Diabetic drugs Flashcards
initial therapy for most diabetics
metformin
lactic acidosis as a life threatening complication
metformin
what is weight neutral and low risk of hypoglycemia
metformin and DPP4 inhibitors (sitagliptin or Januvia)
GLP-1 helps pts lose significant amount of weight.
what is added if metformin is not enough
sulfonylureas (as second agent)
if weight loss is desired or at risk for hypoglycemia, can use GLP-1 receptor agonist (exenatide)
what are the side effects of sulfonylureas
weight gain and hypoglycemia
what can be used if unable to tolerate metformin or sulfonylureas
pioglitazone
side effects of pioglitazone
weight gain,
edema,
CHF,
bone fracture,
bladder cancer
what is the benefit of pioglitazone
low risk of hypoglycemia when used alone or with metformin and can be used in RENAL insufficiency
What are the benefits of using DPP4 inhibitors
low risk of hypoglycemia,
weight neutral
and can be used in renal insufficiency
only modest effective with average lower of 0.5% of A1c.
What oral diabetic drugs can be used with renal insufficiency?
DPP4 inhibitors and pioglitazones (TZDs)
What is the benefit with GLP-1 receptor agonist (exenatide)
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
exenatide, liraglutide, dulaglutide, semaglutide
GLP_1 receptor agonists - they should not be used with DDP-4 inhibitors.
benefit - loose significant weight
contraindicated against medullary thyroid cancer.
Contraindications to starting a GLP-1 receptor agonist?
prior history of MEN2
thyroid cancer (medullary thyroid)
pancreatitis
this drug also can precipitate pancreatitis
Diabetic drugs effects on weight:
drugs that cause weight loss: GLP-1 and metformin
drugs that are weight neutral: DPP4 inhibitors,
drugs that cause weight gain: sulfonylureas and pioglitazone
how these diabetic medications work:
Mechanism of how GLP-1 and DPP4 inhibitors work. They should not be used at the same time in a diabetic pt.
What diabetic drug may cause acquired gastroparesis?
GLP-1 agonists as they delay gastric emptying - exenatide, liraglutide or dulaglutide (trulicity),
can hypoglycemia happen with SGLT2 inhibotors
Rarely an issue.
Side effects of pioglitazone
weight gain (can be dramatic), edema, CHF and possible increased risk for bladder cancer and bone loss . Not used for diabetic prevention.
Side effects of SGLT2 inhibitors
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
If someone is started on SGLT2 inhibitor what do you do?
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.
what to check periodically when a pt is on metformin?
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.
Antihyperglycemic therapy in type 2 diabetes
Metformin and CKD
What level GFR should metformin not be initiated?
IF already on metformin, it be continued to WHAT GFR level?
Metformin should not be started if GFR<45
If already on metformin should be continued through 30-45
STOP metformin wonce GFR <30.
when should insulin be started?
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.
