DM Pharmacology Part II Flashcards
Patients with liver/renal disease, age over 65, hypoxic states and use excessive EtOH who take metformin should be monitored for?
lactic acidosis
medications that predispose you to hypoglycemia
combinind antidiabetics aspirin beta blockers fluoroquinolones fenugreek MAO inhibitors psyllium ACE inhibitors
Effect of metformin in PCOS
can help with conception
why do you have to frequently dose glinides?
short half life
Two types of Thiazolidinedione drugs
pioglitazone → MC
rosiglitazone
black box warning for GLP1 agonist
thyroid cancer in rat studies
what drug do you want to avoid interacting with acarbose?
digoxin
this receptor regulated gene transcription associated with proteins which interact in carb and lipid metabolism
peroxisome proliferator-activated receptor gamma (PPAR-y)
if the patient has ASCVD or needs weight loss you should consider
GLP1 agonist
MOA for thiazolidinediones
increases insulin sensitivity by stimulating PPAR-y
MOA of a-glucosidase inhibitors
decreases prostprandial hyperglycemia with delayed intestinal carbohydrate absorption
pro of nateglinide
doesn’t need renal dosing → good for patient with renal insufficiency
what drug can you prescribe to a prediabetic patient?
a-glucosidase
what is the incretin effect?
INtestinal seCRETion of INsulin→ oral glucose ingestion results in greater insuline response in comparion to IV glucose administration
two types of insulin secretagogues
sulfonylurea (SUR) and meglitindes
effects of GLP1 on the pancease
increases insulin release
decrease glucagon release
adverse effects for SGLT2 inhibitors
potential for DKA potential for leg and foot amputations yeast infections increased fracture risk hypotension hyperkalemia bladder cancer UTIs
T2DM with HF or CKD → first line? Second line?
metformin
metformin + GLP1RA or SGLT2i
T2DM with established ASCVD → first line
metformin
GLP1 agonist that is the best at lowering glucose and has benefit of weight loss
semaglutide
Adverse effects in GLP1 agonists
GI → D/N
gallbladder disease
hypoglycemia
Patient is on GLP1 agonist and experiences severe abdominal pain that radiates to the back, they also are experiencing nausea and vomiting → work them up for?
pancreatitis
4 types of DPP-4 inhibitors
alogliptin
linagliptin
saxagliptin
sitagliptin
MOA of SUR
block ATP sensitive potassium channels in pancreatic B cell membrane → increase insulin secretion
which DPP-4 would you give to a patient with renal failure since there are no adjustments required?
linagliptin
Besides decreasing glucose levels how else is SGLT2 benefitial?
decreases SBP
decreases body weight
decreases urinary albumin excretion
you should avoid DPP-4 inhibitor in patient already on
GLP1 agonist
Black box warning for TZD
congestive heart failure
adverse effect to be on the lookout for with exenatide
injection site reactions
If the eGFR falls below 45 in a patient who just started Metformin, what is the next step you should take?
consider risk/benefit for treatment
Actions of GLP1
neuroprotective appetite suppression decreased gastric emptying increased insulin secretion decreased glucagon secretion increased B cell proliferation increased glucose uptake/storage in muscle and adipose decreased glucose production by liver cardioprotective
T2dM with established ASCVD → second line
metformin + GLP 1RA or SGLT2i
what heart failure signs do you want to monitor for in starting and increase TZD dose?
excessive rapid weight gain
dyspnea
edema
According to ADA, the recommended glycemic management for T2DM with establish ASCVD is
SGLT2 inhibitor or GLP1 agonist
If a patient has eGFR between 30-45, can they take metformin?
not recommended
Patient on metformin should stop their meds before receiving contrast media if their eGFR is between
30-60
What do you do with a patient on metformin whose eGFR falls below 30?
discontinue therapy
4 types of SGLT2 inhibitors
canagliflozin
dapagliflozin
empagliflozin
etrugliflozin
3 pros of metformin
highly efficacious
low risk of hypoglycemia
weight neutral
this transporters main role is glucose/galactose reabsorption in the small intestines
SGLT1
Where do SGLT1 mainly act?
Where do SGLT2 mainly act?
SGLT1 → gut
SGLT2 → renal
How should a patient take Nateglinide?
with food → more effective
Pregnancy category for a-glucosidase inhibitors
B
What do you want dose adjust SGLT2 inhibitors for?
renal impairment
when prescribing metformin, you can go ahead and inititate the required dose for the patient?
no → must titrate up
Adverse effects in meglitinides
hypoglycemia
weight gain
diarrhea
MOA of dipeptidyl peptidase enzyme inhibitor
protects GLP1 from inactivation →
increases glucose depended insulin secretion
decreases glucagon secretion
biggest adverse effect for SUR and some others
weight gain
nausea and vomiting, hypoglycemia, CV events, hyponatremia
metformin is pregnancy category __
B
biggest side effect with Metformin
diarrhea → seen less with XR
MOA of SGLT2 inhibitors
increases urinary glucose excretion
Three 2nd generation SUR that are most often used
glyburide
glipizide
glimipride
two types of Meglitinides (nonsulfonylurea secretagogues)
nateglinide
repaglinide
MOA of Meglitinides
similar to SUR → block ATP Na/K channels on pancreatic B cells → enhances insulin secretion
examples of GLP1 agonists
dulaglutide
exanatide
liraglutide
lixisenatide
Adverse effects of TZD
fluid retention → edema and HF increased risk of MI bone fracture risk bladder cancer hepatotoxicity
pro of second generation SUR
low cost and highly effective
this enzyme converts complex startes (oligosaccharides, disaccharides) to simple start (monosaccharides)
alpha-glucosidase
T2DM without ASCVD or CKD: what do you add on if you need to manage weight loss?
GLP 1 RA
SGLT2 i
GLP1 agonist with best cardiovascular benefit
liraglutide
incretin hormones are responsible for ___% of postprandial insulin release
60%
adverse effects of DPP-4 inhibitors (gliptins)
angioedema heart failure hepatic failure joint pain renal impairment acute pancreatitis hyperlipidemia
first line in treating T2DM
metformin
what gylcemic lowering drug should be avoided in a patient with heart failure?
TZD
When you should start to consider dose adjusting for renal function for SUR?
CrCl < 50
metformin is at risk for lowering what level?
B12
Pro of using meglitinide over SUR
patients with sulfa allergy
this transporter facilitates renal glucose reabsorption
SGLT2
2 incretin hormones
gastric inhibitory peptide (GIP)
glucagon-like peptide (GLP1)
while Beta Blockers can decrease signs of hypoglycemia, they will not decrease what?
sweating
Is SUR effective in T1DM?
no → need functioning pancreatic B cells
Who are TZD contraindicated in?
heart failure patients
side effects of SGLT1 inhibitors
diarrhea and dehydration
3 MOA of GLP1 agonists
increases glucose dependent insulin secretion
decreases glucagon secretion
slows gastric emptying
Con of linagliptin that may cause lots of DDI
long half life → > 100 hours
T2DM without ASCVD or CKD: add on if cost is concern for patient?
SU
TZD
biggest adverse effects of a-glucosidase inhibitors
flatulence → MC
diarrhea
abdominal pain
what levels do you check before prescribing TZD?
LFTs
effects of GLP1 on the hypthalamus
decreases appetite
MOA for TZD at the liver, muscle, and adipose tissue
decreases hepatic glucose production
increases glucose uptake in muscles
T2DM without ASCVD or CKD: what do you add on if you need to address hypoglycemia?
DPP-4 I
GLP 1 RA
SGLT2i
TZD
2 MOA of Metformin
decreases hepatic glucose production
increases glucose uptake in muscles
effects of GLP1 on the stomach
delays gastric emptying
Black box warning for canagliflozin
increased risk of lower limb amputation in patients with T2DM and established CVD
two types of a-glucosidase inhibitors used
acarbose
miglitol
