DM Meds: Non-insulin Medications Flashcards
What medication/s is/are included in the biguanide class?
Metformin
How do Metformin maximum doses change with regard to renal function studies (eGFR) and how often should studies be repeated?
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
Name examples of 2nd generation Sulfonylurea medications.
Glimepiride (amaryl)
Glipizide (glucotrol)
Glyburide (diabeta, micronase)
Note: this is a less popular class since newer classes also treat comorbidities
Name examples of meglitinide medications.
Repaglinide (prandin)
Nateglinide (starlilx)
Name examples of DPP-4 (dipeptidyl-peptidase 4) inhibitor medications.
Alogliptin (nesina)
Saxagliptin (onglyza)
Linagliptin (tradjenta)
Sitagliptin (januvia)
Name examples of GLP-1 (glucagon-like peptide) medications.
Exenatide (byetta, bydureon)
Liraglutide (victoza)
Dulaglutide (trulicity)
Semaglutide (ozempic, rybelsus)
Name examples of TZD (thiazolidinedione) medications.
Pioglitazone (actos)
Rosiglitazone (avandia)
Name examples of SGLT2 (sodium-glucose cotransporter-2) inhibitor medications.
Canagliflozin (invokana)
Dapagliflozin (farxiga)
Empagliflozin (jardiance)
Ertugliflozin (steglatro)
What is the mechanism of action and average A1C decrease of sulfonylurea medications?
Potentiates insulin secretion
1% - 2%
What are the pro’s and con’s of sulfonylurea medications?
Pro’s:
- long history
- decreased vascular events
- CHEAP!!!
Con’s:
- hypoglycemia
- weight gain
What is the mechanism of action and average decrease of DPP-4 inhibitors?
Mechanism of action:
- slows inactivation of incretin
- decreases glucagon secretion
- increases insulin secretion
Average A1C decrease: 0.7%
What are the pro’s and con’s of DPP-4 inhibitors?
Pro’s:
- can be combo or monotherapy
- oral medication
- no hypoglycemia
- weight neutral
Con’s:
- long-term effects unknown
- cost
What is the mechanism of action and average A1C decrease of GLP-1 medications?
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%
What are the pro’s and con’s of GLP-1 medications?
Pro’s:
- no hypoglycemia
- decreased CV risks **
- weight loss **
- delays gastric emptying
Con’s:
- injectable only
- long-term effects unknown
- COST ***
What is the mechanism of action and average A1C decrease of TZD medications?
Mechanism of action:
- improves insulin sensitivity
Average A1C decrease: 0.7%
What are the pro’s and con’s of TZD medications?
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 ***
What is the mechanism of action and average A1C decrease of SGLT-2 inhibitors?
Mechanism of action:
- prevents reabsorption of renal glucose
Average A1C decrease: 1%
What are the pro’s and con’s of SGLT-2 inhibitors?
Pro’s:
- weight loss
- decreased BP **
- reduces CV risk **
Con’s:
- UTI*
- yeast infections*
- hyperkalemia
- COST ***
- d/t glucose excretion in urine
Which medications should be considered/used for DM patients with the following comorbidities or goals: ASCVD, HF, CKD, minimize hypoglycemia, weight loss, financial?
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
Which specific medications should be considered for DM patients who need a 2nd agent and who have ASCVD/CKD risks?
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
In patients with T2DM, which is preferable, a GLP-1 or insulin?
GLP-1, when possible
