DM treatment Flashcards
what medication is a biguinaide?
metformin
what is the MOA of metformin?
biguinide
- insulin sensitizer of hepatic and muscle tissues to increase glucose uptake
- lower hepatic glucose production
is metformin associated with hypoglycemia?
no
what is the max effective dose of metformin?
2000mg
what are the ADE of metformin?
N/D/V
metallic taste
interferes with B12 absorption
Lactic acidosis when used with contrast dye
what are the contraindications for metformin?
GFR <30
what are the dose adjustment for GFR when using metformin?
GFR <30: stop therapy
GFR <45: do not initiate therapy
what medications are thiazolinidones?
-glitazones
pioglitazone
rosiglitazone
what is the MOA pioglitazone?
thiazolinidiones
- activates PPAR-y to increase insulin sensitivity
- increase glucose uptake in muscles and adipose tissue
- decrease glucose output by liver
- increase fatty acid uptake
is pioglitazone associated with hypoglycemia?
no
what are the ADE of pioglitazone?
insulin sensitizer
- edema
- HF exacerbation
- increased LFTs
- increased risk of bone fracture
what are the contraindications for pioglitazone?
- NYHA Class III/IV HF
- LFT >2.5x ULN
- Hx of bladder cancer
what medications are sulfonylureas?
Gli- or Gly-
- Glimepiride
- Glipizide
- Glyburide
what is the MOA of sulfonylureas?
Glimepiride, glipizide, glyburide
bind to sulfonylurea receptors on beta cells to increase insulin secretion
- squeeze out insulin
where is significant about Glipizide?
second generation sulfonylurea
- associated with the most hypoglycemia in its class
- metabolized int he liver to inactive metabolites
what is significant about Glimepiride?
2nd gen sulfonylurea
- metabolized in liver to inactive components
- best A1C benefit
- less hypoglycemia, but weight gain
what is significant about glyburide?
2nd gen sulfonylurea
- metabolized in the liver to active metabolites
which of the 2nd gen sulfonylurea is a prodrug?
glyburide
what are the ADE of Glimepiride, glipizide, glyburide?
hypoglycemia
weight loss
pruritis
hemolytic anemia
what is the MOA of nateglinide and repaglinide?
bind to sulfonylyrea receptors on beta cells to increase insulin secretion
- nateglinide and repaglinide
- glimepiride, glipizide, glyburide
both drug classes have the same MOA, what is the difference between the 2?
- nateglinide and repaglinide have a shorter onset
what are the ADE of nateglinide and repaglinide?
- hypoglycemia
- weight gain
what is the MOA of sitagliptin, linaglitin, and alogliptin?
Glucose dependent
- increase insulin synthesis and release from beta cells
- decrease glucagon secretion from alpha cells
out of these meds, which one has no renal adjustments? sitagliptin, linaglitin, and alogliptin
linaglitin
what is the ADE of sitagliptin, linaglitin, and alogliptin?
- acute pancreatitis
- H/A
- severe joint pain
- UTI
- URI
- hypersensitivity
what are the contraindications for sitagliptin, linaglitin, and alogliptin?
- hypersensitivity
- DKA
- Saxgliptin worsens HF
what is the MOA of liragluTIDE, exenaTIDE, exenaTIDE?
- decrease glucagon secretion
- improve satiety and decrease food intake
what are the ADE of liragluTIDE, exenaTIDE, exenaTIDE?
- GI discomfort
- acute pancreatitis
- injection site reaction
- thyroid carcinoma
what are the contraindications for liragluTIDE, exenaTIDE, exenaTIDE?
- hx of thyroid cancer
- MEN2
- risk for thyroid C-cell tumor
what is the MOA of canaGLIFLOZIN, dapaGLIFLOZIN, empaGLIFLOZIN, ertuGLIFLOZIN?
- increase glucose excretion by inhibiting Na+/glucose co-transporter 2 in the proximal convoluted tubule
- lowers renal threshold for glucose
what is the ADE of canaGLIFLOZIN, dapaGLIFLOZIN, empaGLIFLOZIN, ertuGLIFLOZIN?
- fungal UTI
- genital mycotic infections
- polyuria/dehydration
- electrolyte imbalance
- DKA
- bone fracture
- Fournier’s gangrene
what are the contraindications for canaGLIFLOZIN, dapaGLIFLOZIN, empaGLIFLOZIN, ertuGLIFLOZIN?
- severe renal impairment
- end stage renal disease
- dialysis
what is the MOA of acarbose and miglitol?
- inhibits alpha-glucosidase enzymes to slwo the rate of digestion = less glucose absorbed
what are the ADE of acarbose and miglitol?
- hypoglycemia
- GI distress
- increased LFTs
what are the contraindications for acarbose and miglitol?
- IBS
- colonic ulcerations
- intestinal obstruction
- cirrhosis
what is the MOA of pramlintide?
- decrease glucagon production and slows gastric emptying
what are the ADE of pramlintide?
- hypoglycemia
- N/V
- lack of appetite
- abdominal pain
what are the contraindications for pramlintide?
gastroparesis
what is the use of bile acaid sequestrants in DM treatment?
bind bile acids in intestines and increase bile acid production
what are the contraindications for using bile acid sequestrants in treating DM?
- TG >500
- bowel obstruction
- h/o pancreatitis
- T1DM
- DKA
out of the T2DM drug classes, which medications are injections?
- liragluTIDE, exenaTIDE, exenaTIDE
(only oral option is semaglutide) - pramlintide
out of the medication class GLP1 receptor agonist, which is an oral medication?
Semaglutide
out of the Type II DM drug classes, which ones have a risk for hypoglycemia?
- insulin
- 2nd gen sulfonylurea: Glipizide has the highest hypoglycemia in its class
- pamlintide
- meglinitides: nateglinide and repaglinide
what is the approrpaite initial therapy for type II DM?
metformin
what is the add on therapy for a patient with type II DM and wants to lose weight?
- insulin for those A1C >10% and BG >300
- SLGT2i: -gliflozin
- GLP1 agonist: -tide
what is the add on therapy for type II DM who has ASCVD, CVD, HF?
- SGLT2i: -gliflozin
- GLP1-receptor agonist: -tide
what is the use of insulin in treating type II DM?
- when A1C >10%
- start with basal at 0.1-0.2 units/kg/day
- consider adding prandial
- continue metformin
when fasting insulin in out of range, what insulin do you adjust?
- basal insulin
- evening NPH insulin
when post-breakfast/pre-lunch in out of range, what insulin do you adjust?
- prebreakfast rapid insulin or
- short acting insulin
when post-lunch/pre-dinner insulin in out of range, what insulin do you adjust?
- prelunch rapid insulin or short acting insulin
- morning NPH insulin
when bedtime insulin in out of range, what insulin do you adjust?
- predinner rapid or short acting insulin
what is the recommended rx therapy for T1DM?
- multiple daily injections of prandial and basal insulin OR continous insulin
- potential add-ons: pramlintide, metformin, GLP1 agonist, SGLT2i
what is the ultra-rapid bolus insulin?
Fiasp
what are the rapid acting insulins?
bolus
- Humalog, ademelob, novolog, apidra, afrezza (inhaled)
what are the intermediate acting basal insulins?
- humulin
- novolin R
what are the long acting basal insulins?
- lantus
- toujeo
- basaglar
- levemir
what are the ultra long acting basal insulins?
- tresiba
what is the treatment for a patient with DM and HTN?
- ACEi/ARB
- CCB
- diuretic
what is the treatment for a patient with DM and high lipids?
statin
what is the use of anti-platelet therapy for patients with DM?
- ASA for secondary prevention
- DAPT for ACS
what is the management for a patient with DM and ASCVD?
- canagliflozin
- empagliflozin
- dulaglutide
- liraglutide
- semaglutide
what is the management for a patient with DM and HF?
- dapagliflozin
- empaglifozin
what medications should be avoided when treating patient with DM and HF?
- thiazolidinediones (-glitazone)
- DPP4 inhibotors: saxagliptin and alogliptin
what is the management for a patient with DM and CKD?
- canagliflozin and daptagliflozin
- dulaglutide, liraglutide, semaglutide
how do you switch basal insulins?
From NPH daily to glargine, detemir, and debludec?
1:1
how do you switch from NPH 2x daily to glargine, detemir, or degludec?
80% total daily dose NPH -> glargine or detemir once daily
how do you switch from premix insulin to glargine, detemir, and degludec?
80% of basal component to once daily
how do you switch long acting insulin to glargine, detemir, or degludec?
1:1
how do you calculate insulin to carbohydrate ratio (ICR)?
Rule of 500: people usually consume 500g carbs a day
500/total dose (TDD) of insulin
e.g. if you use 20 units of insulin, ICR is 1:25
how do you calculate the correction factor?
Rule of 1800:
- for rapid acting insulin correction and to show how much it will lower blood sugar by
1800/TDD insulin
e.g if you take 30 units of rapid acting, 1800/30 = 60. Blood sugar will decrease by 60 mg/dL
what is the correction dose?
(Current BG - Target BG)/correction factor
e. g. (220-120)/50
- need 2 units of rapid acting insulin
for T1DM, how do you determine insulin?
50% basal, 50% prandial
how do you calculate total daily insulin for T1DM?
- 0.4-1 units/kg/day
- 0.5 units kg/day starting dose that is 50% prandial and 50% basal
how do you initiate basal insulin therapy for a T2DM?
0.1 - 0.2 units/kg/day
how do you initiate prandial insulin therapy for a T2DM?
4% of basal insulin dose
