformin

drugs that are weight neutral: DPP4 inhibitors,

drugs that cause weight gain: sulfonylureas and pioglitazone

Question 15

how these diabetic medications work:

Answer 15

Mechanism of how GLP-1 and DPP4 inhibitors work. They should not be used at the same time in a diabetic pt.

Question 16

What diabetic drug may cause acquired gastroparesis?

Answer 16

GLP-1 agonists as they delay gastric emptying - exenatide, liraglutide or dulaglutide (trulicity),

Question 17

can hypoglycemia happen with SGLT2 inhibotors

Answer 17

Rarely an issue.

Question 18

Side effects of pioglitazone

Answer 18

weight gain (can be dramatic), edema, CHF and possible increased risk for bladder cancer and bone loss . Not used for diabetic prevention.

Question 19

Side effects of SGLT2 inhibitors

Answer 19

genitourinary infections (UTI and vulvovaginal candidasis)

fluid loss: symptomatic hypotension and AKI

metabolic abnormalities: hyperkalemia and hyperlipidemia and euglycemic DKA

Misc: low trauma fracture, increased risk for amputation

Question 20

If someone is started on SGLT2 inhibitor what do you do?

Answer 20

Need repeat BMP and adjustment of diuretics or those that affect RAAS (ACEi and ARBs) need to have this adjusted due to osomotic diuresis and hypotension and less renal perfusion.

Question 21

what to check periodically when a pt is on metformin?

Answer 21

Vitamin B 12 deficiency; metformin can reduce intestinal absorption by 30% and this is supposed be via impaired calcium depedent binding to intrinsic factor B12 complex to it’s receptor and so it decreases ileal absorption.

Seen with higher doses, older pts, and longer durations of treatment. Seen with neurological symptoms before anemia develops. Small amounts of B12 in daily vitamins are not protective.

Question 22

Antihyperglycemic therapy in type 2 diabetes

Answer 22

Question 23

Metformin and CKD

What level GFR should metformin not be initiated?

IF already on metformin, it be continued to WHAT GFR level?

Answer 23

Metformin should not be started if GFR<45

If already on metformin should be continued through 30-45

STOP metformin wonce GFR <30.

Question 24

when should insulin be started?

Answer 24

A1c>10% or glucose >300 or osmotic (polyuria or polydipsia) or catabolic symptoms of weight loss and urine ketosis should be considered.

People who did not achieve glycemic controls on 2 or 3 agents should be considered for insulin.

At time of insulin intiation, most oral agents should be stopped but meformin can be continued.

Question 25

Chart for non insulin antidiabetic agents for type 2 DM

Mechanism of action and side effects

Answer 25

Question 26

linagliptin is a

Answer 26

DPP4 inhibitor

it is oral med and cleared by the hepatobiliary system allows for excretion into the feces.No dose adjusments for pts who have CKD. (dose requirement is needed for other DDP4 inhibitors like sitagliptin and saxagliptin).

No risk for hypoglycemia. It’s less potent than other classes but adequate for CKD pts.

Question 27

elderly woman with CKD is at particular risk for —- when on glyburide and bactrim?

Answer 27

hypoglycemic episodes

Bactrim can attenuate effect of sulfonylureas and cause unexpected hypoglycemia in previously stable pts.

Question 28

Liraglutide is NOT FDA approved for

what it’s formulation?

Answer 28

not approved for concurrent use with insulin

It’s an injectable

Question 29

If someone has a mild A1c of 7.4 and wants to keep A1c<7 what do you check?

Answer 29

check post prandial glucose levels as this has a far greater role in elevating A1c when it is close to 7

Question 30

what medication to avoid if on sulfonylureas?

Answer 30

bactrim

because it can cause unexpected hypoglycemic pts and worse with CKD (as sulfonylureas can accumulate)