Diabetic medications Flashcards
Insulin Lispro
RAPID ACTING
Ex: Ademlog, Humalog, Lyumjev
- Given within 15 minutes before or 15 minutes after the person starts eating
- Onset is quick—15-30 minutes; peaks at 60-90 minutes; effective duration is about 3 hours
- Comes in 10 cc vials and prefilled and cartridge pens [cartridge pens are being phased out]
- Once opened, drug is good for 28 days
Insulin Aspart
RAPID ACTING
Ex: NovaLog, Fiasp
- Given within 15 minutes before or 15 minutes after the person starts eating
- Onset is quick—5-15 minutes; peaks at 60 minutes; effective duration is about 2 hours
- Comes in 10 cc vials and prefilled and cartridge pens [cartridge pens are being phased out]
- Once opened, drug is good for 28 days
Insulin Glulisine
RAPID ACTING
Ex: Apidra
- Given within 15 minutes before or 15 minutes after the person starts eating
- Onset is quick—5-30 minutes; peaks at 90-120 minutes; effective duration
is about 3 hours - Comes in 10 cc vials and prefilled SoloStar pen
- Can be refrigerated or stored at room temperature
- Once opened, drug is good for 28 days
3 rapid acting insulins
- lispro
- aspart
- glulisine
Regular Insulin
SHORT ACTING
Ex: Humulin R u-100, Humulin R u-500, Novolin R
- Both forms will begin to work in 30
minutes, but peak in 2-3 hours, and
duration of action is 6-12 hours—it
hangs around a long time… - Humulin R is made from nonpathogenic
E. coli and is zinc-insulin crystals
dissolved in a clear fluid—it is available
in U100 and U500 concentrations - expires 31 days after opened
Inhaled Insulin
SHORT ACTING
EX: Afrezza
Can be used in both types of DM [in those >18 years]—use with basal in the Type I diabetic
Insulin is delivered in microparticles; absorbed & eliminated more rapidly
Provides higher insulin levels with peak effects in about 2 hours
4-, 8- and 12-unit single use cartridges
Dosed beginning with largest meal
Interactions and side effects—same as regular insulin
Can affect lung function—contraindicated in COPD [risk acute bronchospasm]
Patient must have baseline PFTs, then repeated every 6- 12 months
Should not be used in smokers or in those with severe asthma
2 Short acting insulins
- regular
2. inhaled
Intermediate Acting Insulin and example
Ex: NPH
Only one formulation available in US
Formed by adding zinc and protamine to regular insulin
Used for basal in Type I or Type II diabetes—is usually given with rapid or short acting insulin to cover mealtime—it can only be given SQ—and it should never be used when rapid BS lowering in needed
Neutral Protamine Hagedorn [NPH]
- Manufactured as Novolin N or Humulin N
- Both are zinc suspension that includes
protamine - Both come in U100 concentrations and are
cloudy suspensions - NPH is made from noninfectious E. coli
- Comes in 10 cc vials and prefilled pens
- Onset of action—2 hours; peaks in 5-6 hours and duration of action is 12 hours
- should be room temp before injecting
- can be mixed with aspart, lispro, and glulisine
Long Acting insulin
Long-acting insulins are used for basal control and should only be given SQ—and they should not be mixed with any other insulin
Lantus is the prototype in the class
Long Acting insulin examples
- Glargine
- Detemir
- Degludec (ultra long acting
Insulin Glargine
LONG ACTING
EX: Basaglar, Lantus, ZSemglee, Toujeo
- The isoelectric point of insulin glargine is lower than that of human insulin leading to a formation of a precipitate at the injection stie that releases the insulin over an extended time—it has a slower onset than NPH, and a flat prolonged blood sugar lowering effect with no peak
- Available in 10 cc U100 vials and Solostar pen
- Onset of action in 2-3 hours; duration of near 24 hours
- No difference in absorption regardless of site used
Insulin Detemir
Long acting
- This insulin has a fatty acid chain that enhances association to albumin—slow dissociation from albumin results in long-
acting properties, much like that of insulin glargine - Used as basal insulin in both Type I and Type II diabetics
- Onset of action is 3-8 hours, no peak, and duration of 6-23 hours [depends on the dose]—usually given as a BID insulin
Insulin Degludec
Ultra long-acting insulin
Brand name is Tresiba
Duration of action is 42 hours; given SQ once per day any time of the day
Comes in U100 vial and FlexTouch pen; also comes in U200 FlexTouch pen
When converting from glargine or detemir—it is a 1:1 unit conversion—however, Triseba is about 70% as potent—so expect
to have to increase the dose over the first few weeks by 30%
Side effects of long acting insulin
The greatest risk is low BS—s/sx include headache, anxiety, tachycardia, confusion, vertigo, sweating, shakiness, increased appetite, blurred vision, weakness/fatigue
standard insulin treatment
injections twice a day
intensive insulin treatment
3 or more injections per day
- But those on intensive therapy have less
retinopathy, nephropathy and neuropathy
- But intensive therapy is not for everyone—
those with long-standing disease, those with
significant microvascular complications,
those with advanced age and those with
hypoglycemic unawareness should not be
on intensive treatment regimens
Synthetic Amylin Analogs
Amylin is a hormone that is co-secreted with insulin from the beta cells after food is eaten
Amylin delays gastric emptying, decreases
postprandial glucagon secretion and improvessatiety—its production is decreased in diabetes
Amylin, GLP-1 and DPP-4 are a group of endocrine hormones referred to an incretins
Incretin Hormones—GIP and GLP-1
GLP-1 secreted from L cells in the small intestine
- Stimulated by oral nutrients
- Stimulates insulin secretion
- Suppresses secretion of glucagon
- Slows gastric emptying; reduces food intake & promotes weight loss
➢ In Type 2 diabetes, they lack the glucose lowering response; circulating levels of postprandial GLP-1 are deficient
Incretin Hormones- Pramlintide [Symlin]
Approved by FDA in 2005, a synthetic amylin analogue that is indicated as an add on to mealtime insulin therapy in those with Type I or Type II DM It is given SQ right before meals When started—the dose of mealtime insulin should be decreased by 50% to avoid severe low BS
Side effects: Pramlintide [Symlin]
ADEs—nausea, anorexia, vomiting, dizziness, pharyngitis
Avoid in those with gastroparesis or hypoglycemic unawareness
It can potentially cause weight loss—as it slows gastric emptying, and effect that last for about 3 hours after each dose—it reduces the initial postprandial increase
in BS, but does not alter the absorption of CHOs, fats or other nutrients
Primary Action of Amylin
Regulates rate of gastric emptying
Regulates hypersecretion of postprandial glucagon
Promotes reduction of food intake
Primary Action of GLP-1 (Glucagon-like peptide)
Stimulate glucose-dependent insulin
secretion
Regulates rate of gastric emptying
Regulates hypersecretion of
postprandial glucagon
Promotes reduction of food intake
Inhibits gastric acid secretion
Primary Action of GIP (gastric inhibitory peptide)
Stimulate glucose-dependent insulin
secretion
Inhibits gastric acid secretion
Examples of GLP- 1 Agonists examples
Aligulutie (Tanzeum)
Dulaglutide(Trulicity)
Lixisenatie (Adlxin)
MOA GLP-1 agonists
These drugs exert their activity by improving glucosedependent insulin secretion, slowing gastric emptying time, reducing food intake as they increase satiety, decrease the postprandial glucagon secretion and promoting beta cell proliferation
Postprandial elevated BS is reduced; weight is reduced; and weight loss occurs
Pharmacokinetics GLP-1 agonists
- Most are given SQ as they are polypeptides
Abiglutide, Dulaglutide and Semaglutide are given SQ weekly - Liraglutide is given SQ once daily
- Lixisenatide is also given SQ daily, but is considered a short acting agent, as is
- Exenatide—which is given SQ twice daily
• Semaglutide comes in a short-acting oral form - Exenatide does come in an ER form—that is given once weekly
• Exenatide should not be used in those with renal impairment
ADEs of GLP-1 Agonists
Nausea, vomiting, diarrhea, constipation [constipation is very common]
Prototype drug has been associated with pancreatitis—so do not prescribe to those who have a history of pancreatitis
In the animal trials, there was an association with thyroid C-cell
cancers, so do not prescribe to those with history of medullary
thyroid cancer or multiple endocrine neoplasia type II
Exenatide— Prototype Drug
- First GLP-1 analog FDA approved [2005], but not usedas often as some of the newer agents, as the CV data are not as compelling
- Exenatide enhances insulin secretion by pancreatic beta cells, slows gastric emptying, and suppresses glucagon secretion—it binds to and activates GLP-1
receptor, which increases synthesis and secretion of insulin
onset: 30 minutes
duration: 10 hrs
SE: n/diarrhea/constipation/dizziness/headache/dyspepsia
DO NOT USE IN RENAL DISEASE, HX PANCREATITIS, USE CAUTION IN THOSE WITH SEVERE GASTROPARESIS
Liraglutide-antidiabetic RX
GLP 1 agonist
- helping the pancreas to release the right amount of insulin when blood sugar levels are high.
- It is a long-acting GLP-1 agonist with the same MOA as Exenatide—branded as Victoza
- Like Exenatide, is causes weight loss—and in high dose [as Saxenda] it is approved as a weight loss agent
- Also thought to improve beta cell function and rejuvenation
- Has FDA labeling—shown to reduce CV events i nadults
Peak 8-12 hrs and 1/2 life is 13 hours - High dose Liraglutide—3 mg SQ daily is approved for adults and children aged 12 and older for
long-term treatment of obesity in non-diabetics
DO NOT USE IN PREGNANCY
Albiglutide (Tanzeum) GLP -1 AGONIST
Another once per week GLP-1— but did not capture a large market share, so production in the US halted—and no longer available here
Dulaglutide (Trulicity) GLP 1 agonist
- for DM II
- no for pregnancy
- subQ one a week
Lixisenatide (Adlyxn) GLP 1 agonist
- for adults
- do not use with GFR <15
- only agent in family without a BB for medullary thyroid cancer in Men
- subQ after 1st meal of day within 1 hour
Semaglutie (Ozempic-injection) (Rybelsus-PO) GLP 1 agonist
–SQ weekly for DM II
- nausea big SE
-caution with those with retinopathy
-When added to Metformin, 14 mg
of oral Semaglutide (oral) lowered A1C
more than did adding a SGLT2
agent
Candidate for sulfonylureas
Type II diabetic without severe dyslipidemia
Diabetic of normal weight
Diabetic having elevated BS, in spite of meal planning and exercise
Patient who is willing and able to follow LSM
Has had disease <5 years
Older than age 30
MOA of sulfonylureas
- Stimulate insulin release from the beta cells of the pancreas
- May reduce hepatic glucose production and increase peripheral insulin sensitivity
- will lower A1C by about 1%
Pharmacokinetics of sulfonylureas
-Given orally, these agents bind to serum
proteins, are metabolized by the liver, and areexcreted in the urine and feces
-Duration of action is from 12-24 hours
ADEs of sulfonylureas
- Hypoglycemia and weight gain
- Hyperinsulinemia
- Use with caution in renal and liver disease
-Glipizide or Glimepiride are better
options in older adults and in those with
renal disease
First Generation Sulfonylureas
- Tolbutamide is dosed at 500-3000 mg per day in divided doses
- Onset of action is 1 hour; ½ life is 6-8 hours; duration of action is 12-18 hours
- Metabolized in the liver and excreted via the renal system
- Again, difficult to find, as it is not prescribed often in the US
Second generation sulfonylureas: GLYBURIDE - prototype
With the regular preparation, start with 2.5-5 mg per day, which can be increased weekly up to 20 mg/day
With the micronized preparation, start with 1.5-3 mg per day, which can be titrated up weekly up to 12 mg/day
Onset of action in 90 minutes, with maximum effect seen in 60 minutes; ½ life is 10 hours [regardless of the preparation]; duration of action is 12-24 hours [micronized] or 16-24 hours [nonmicronized]
Not approved for use in children; it does cross the placenta, so use caution in women of childbearing age
Glimepiride-sulfonylureas
-Prescribed in 1-4 mg per day; with a maximum dose of 8 mg per day
=Taken with breakfast [or 1st meal of the day
-Onset of action is 2-3 hours; ½ life is 5-9 hours; maximum effect is seen in 2-6 hours; duration of action is 24 hours
-Can be used in children aged 8 years and older
-Also crosses placenta, so use caution in women of child-bearing age
Glipizide -sulfonylureas
Start at 2.5 mg; can be titrated up to 40 mg per day for standard preparation or 20 mg per day of the extended-release preparation
•Standard preparation is prescribed 3 times per day
•ER preparation is taken once per day
Onset of action for both preparations is 3.5-6 hours; maximum effect is obtained within 1 hour; duration of action if 12-24 hours; ½ life is 2-5 hours
Not approved for use in children; does cross the placenta and can affect a fetus
SEs of sulfonylureas
- Low blood sugar and weight gain
- Less common ADEs—skin rash, GI disturbances
- Use care when treating malnourished, debilitated and older adults—as these groups are particular risk for hypoglycemia
Timing of Sulfonylureas
- Most sulfonylureas should be taken with
breakfast or with the first main meal of the
day to obtain the maximum effect and
safety - Patients on this type of medication should
carry a rapid-acting glucose source—such
as tablets or gel, in order to swiftly treat
hypoglycemia—at the initial signs of low BS - Advise these patient regarding safe use of
alcohol—it lowers BS
Examples of Sulfonylureas
- Glyburide
- Glimepiride
- Glipizide
Drugs that my potentiate the effects of sulfonylureas leading to hypoglycemia
- azole antifungals
- B blockers
- chlorampheimcol
- clarithromycin
- monoamine oxidase inhibitors
- probenecid
- salicylates
- sulfonamides
Nonsulfonylurea Secretagogues
It inhibits the amount of glucose produced by the liver, increases the insulin-receptor binding and stimulates tissue uptake of glucose.
Candidate for Nonsulfonylurea Secretagogues
a Type II diabetic, for which LSM alone or in combination with another agent has not obtained normoglycemia
**These agents are not for use in Type I diabetes,ketoacidosis, severe infections, surgical or trauma patients
MOA of Nonsulfonylurea Secretagogues—
Short-acting insulin secretagogues
Stimulate insulin release rapidly and have a short duration of action
Very effective in the early release of insulin that occurs after a meal—they are known as
postprandial glucose regulators
Should NOT be used with sulfonylureas
Pharmacokinetics of Nonsulfonylurea Secretagogues—
Taken prior to a meal; are well metabolized after oral administration
If the patient is not going to consume 70 grams of CHO with the meal—the
drug should be skipped
ADEs of Nonsulfonylurea Secretagogues—
Hypoglycemia and weight gain—but to a lesser degree than do sulfonylureas
Do NOT prescribe Gemfibrozil with the agents—can markedly increase their effects
Use with caution in those with
liver disease
Repaglinide—Prototype
Nonsulfonylurea Secretagogues
-Closes ATP dependent K+ channels in the beta cell membrane, which
depolarizes the beta cell and leads to opening of calcium channels—
resulting in increased Ca++ influx causing insulin secretion
-Action of this agent is highly tissue selective, with low affinity for heart
and skeletal muscle
-Best results occur when drug is taken within 15-30 minutes of a meal—
leading to greater insulin release during the 1st phase
- Onset of action is 15-60 minutes; ½ life is 1 hour; duration 4 hours
- It is excreted in the feces
- Can be used as monotherapy or with Metformin, TZD or both
Nonsulfonylurea Secretagogues-Natelinide
Rapid acting amino-acid derivative known as Dphenylalanine
MOA is similar to the prototype
Like Repaglinide, the extent of insulin release is glucose dependent—and it diminishes with low glucose levels
Rapidly absorbed after oral ingestion—onset is within 20 minutes; ½ life is 90 minutes; duration of action 4 hours
Like the prototype, it is excreted in the feces; can be used alone, with Metformin or TZD or both
- not safe for pregnancy
-SEs:bronchitis, rhinitis, nausea,
vomiting, diarrhea or constipation, headache, chest pain, UTI, back pain, dizziness
Nonsulfonylurea Secretagogues
Biguanides
Considered an insulin sensitizer
Metformin increases glucose uptake and use bytarget tissues, thereby decreasing insulin secretion
Also used in the treatment of PCOS
MOA of Biguanides
Reduces hepatic gluconeogenesis—the liver is a major source of high BS in Type II DM, accounting for high fasting BS
Metformin slows intestinal absorption of sugars and improves peripheral glucose uptake and utilization
Weight loss can occur as it causes loss of appetite
The drug does not cause low BS—unless the patient is taking insulin or another secretagogue
Pharmacokinetics of Biguanides
Well absorbed after oral ingestion, is not bound toserum proteins, and is not
metabolized
Excreted via the urine
ADEs of Biguanides
Mainly GI—diarrhea, nausea, vomiting
These ADEs can be muted by slow titration—and use of the ER version of the drug, which causes far fewer GI SE
Should be taken with food to reduce ADEs
Metallic taste—when initiating
Contraindicated in renal dysfunction—due to risk of lactic acidosis
When should you hold Biguanides?
Procedures requiring IV contrast
What is long term Biguanides associated with\
What is long term Biguanides associated with
Biguanides:
METFORMIN what does it do?
- Preferred 1st line agent in those with Type II DM—it lowers both basal and
postprandial glucoses and improves glucose tolerance - Metformin inhibits hepatic glucose production and intestinal absorption of
glucose; it also increases peripheral glucose uptake and utilization - It does not cause elevated insulin levels
- Again, it causes weight loss—and it is associated with a lower risk of CV
events in diabetics with reduced renal function—compared to sulfonylureas
Candidates for metformin
The ideal candidate has Type II DM, is obese, has dyslipidemia and has elevated BS
It is approved for adults and children aged 10 and older; it can be used in pregnancy
Metformin (Biguanides)
The drug should always be started with the evening meal and titrated upwards—it is most often given in 2 divided doses
Onset of action is within days, but peak effect is within 4 hours
[for both SA and ER formulations]
Duration of action is 6 hours for the SA and 24 hours for the ER
½ life of both formulations is 4-9 hours
Not metabolized by the liver; renal tubular secretion is route of
elimination
Metformin Extended Release
This drug—same compound, but with a different release mechanism, that essentially prevents most of the GI side effects
Currently, it is priced the same as the SA
formulation—and is preferred—as it allows for titration up to the 2000 mg per day dosing that is needed for full therapeutic effect
At this dosing—A1C reduction is 1-1.5%
ER product is ALWAYS preferred—it is dosed the same as the SA
product—no difference in efficacy—but unlikely to reach full therapeutic dose with SA formula—as the GI SE are dose dependent and do not abate with duration of use of the SA formula
Will LOWER cholesterol, triglycerides and LDL and causes weight loss in
most
With Metformin, watch for…
- Hold for situations that cause dehydration—as this predisposes the patient to lactic acidosis [acute illness, gastroenteritis, NPO for procedures, etc.]
- Hold for 48 hours after radiology testing that utilized iodinated contrast
- This drug is contraindicated in men with creatinine 1.5 mg/dL or greater and women with creatinine of 1.4 mg/dL or more
- Should not be started in those with creatinine clearance <46 cc/min;
and in those on the drug, if the creatinine clearance falls to <30 cc/min, the drug must be stopped - Calculate eGFR before starting the drug—do not start if this value is between 30-45 cc/minute
- Check creatinine and calculate eGFR annually in all patients on Metformin—more frequently in those at risk, such as the older adult
- In those on the drug—assess the risk/benefit ratio if the eGFR falls below 46 cc/minute to decide upon continuation—but stop when eGFR is 30 cc/minute or less
- At risk patients—those with liver dysfunction; those with a history of alcohol abuse or binge drinking; those with COPD or unstable HF should not receive Metformin due to lactate accumulation in these
hypoxic states - Lactic acidosis—rare—but deadly
Thiazolidinediones
-Pioglitazone—Actos [not really the prototype—but only agent left on
the market in US that is prescribed commonly in the class]
- Rosiglitazone—Avandia [rarely prescribed, and usually only by endo in the US—b/c of increased risk of MI and angina with this agent]
- Drugs in this class are also considered insulin sensitizers
- Insulin is required for their action—TZDs do not promote insulin release
These agents do not cause hypoglycemia These agents reduce BS, insulin levels and triglyceride levels There is increased responsiveness of insulin-dependent tissues Can be used as monotherapy or with Metformin, a SU, a secretagogue and/or insulin
MOA of Thiazolidinediones—also known as TZDs
Decrease insulin resistance by acting as an agonist for peroxisome proliferator-activated receptor gamma [PPARγ]—a nuclear receptor
Activating PPARγ causes increased insulin sensitivity in adipose tissues, liver and skeletal muscles
These are 2nd or 3rd line agents that can lower A1C about 1%
Pharmacokinetics of Thiazolidinediones—also known as TZDs
Well absorbed after oral administration
Extensively bound to serum albumin
ADEs of Thiazolidinediones—also known as TZDs
- Liver toxicity—but rare
- Baseline and periodic management of LFTs is required
- Weight gain—these drugs increase SQ fat
and they cause fluid retention - Should not be used in those with HF
- Osteopenia and increased fracture in
women - Increased risk of bladder cancer with Actos
Thiazolidinediones : Pioglitazone
- Approved for adults and children >15 years with Type II diabetes; avoid in pregnancy
- Contraindicated in—active liver disease or ALT levels greater than 2.5 times ULN; NYH class III or class IV HF [BB warning]; jaundice; Type I diabetes; DKA
- Onset of action is not known; peak effect is in 2 hours [this is delayed by food]; ½ life is 16-24 hours
- Excreted into the bile unchanged and eliminated in the feces
With Pioglitazone watch for…
Weight gain
Increased total cholesterol
Fluid retention; headache; arthralgias; back pain; nausea and diarrhea
Atorvastatin—can decrease effectiveness of both Atorvastatin and Actos
Actos reduces effectiveness of OCP
Ketoconazole inhibits the breakdown of Actos
Change—elevation of LFTs
Alpha-Glucosidase Inhibitors
- Acarbose—Precose—prototype
- Miglitol—Glyset
- Ideal candidate for one of these drugs is a Type II diabetic who is obese, has dyslipidemia and postprandial hyperglycemia
- These drugs reduce insulinotropic and weight increasing effects of
SU
MOA Alpha-Glucosidase Inhibitors
Located in the brush border of the intestine—alpha-glucosidase enzymes breakdown CHO into glucose and other simple sugars that can be absorbed
- These drugs reversibly inhibit alpha-glucosidase enzymes—thus
delaying the digesting of CHOs leading to lower postprandial BS levels - Taken at the start of a meal; these drugs do not cause hypoglycemia
[unless used with insulin or a secretagogue—and remember if low BS were to occur in this scenario—must use glucose—NOT sucrose [as its breakdown is inhibited by these drugs]
Pharmacokinetics of Alpha-Glucosidase Inhibitors
Acarbose poorly absorbed—excreted in the urine
- Miglitol is very well absorbed—but no systemic effects—excreted unchanged by the kidney
- In the US, these drugs lower A1C by .5% —while in other countries— where these agents are used more commonly, lower A1C by 1%
ADEs of Alpha-Glucosidase Inhibitors
Flatulence, diarrhea, abdominal cramping
These limit the use of these agents in the US
Do not use in those with inflammatory bowel disease, colonic ulceration or intestinal obstruction, cirrhosis, creatine levels of >2 mg
Avoid use in pregnancy or lactation
Alpha-Glucosidase Inhibitors –Acarbose
-prototype
Taken right before each meal
Onset of action is immediate; peaks in 1 hour; duration is near 6 hours; ½ life of the drug is 2 hours
Alpha-Glucosidase Inhibitors–Miglitol
- take before each meal
- rapid onset of action; peaks in 2 hours; `` of action is near 4 hours
Effects of these drugs are altered by
charcoal products
These drugs reduce bioavailability of
Ranitidine, Propranolol and Digoxin
These drugs reduce the efficacy of—
CCBs, corticosteroids, estrogens, INH,
nicotinic acid, Phenytoin [and its
derivatives], thiazides
iming considerations of Alpha-Glucosidase Inhibitors
Must take—essentially, with the first bite of food with each meal
If the patient is on insulin or a SU and one of these agents—and low BS occurs—treat with simple sugar sources—glucose tablets or gels—they should always have these on hand if the patient is on a secretagogue and an alpha-glucosidase inhibitor
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]—also known as Gliptins
These agents slow the inactivation of incretin hormones
Examples of Dipeptidyl Peptidase-4 Inhibitors
Sitagliptin—Januvia [prototype]
Saxagliptin—Onglyza
Linagliptin—Tradjenta
Alogliptin—Nesina
MOA Dipeptidyl Peptidase-4 Inhibitors
Well absorbed after oral administration
Alogliptin and Sitagliptin are excreted unchanged in the urine
Linagliptin eliminated by enterohepatic system
Saxagliptin metabolized by CYP450-3A4/5 to an active metabolite; metabolite is excreted renally
All gliptins except Linagliptin [Tradjenta] require dose adjustments for renal disease
ADEs of Dipeptidyl Peptidase-4 Inhibitors
Generally, well tolerated
Can cause nasopharyngitis, headache and pancreatitis, severe joint pain
Alogliptin and Saxagliptin have been shown to increase the risk of
HF hospitalizations
Do not use in those with HF or at risk for such; do not use in those with a history of pancreatitis; not to be used in pregnancy or in children
Pharmacokinetics of Dipeptidyl Peptidase-4 Inhibitors
Well absorbed after oral administration
Alogliptin and Sitagliptin are excreted unchanged in the urine
Linagliptin eliminated by enterohepatic system
Saxagliptin metabolized by CYP450-3A4/5 to an active metabolite; metabolite is excreted renally
All gliptins except Linagliptin [Tradjenta] require dose adjustments for renal disease
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
SITAGLIPTIN (PROTYPE)
Given once per day at 100 mg per day; if eGFR is 30-50 cc/minute, the dose is 50 mg per day; and if eGFR is <30 cc/minute the dose is 25 mg per day
Rapidly absorbed, with peak action in 1-4 hours; duration of action is 24 hours; ½ life is 12 hours
Most common side effects are nasopharyngitis or URI; headache;
abdominal pain; diarrhea or nausea
Severe necrotizing pancreatitis has been reported—this agent is thought to double the risk of developing pancreatitis for all who take it
- precanerous cellular changes of the pancreas
- pancreatitis
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
Saxagliptin
Dosed as 5 mg per day; 2.5 mg dose is used in those with moderate-severe renal disease
Peaks in 2 hours; duration of action is 24 hours; metabolized hepatically
Common SE and ADEs are the same as the prototype
Latest FDA safety review found that this agent can increase the risk of HF, particularly in those with CV or renal disease
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
Linagliptin
Approved by FDA in 2011
If given with a secretagogue, the dose of the secretagogue should be reduced—to prevent low BS
Rapidly absorbed after oral administration—onset of action 90 minutes; duration of action is 24 hours
No dosage change in liver or renal disease
Common SE and ADEs same as prototype
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
Alogliptin
-Approved by FDA in 2013—given once daily
as a 25 mg tablet or 12.5 mg if the patient
has renal disease
- Common SE and ADEs are the same as the
prototype
- In 2016, FDA found that this agent may
increase the risk of HF in diabetics with heart or renal disease
Timing considerations of Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
These agents can be taken any time during the day—regardless of food intake
Sodium-Glucose Cotransporter 2
Inhibitors [SGLT2 Inhibitors]—also known as Flozins
Approved by FDA in 2014, these agents inhibit sodiumglucose transporter-2 in the proximal renal tubules, which
decreases resorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose
Examples of Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Canagliflozin—Invokana [prototype]
Dapagliflozin—Farxiga
Empagliflozin—Jardiance
Ertugliflozin—Steglatro
MOA Sodium-Glucose Cotransporter 2
Inhibitors aka Flozins
By inhibiting SGLT2, these drugs decrease the resorption of glucose, increase urinary glucose excretion and lower BS
Inhibition of SGLT2 also decreases resorption of sodium and causes
osmotic diuresis—in some this will lower blood pressure
Approved for adults; should avoid in pregnancy
Will lower A1C 1%
Pharmacokinetics Sodium-Glucose Cotransporter 2 Inhibitors aka Flozins
- Given once daily in the morning
- Canagliflozin should be taken before the first meal of the day
- All are metabolized by glucuronidation to inactive metabolites
- Avoid these drugs in those with renal disease, history of UTIs or at risk
of them [those with renal stones, neurogenic bladder and BPH]
ADEs of Sodium-Glucose Cotransporter 2 Inhibitors aka Flozins
Genital mycotic infections, severe UTIs, urinary frequency, low blood pressure in older patients and in those on diuretics, ketoacidosis without elevated BS,
Fournier’s gangrene**, increased risk of LE
amputation*, bone fractures, acute kidney injury, electrolyte abnormalities
**should NOT use this family of drugs in patients who have decreased arterial
flow below the femoral vessels [as assessed by poor or absent pulses]
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Canagliflozin—Invokana [prototype]
100 or 300 mg tablets
Take before 1st meal of the day; use 100 mg per day if
eGFR <60 cc/minute
Do not use in eGFR <30 cc/minute; do not use in severe liver disease
Highest risk of LE amputation with this SGLT2 inhibitor
Some beneficial effects for risk reduction of CV events in diabetics with CV disease and progression of renal disease to ESRD
Hold for 3 days before procedures and surgery
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Dapagliflozin—Farxiga 10 and 25 mg tablets
10 and 25 mg tablets
Once a day in the AM—with or without food
Do not give if eGFR is <45 cc/minute
Robust data for prevention of hospitalization from HF in those
with risk factors or those with a HF diagnosis—diabetic and nondiabetic
Evaluate volume status before initiating; stop for 3 days before surgery and procedures that could cause
dehydration and alcohol abuse—all of these scenarios predispose the diabetic to ketoacidosis without an elevated
blood sugar
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Empagliflozin—Jardiance
- 5 and 10 mg tablets
- Once a day in the AM—with or without food
- Do not give if eGFR is <45 cc/minute
- Strong data for reduced risk of adverse CV events—including death in diabetics with CV
disease - Evaluate volume status before initiating; stop for 3 days before surgery and proceduresm that could cause dehydration and alcohol abuse—all of these scenarios predispose them diabetic to ketoacidosis without an elevated blood sugar
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Ertugliflozin—Steglatro
5 and 15 mg tablets
Once a day in the AM—with or without food
Do not give if eGFR is <60 cc/minute
No specific data for cardiovascular, renal or HF risk reduction for this agent, at this time
Evaluate volume status before initiating; stop for 3 days before surgery and procedures that could cause
dehydration and alcohol abuse—all of these scenarios predispose the diabetic to ketoacidosis without an elevated
blood sugar
With Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—watch for..
Elevated potassium
Renal insufficiency [from the diuretic effect]
Ketoacidosis with BS < 250 mg/dL [yes, ketoacidosis in Type II diabetic—which is not something that is seen—and true mechanism is not well understood]
Severe UTIs
Genital yeast infections
Bromocriptine—Cycloset
Ergot derivative that stimulates the dopamine receptors—MOA in diabetes is unknown
Start with 0.8 mg each AM with food; increase by 0.8 mg per week [diabetic dose is 1.6 – 4.8 mg per day]
Contraindications—syncope, migraines, pregnancy, lactation, psychosis
Common side effects—GI upset, nausea, headache, orthostatic
hypotension
Sulfyonylureas
- glimepiride
- glipizide
- glyburide
MOA: stimulates insulin secretion
Effect on plasma insulin: increases
Risk of Hypoglycemia: yes
Comments: well established hx of effectiveness. Weight gain can occur. Hypoglycemia most common with this class of oral agents
GLINIDES
- Nateglinide
- Repaglinide
MOA: stimulates insulin secretion
Effect on Plasma Insulin: increase
Risk of Hypoglycemia: yes (rare)
Comments: taken with meals. short action with less hypoglycemia. postprandial effect.
BIGUANIDES
1. Metformin
MOA: decrease hepatic production of glucose
Effect on Plasma Insulin: decrease
Risk of Hypoglycemia: no
Comments: preferred agent for type 2 DM. well est. hx of effectivness. weight loss my occur. Monitor renal function and Vit B12 levels.
THIAZOLIDNESDIONES
- Pioglitazone
- Rosiglitazone
MOA: binds to peroxisome proliferator-activated receptor in muscle, fat, and liver to decrease insulin resistance
Effect on Plasma Insulin: decrease
Risk of Hypoglycemia: no
Comments: Effective i highly insulin-resistant patients. Once daily dosing for pioglitazone. Check liver function before initiation. Avoid in liver disease or heart failure.
⍺ Glucosidase Inhibitors
- Acarbose
- Miglitol
MOA: decease glucose absorption
Effect on Plasma Insulin: same
Risk of Hypoglycemia: No
Comments: taken with meals. Adverse gastrointestinal effects. Not a preferred therapy. .Reserve for pts unablet o tolerate other agents.
DPP 4 inhibitors 1 . Alogliptin 2. Linagliptin 3. Sitagliptin 4. Saxaogliptin
MOA: increase glucose dependent insulin insulin release; decrease secretion of glucagon
Effect on Plasma Insulin: increase
Risk of Hypoglycemia: no
Comments: once daily dosing. may be taken with or without food. Well tolerated. Risk of pancreatitis.
SGLT2 inhibitors
- Canagliflozin
- Dapagliflozin
- Dmpagliflozin
- Ertugliflozin
MOA: increase urinary glucose secretion
Effect on Plasma Insulin: same
Risk of Hypoglycemia: no
Comments: once daily dosing in the morning. Risk of hypotension, genitourinary infections. Avoid in severe renal impairment. Empagliflozin is approved to reduce cardiovascular evens in pts with DM II
GLP-1 receptor agonist
- Albiglutide
- Dulaglutide
- Exenatide
- Liraglutide
- Lixisenatide
- Semaglutide
MOA: increase glucose-dependent insulin release; decrease secretion of glucagon; slows gastric emptying; increase satiety
Effect on Plasma Insulin: increase
Risk of Hypoglycemia: no
Comments: Injection formulation. Liraglutide and Lixisenatide are dose once daily. Albiglutide, dulaglutide, and semaglutdie are dosed once weekly.
Liraglutide is approved to reduce cardiovascular events in pts with DM II
Weight loss my occur. Risk of pancreatitis.
Advantage and Disadvantage of
METFORMIN
AD: Weight neutral No hypoglycemia Improve lipids Dec micro-macro risks Dec hyperinsulinemia
DISAD: Number of contraindications Adverse GI effects Rarely, lactic acidosis B12 deficiency
Advantage and Disadvantage SULFONYLUREAS
AD:
Convenient dosing
Inexpensive
Well-established efficacy
DISAD:
Hypoglycemia
Weight gain
Advantage and Disadvantage
TZDs
AD: No hypoglycemia Improved lipids Improved endothelial function Increased fibrinolysis Convenient dosing
DISAD: Inc risk for CHF Edema Weight gain Liver function monitoring Other adverse effects
Advantage and Disadvantage
GLINIDES
AD: Short duration of action Low incidence of hypoglycemia Less wt gain than SUs
DISAD:
Frequent dosing
Expensive
Advantage and Disadvantage
ALPHA GLUCOSIDASE INHIBITORS
AD: No weight gain Targets PP glycemia No hypoglycemia Nonsystemic
DISAD:
Frequent GI adverse effects
Frequent dosing
Expensive
Advantage and Disadvantage
DPP-4 INHIBITORS
AD:
Low rate of Adv effects
Convenient dosing
No weight gain
DISAD:
Minimal reduction in A1C
Pancreatitis risk
Expensive
Advantage and Disadvantage
GLP-1 AGONIST
AD:
Weight loss
DISAD: Injections Slight risk of pancreatitis GI adverse effects Expensive
Herbs that can lower CBG
Aloe Vera, Ginseng, Ginger, Turmeric
Bilberry, Cinnamon Bark, Milk Thistle
Kudzu, Blond Psyllium
Herbs that can increase CBG
Ma Huang
Licorice
Rosemary
• If ASCVD predominates—
reach for a GLP-1 agonist; best evidence is for Liraglutide, Semaglutide or ER Exenatide [in order of strongest to weakest
evidence]
• If HF or chronic kidney disease predominates
reach for SGLT2 inhibitor; best evidence is for Dapagliflozin, Empagliflozin or Canagliflozin [in order of strongest to weakest]
General considerations for prescribing antidiabetic meds
- If the patient does not have established ASCVD, HF or renal disease, the
recommendations are driven by factors such as weight gain, risk of low BS or cost - If hypoglycemia prevention is the most compelling concern—then add a
GLP-1 agonist, or an SGLT2 inhibitor, a TZD or a DPP-4 inhibitor - If you need the patient to lose weight—then go to the GLP-1 agonist,
followed by a SGLT2 inhibitor—as both of these cause weight loss - If cost is a large issue—then the next agent to add is
a SU or a TZD
Insulin Therapy Updates—Consider GLP-1
Agonists before Insulin in Type II Diabetes
Most recent diabetic standards recommend that most patients with Type II diabetes who continue tohave elevated A1C in spite treatment with 2 or 3 drugs—should receive a GLP-1 agonist BEFORE insulin
GLP-1s are as good or better than insulin at lowering A1C, they cause weight loss and do not cause low BS
Insulin, of course, is still used without a trial of a GLP-1 agonist in Type I diabetes and in the Type II diabetics with A1C values >11%
Insulin can also be used in Type II diabetes already on a GLP-1 who are still not controlled [insulin is added]; those
who cannot take a GLP-1 and for those who prefer insulin over a GLP-1
