DM Meds: Non-insulin Medications

Question 1

What medication/s is/are included in the biguanide class?

Answer 1

Metformin

Question 2

How do Metformin maximum doses change with regard to renal function studies (eGFR) and how often should studies be repeated?

Answer 2

For eGFR of 60mL/min:
- max dose: 2,550mg daily
- renal function studies: annually

For eGFR of 45 - 59mL/min:
- max dose: 2,000mg daily
- renal function studies: every 3-6 months

For eGFR of 30 - 44mL/min:
- max dose: 1,000mg daily if already on Metformin & level drops to this level
- don’t start Metformin at this level if not already on it
- renal function studies: every 3 months

For eGFR of < 30mL/min:
- max dose: n/a, no Metformin at this level
- renal function studies: N/A

Question 3

Name examples of 2nd generation Sulfonylurea medications.

Answer 3

Glimepiride (amaryl)
Glipizide (glucotrol)
Glyburide (diabeta, micronase)

Note: this is a less popular class since newer classes also treat comorbidities

Question 4

Name examples of meglitinide medications.

Answer 4

Repaglinide (prandin)
Nateglinide (starlilx)

Question 5

Name examples of DPP-4 (dipeptidyl-peptidase 4) inhibitor medications.

Answer 5

Alogliptin (nesina)
Saxagliptin (onglyza)
Linagliptin (tradjenta)
Sitagliptin (januvia)

Question 6

Name examples of GLP-1 (glucagon-like peptide) medications.

Answer 6

Exenatide (byetta, bydureon)
Liraglutide (victoza)
Dulaglutide (trulicity)
Semaglutide (ozempic, rybelsus)

Question 7

Name examples of TZD (thiazolidinedione) medications.

Answer 7

Pioglitazone (actos)
Rosiglitazone (avandia)

Question 8

Name examples of SGLT2 (sodium-glucose cotransporter-2) inhibitor medications.

Answer 8

Canagliflozin (invokana)
Dapagliflozin (farxiga)
Empagliflozin (jardiance)
Ertugliflozin (steglatro)

Question 9

What is the mechanism of action and average A1C decrease of sulfonylurea medications?

Answer 9

Potentiates insulin secretion
1% - 2%

Question 10

What are the pro’s and con’s of sulfonylurea medications?

Answer 10

Pro’s:
- long history
- decreased vascular events
- CHEAP!!!

Con’s:
- hypoglycemia
- weight gain

Question 11

What is the mechanism of action and average decrease of DPP-4 inhibitors?

Answer 11

Mechanism of action:
- slows inactivation of incretin
- decreases glucagon secretion
- increases insulin secretion

Average A1C decrease: 0.7%

Question 12

What are the pro’s and con’s of DPP-4 inhibitors?

Answer 12

Pro’s:
- can be combo or monotherapy
- oral medication
- no hypoglycemia
- weight neutral

Con’s:
- long-term effects unknown
- cost

Question 13

What is the mechanism of action and average A1C decrease of GLP-1 medications?

Answer 13

Mechanism of action:
- increases synthesis of insulin in response to rise in BG
- increases insulin secretion
- decreases glucagon secretion
- slows gastric emptying
- increases satiety

Average A1C decrease: 1 - 1.5%

Question 14

What are the pro’s and con’s of GLP-1 medications?

Answer 14

Pro’s:
- no hypoglycemia
- decreased CV risks **
- weight loss **
- delays gastric emptying

Con’s:
- injectable only
- long-term effects unknown
- COST ***

Question 15

What is the mechanism of action and average A1C decrease of TZD medications?

Answer 15

Mechanism of action:
- improves insulin sensitivity

Average A1C decrease: 0.7%

Question 16

What are the pro’s and con’s of TZD medications?

Answer 16

Pro’s:
- No hypoglycemia
- improves insulin sensitivity

Con’s:
- high risk of fractures at high doses **
- not appropriate for patients with HF **
- weight gain
- edema
- COST ***

Question 17

What is the mechanism of action and average A1C decrease of SGLT-2 inhibitors?

Answer 17

Mechanism of action:
- prevents reabsorption of renal glucose

Average A1C decrease: 1%

Question 18

What are the pro’s and con’s of SGLT-2 inhibitors?

Answer 18

Pro’s:
- weight loss
- decreased BP **
- reduces CV risk **

Con’s:
- UTI*
- yeast infections*
- hyperkalemia
- COST ***

• d/t glucose excretion in urine

Question 19

Which medications should be considered/used for DM patients with the following comorbidities or goals: ASCVD, HF, CKD, minimize hypoglycemia, weight loss, financial?

Answer 19

ASCVD:
- GLP-1
- SGLT2

HF:
- SGLT2

CKD:
- SGLT2
- GLP-1

Minimize hypoglycemia:
- DPP-4
- SGLT2
- GLP-1
- TZD

Weight loss:
- SGLT2
- GLP-1

Financial:
- SU (sulfonylurea)
- TZD

Question 20

Which specific medications should be considered for DM patients who need a 2nd agent and who have ASCVD/CKD risks?

Answer 20

GLP-1 with CVD benefits:
- liraglutide (Victoza)
- semaglutide (Ozempic)
- dulaglutide (Trulicity)

       —OR—

SGLT2 with proven CV/renal benefits:
- empagliflozin (Jardiance)
- canagliflozin (Invokana)
- dapagliflozin (Farxiga)

*Per Level A evidence

Question 21

In patients with T2DM, which is preferable, a GLP-1 or insulin?

Answer 21

GLP-1, when possible