DM Medications Flashcards
Pramlinitide (Symlin®) MOA
↓ glucagon secretion
↑ Satiety (↓ appetite)
↓ gastric emptying
Excretion: Most all in the urine
Pramlinitide (Symlin®) side effects
Nausea (28-48% )
Anorexia (9-17%)
HA (13%)
Vomiting (8-11% )
Abdominal pain
Fatigue
Arthralgias
Pramilmitide BBW
increased risk of insulin-induced severe
hypoglycemia, particularly in patients with type 1
diabetes
Pramlinitide (Symlin®) practice PEARLS
Give any oral drugs requiring rapid
GI absorption 1 hr before injection
or 2 hrs after meal
Metformin (Glucophage®) MOA
↓ intestinal absorption of glucose
↓ hepatic gluconeogenesis
↑ insulin sensitivity in peripheral tissues
Excretion: 90% in the urine, 10% feces
Additional benefit of Metformin
↓ serum LDL
↑ fatty acid oxidation
Does not ↑ insulin secretion,
hypoglycemia, or weight gain
Contraindications of Metformin
- Acute or chronic metabolic acidosis including diabetic ketoacidosis
- Hypersensitivity to metformin
- Severe renal impairment: eGFR below 30 mL/min/1.73 m(2)
Metformin (Glucophage®) side effects
Diarrhea (10-53%)
Nausea/vomiting (7-26%)
Flatulence (12%)
Monitoring & Follow-up for metformin
Creatinine at baseline, then annually
Metformin practice PEARLS
Start low & titrate up, Push through the nausea
DPP-4 inhibitors
Sitagliptin (Januvia®)
Saxagliptin (Onglyza®)
Linagliptin (Tradjenta®)
Alogliptin (Nesina®)
DPP-4 inhibitors MOA
- DPP-4 enzyme brakes down GLP-1
naturally - Inhibition allows GLP-1 longer action
- Slows incretin metabolism
- ↑ insulin synthesis & release
- ↓ glucagon levels
- Excretion: 75% urine, 22% feces
Common side effects of DPP-4 Inhibitors
- URI (5%)
- HA (1-6%)
- Hypoglycemia (.5-12%)
- UTI
- Vomiting
- Abdominal pain
- Gastroenteritis
Practice PEARLS for DPP-4 inhibitors
- Report severe abdominal pain &
discontinue - Report severe joint pain
- Report stress, such as fever,
trauma, infection, or surgery,
that may require medication
dosage adjustments
GLP-1 Agonists
Exenatide (Byetta®) (Twice daily)
Exenatide (Bydureon®) (weekly)
Liraglutide (Victoza®, Saxenda®) (Daily)
Dulaglutide (Trulicity®) (weekly)
Semaglutide (Ozempic®, Wegovy) (weekly)
Semaglutide (Rybelsus®) (oral daily)
Lixisenatide (Adlyxin®) (daily)
GLP-1 Agonists MOA
↑ Insulin secretion
↓ Glucagon secretion
Delays gastric emptying
↓ liver gluconeogenesis
↑ satiety
Excretion: Most all in the urine
Common side effects with GLP-1 Agonists
Nausea
Practice PEARLS for GLP-1 Agonists
- Avoid dehydration
- Report S/S of a thyroid tumor,
cholelithiasis, or pancreatitis - Monitor for hypoglycemia
& report difficulties with
glycemic control
Tirzepatide (Mounjaro®) is a _____
New Class: GLP-1 RA, GIP
How is Tirzepatide different from the original GLP-1 agonists?
- Superior to 1-mg semaglutide for ↓
HbA1c & body weight in DMII
Tirzepatide acts in two ways
GLP-1 RA
Glucose-dependent insulinotropic polypeptide (GIP)
- Incretin hormone
↑ insulin release in response to
↑ blood glucose
↑ glucagon levels when blood glucose is normal to low
What is GIP?
Glucose-dependent insulinotropic polypeptid: incretin hormone; induces insulin secretion in
response to duodenal hyperosmolarity of glucose
Common side effects of Tirzepatide (Mounjaro®)
Nausea
Practice PEARLS for GLP-1 RA, GIP
- Avoid dehydration
- Report S/S of a thyroid tumor, cholelithiasis, or pancreatitis
- Monitor for hypoglycemia & report difficulties with
glycemic control
SGLT-2 Inhibitors
Canagliflozin (Invokana®)
Dapagliflozin (Farxiga®)
Empagliflozin (Jardiance®)
Ertuglifozin (Steglatro®)
SGLT-2 Inhibitors MOA
↓ glucose reabsorption in
the kidney
↑ insulin sensitivity
↓ gluconeogenesis in the liver
↑ insulin release from �-cells
Excretion: 33% urine, 60% feces
Common side effects of SGLT-2 Inhibitors
Genital mycotic infection* (4-11%, > in females)
Sulfonylureas
Glimepiride (Amaryl®)
Glyburide (DiaBeta®)
Glipizide (Glucotrol®)
Sulfonylureas MOA
Stimulates islet � cells to release insulin
Blocks the ATP sensitive K+ pump, → action
potential to open voltage Ca++ channels → release
insulin vesicles
Excretion: 80% urine, 10% feces
Common side effects of Sulfonylureas
Hypoglycemia (4-20%)
Practice PEARLS of Sulfonylureas
Avoid prescribing together with insulin
Thiazolidinediones (TZDs)
Pioglitazone (Actos®)
Rosiglitazone (Avandia®)
TZDs MOA
↑ insulin receptor sensitivity
↑ energy storage in fat & muscle
↓ glucose production
Stimulate fat, muscle, & liver cells
to ↑ insulin receptors
Excretion: 15-64% urine, 23% feces
TZDs Common side effects
Fluid retention (5-15%)
TZDs BBW
May cause or worsen congestive heart failure (CHF).
TZDs Practice PEARLS
Report S/S of CHF
Make a chart of all slides 57-67 in DM Medications slides
:)
Insulin is required for survival in ___
DM I
____ regimens & ____ should be used for most pts with DM1
Physiologic (Basal-Bolus) & insulin analogs
Total Daily Insulin (TDI) dose based on weight typical range
Range: 0.4 — 0.5 units/kg per day
Insulin Daily dosing - basal and prandial
Basal 40% — 50% TDI
- Given as single injection of basal
analog (QHS) OR
injections of NPH BID
Prandial: 50% — 60% of TDI in divided doses
15 min before each meal
Actual prandial insulin dose determined by carbohydrate content & experience with SMBG testing.
T/F all patients respond the same to insulin
F
Any 2 people with DM I can have
different insulin-to-carbohydrate ratios
The starting insulin-to-carbohydrate
ratio for a person is ____
estimated
- Then, adjust the actual dose by
analyzing blood glucose readings
pre- & post meals
- Starting insulin-to-carb ratio is
estimated using the 450/500 Rule
- Only for people with Type I DM
500 Rule
Grams of carbohydrate covered by 1 unit of rapid acting insulin
Divide 500 by the total daily dose of insulin
* Quotient = # grams of carbohydrate that are
managed by 1 unit of Rapid Acting insulin
450 Rule
Grams of carbohydrate covered by 1 unit of regular insulin
* Divide 450 by the total daily dose of insulin
* Quotient = # grams of carbohydrate that are
managed by 1 unit of Regular insulin
1800 Rule
Estimates serum glucose point drop in mg/dL per unit of rapid acting insulin
* Divide 1800 by the TDI
* Quotient = mg of serum glucose/dL
that are approximately managed by
1 unit of rapid acting insulin
1500 Rule
Estimates serum glucose point drop in mg/dL per unit of regular insulin
* Divide 1500 by the TDI
* Quotient = mg of serum glucose/dL
that are approximately managed by
insulin
When should you inject Regular U-100 insulin?
Inject 30-45 min before a meal
* Injection with or after a meal could
increase risk for hypoglycemia
Rapid Acting insulin administration considerations
- Administer 0-15 min before meals
- ↓ risk of postprandial
hypoglycemia compared to regular
insulin
Role of Rapid-acting (Analogs) insulin
Covers needs for meals eaten at the same time as the injection, & often used with basal insulin.
Role of NPH U-100 immediate acting insulin
- Covers needs for about half a
day or over night. - Often combined with shortacting insulin (pre-mixed)
Basal (long-acting) insulin Role
Covers needs for ~1 day Often combined with other
insulin types if needed for tighter control.
Basal insulin forms microprecipitate in fatty tissue & is gradually released
Pre-mixed insulin
Pre-mixed: Mixture of long intermediate-acting insulin with short rapid-acting insulin
Pre-mixed insulin role
Generally used 2 – 3 times a day, before mealtime.
The most common adverse effect (27%) of inhaled insulin was ___
cough
CSII is
Continuous subcutaneous insulin infusion
MDI vs CSII therapy
- Significant ↑ glycemic control
- Greater ↓ HbA1c & ↓ insulin
requirements lower in DM I - Severe hypoglycemia risk ↓
Insulin Administration locations
Abdomen →Fastest
Arms
Legs
Buttock →Slowest
injection sites should be rotated
