E1 Flashcards
What BG is considered hyperglycemia?
BG > 250mg/dl
What are the S/Sx of hypoglycemia?
sweaty, tachycardia, pallor, hangry
How to tx hypoglycemia?
Tx with Rule of 15:
- check BG
- 15g carb load of OJ/soda/candy
- wait 15min, then recheck BG
- substantial snack w protein, carb, fat
How do you treat severe hypoglycemia?
impaired mentation –> paramedics + recombinant glucagon
What are the S/Sx of hyperglycemia?
visual changes, polyuria, nocturia, long-term weight loss
How do you tx hyperglycemia?
Home mgmt: monitor BG, insulin, rest, water, exercise
What is severe hyperglycemia?
DKA –> T1DM, hrs-days
HHS –> T2DM, days-weeks, higher mortality
What are microvascular complications?
retinopathy, nephropathy, neuropathy
What are macrovascular complications?
cerebrovascular disease, heart disease (CAD leading cause of death), Peripheral vascular disease
What are the ADA guidelines to treat HTN?
no preference unless albuminuria –> ACEi/ARB
What are the AAE guidelines to treat HTN?
prefer ACEi/ARB
What are the ACC/AHA guidelines to treat HTN?
no preference unless:
- CKD –> ACE
- HF –> avoid nonDHP CCBs
- African American –> Thiazides or CCB if monotherapy
What are the ADA guidelines to tx cholesterol?
under 40y/o:
- ASCVD > 10% –> high intensity statin (+/- ezetimibe, PCSK9i)
over 40y/o:
- ASCVD < 20% –> mod. statin
- ASCVD > 20% –> high intensity statin (+/- ezetimibe, PCSK9i)
What are the ACC/AHA guidelines to tx cholesterol?
all DM its should have mod. intensity statin
What do the ADA guidelines say about ASA in primary prevention?
may in pt with high CVD risk (50+, smoker, HTN, LDL > 100, CKD)
What do the AACE guidelines say about ASA in primary prevention?
when ASCVD > 10%
How do you treat obesity in DM pts?
- diet, exercise, behavioral therapy to 5% weight loss
- BMI >= 27 –> consider weight loss meds/therapy
- BMI >= 35 –> consider bariatric surgery
How do the guidelines address smoking cessation?
AVOID tobacco products, even e-cigs
What do the guidelines say about immunizations?
- influenza annually
- HepB
- Pneumococcus: 19-64y/o: PPSV23, 65+: PCV13 then PPSV23 booster 1yr later
What do the guidelines say to treat retinopathy?
- optimize BG, BP, lipid control to dec. risk and slow progression
- annual eye exams –> T1DM within 5yrs post-DM onset, T2DM at the time of diagnosis
What do the guidelines say about nephropathy?
- risk factors: BG, HTN, proteinuria (ACE/ARB), dyslipidemia (statins)
- annually asses urinary albumin (proteinuria) and eGFR
What do the guidelines say about neuropathy?
- tx options for Sx but not progression (Lyrica, duloxetine)
- annual comprehensive foot exams
How do you tx microvascular complications?
by controlling blood sugars
What does DCCT trial show?
T1DM; largest study ever conducted
- intensive insulin therapy reduces A1C and T1DM microvascular complications –> EDIC
- relative risk of microvascular complication is highly affected by A1C
- CV benefit won’t be realized until ~10yrs from when you started intensive therapy
What does UKPDS trial show?
T2DM; trial we talk about when we consider metformin CV benefit
- intensive therapy (+metformin, SU) reduced microvascular events –> 10yr follow up: need for meticulous glucose control to improve microvasc. complications & long-term macrovasc. comps., necessary to control BG, A1C & BP
what does ACCORD trial show?
T2DM; study that makes us want to individualize goals for pts
- super intensive therapy (AIC< 6%) led to higher risk of death & MI, esp. if A1C >= 8.5, hx of neuropathy, hx of ASA use
What does ADVANCE trial show?
T2DM
- corroborated with UKPDS 10yr follow up with a dec. in micro and macrovascular complications with intensive therapy
What does VADT trial show?
T2DM (white, older men)
- lower threshold to start insulin therapy dec. major microvascular complications; severe hypoglycemia in last 90 days is strong predictor of mortality
What class of drugs don’t have CVD mortality benefits?
DPP4i
only SGLT2 and GLP-1 do
What guidelines (outpt) would you use for someone <65 y/o without clinical ASCVD event?
Strict Guidelines: AACE
- AIC <= 6.5%
- FBG < 110mg/dl
- PPG < 140mg/dl
- want to prevent long-term complications
What guidelines (outpt) would you use for someone >= 65y/o OR any age with a clinical ASCVD event?
Loose Guidelines: ADA
- AIC < 7.5%
- FBG 80-130mg/dL
- PPG < 180mg/dl
- want to avoid hypoglycemia
What are the guidelines to treat a pediatric pt with T1DM?
- BP: tx if consistently > 130/80mmHg
- cholesterol: tx if LDL consistently > 130mg/dl
- microvascular monitoring once >= 10y/o OR had DM for 5yrs
- 60min aerobic exercise with strength training at least 3x/week
What are the guidelines to treat a pediatric pt with T2DM?
- screening once >= 10y/o AND BMI >= 85th percentile
- aim for 7-10% weight loss
- 30-60mins of mod-vigorous physical activity 5x/week with strength training for 3
- goal AIC < 7% (6.5% reasonable if you can avoid hypoglycemia)
What are the guidelines to treat a geriatric pt with DM?
- functional, cognitively intact older adults can use goals developed for younger adults. otherwise…
- A1C goals more lenient < 7.5%
- AVOID HYPOGLYCEMIA
- routinely consider de-escalating regimens
What do you do for sick day mgmt?
Sick day = infection, injury, surgery, trauma, invasive procedure, major life stress
- continue long-acting (basal) insulin as normal
- use rapid-acting (bolus) insulin only If eating
- continue PO meds EXCEPT metformin, SGLT2i, GLP-1 –> d/t all PO meds if N/V/D
- check OTC meds (sugar content)
What are some counseling points for sick day mgmt?
test BG Q2H
- T1DM: check urine/blood ketones Q4H
- monitor temp. and hydration status
- tract Sx: N/V/D, thirst, urination
What is MNT?
medical nutrition therapy
- MNT for all DM pts
- portion control and healthy food choices: low carb, low processed foods
- plate method
- weight loss > 5%
- individualized meal plans
alcohol consumption inc. hypoglycemia
- no more than 1drink/day for females
- no more than 2 drinks/day for males
- preferably drinking with food
What are the target BG values for hypoglycemia and hyperglycemia for inpatient?
- hyperglycemia: > 140mg/dl
- hypoglycemia: < 70mg/dl
- severe hypoglycemia: < 40mg/dl
What are the target BG value for FBG and PPG for inpatient?
- FBG: < 140mg/dl
- PPG: < 180mg/dl
- if BG goes < 100mg/dl we should modify the pts regimen
What factors could affect a pts glucose control in the inpatient setting?
- stress hyperglycemia: pts without DM (AIC < 6.5%) can experience inc. BG readings when ill
- inpatient and pt specific risk factors for Hypo and Hyperglycemia
- drug-induced alterations in BG
What are patient specific factors for hypoglycemia?
- advanced age
- dec. oral intake
- chronic renal failure
- liver disease
- hx of frequent or severe hypoglycemia
What are inpatient factor for hypoglycemia?
- Change in diet
- medication use (BBs)
- failure to adjust regimen based on BG patterns
- poor coordination between testing and timing of insulin delivery
What are inpatient factors for hyperglycemia?
- prolonged use of correctional insulin as monotherapy
- TPN or enteral feeds
- medication use
- failure to adjust regimen based on BG patterns
- poor coordination between testing and timing of insulin delivery
What drugs increase the risk of hypoglycemia?
- BBs
- fluoroquinolone ABX (-oxacin)
- alcohol
- pentamidine
What drugs increase the risk of hyperglycemia?
- corticosteroids (-sone)
- atypical antipsychotics (-zapine)
- Fluoroquinolone ABX (-oxacin)
- calcineurin inhibitors (cyclosporine, Tacrolimus)
- protease inhibitors (-vir)
- thiazide diuretics
What do you do if a pt comes in and they have a hx of T1DM or T2DM and A1C >= 6.5%?
treat them as diabetic (regular POC BG monitoring). no further tests needed
What do you do if a pt comes in with no hx of diabetes but BG > 140mg/dL?
send for A1C and begin POC BG testing while we wait (24-48hrs). Can’t confirm DM status without A1C, further tests needed.
What do you do if a pt comes in with no indication that they have been diagnosed with DM, but have a BG > 140mg/dL & A1C in the last 3 months is >= 6.5%?
treat them as diabetic (regular POC BG monitoring). no further tests needed.
What are the names of long-acting (basal) insulins?
- Glargine (Lantus, toujeo, basaglar)
- determir (Levemir)
What are the names of rapid-acting (bolus) insulins?
- aspart (novolog)
- lispro (Humalog, Admelog)
What insulin dosage do you use for an inpatient with T1DM?
TDD = 0.2-0.4U/kg/day
- 50-60% basal, 40-50% nutritional
What insulin dosage do you use for an inpatient with T2DM but who has never had insulin?
TDD: 0.3-0.5U/kg/day
- 50% basal, 50% nutritional
What insulin dosage do you use for an inpatient with T2DM who was on insulin before they came in?
reduce outpatient dose by 20-25%
If FBG > 140mg/dL how do we adjust insulin dosage?
inc. dose of basal insulin by 20%
If BG < 70mg/dl how do we adjust insulin dosage?
reduce basal dose by 20%
What is a counseling point for Linagliptan (tradjenta)?
URTI
What 2 classes of meds can you never use together?
DPP4i and GLP-1
What DPP4i does not require renal dose adjustments?
Linagliptan (Tradjenta)
What sulfonylurea is not on the BEERs list?
Glipizide
What medication has a DDI with radiopaque contrast dye?
metformin –> D/t 24h before, 48hr after imaging
Glyburide
SU: Diabeta, Micronase, Glynase
Glipizide
SU: Glucotrol, Glucotrol XL
glimepiride
SU: Amaryl
Is glyburide on BEERs list?
yes
Is glipizide on BEERs list?
no
Is glimepiride on BEERs list?
yes
Repaglinide
Meglitinide: Prandin
Nateglinide
Meglitinide: Starlix
metformin
biguanide
rosiglitazone
TZD: avandia
pioglitazone
TZD: actos
acarbose
alpha-glucosidase inhibitor: precose
miglitol
alpha-glucosidase inhibitor: glyset
sitagliptin
DPP4i: Januvia
linagliptin
DPP4i: tradjenta
Saxagliptin
DPP4i: Onglyza
Alogliptin
DPP4i: nesina
canagliflozin
SGLT2i: invokana
dapagliflozin
SGLT2i: farixiga
empagliflozin
SGLT2i: jardiance
ertugliflozin
SGLT2i: steglatro
exenatide
GLP-1: bydureon
liraglutide
GLP-1: victoza
dulaglutide
GLP-1: trulicity
lixisenatide
GLP-1: adlyxin
semaglutide
GLP-1: ozempic
Rybelsus = semaglutide oral
What is basal secretion rate?
0.5-1 unit/hr
Is insulin a hormone?
yes
Where is insulin produced?
in the beta cells of the islets of langerhans in the pancreas
What is insulin formed from?
proinsulin (cleaved by beta cella peptidases to insulin)
insulin aspart
Novolog, Fiasp
Rapid-Acting Insulin
insulin lispro
Humalog, admelog
Rapid-Acting Insulin
Insulin Glusine
Apidra
rapid acting insulin
insulin degludec
Tresiba
long acting insulin
insulin determir
Levemir
Long-Acting Insulin
insulin glargine
Lantus, Toujeo, basaglar, semglee
long acting insulin
Insulin Aspart can be administered IV?
no
Can insulin aspart be mixed with NPH?
yes
Can insulin lispro be administered IV?
no
Can insulin lispro be mixed with NPH?
yes
What are the ultra-rapid acting insulins?
insulin aspart and insulin lispro
What are the rapid acting insulins?
insulin lispro, aspart, glulisine
When should you eat after administering a rapid acting insulin?
eat within 15mins of injection
Can a rapid acting insulin be mixed with NPH?
yes
Can a rapid acting insulin be administered IV?
no
What is a short acting insulin?
Regular insulin (Humulin R, Novolin R)
What color is regular insulin?
clear, colorless
Can regular insulin be given IV?
yes (it is the only insulin that can be administered IV)
- DKA Tx, TPN
What is an intermediate acting insulin?
NPH (humulin NPH , Novolin NPH)
What can NPH insulin be mixed with?
regular insulin, aspart, lispro, glulisine
What color should NPH insulin be?
should be cloudy bc its a suspension but not frosty –> DONT SHAKE WILL DENATURE INSULIN INSIDE
frosting = loss of potency
What are long-acting insulins?
glargine, detemir, degludec
Can you dilute long acting insulins?
no
Can you mix long acting insulin?
no
insulin glargine MOA
forms a precipitate right under the skin
insulin detemir MOA
has neutral pH of 7.4
Insulin degludec MOA
injected as a multi-hexamer –> long time to get broken down to monomer then attaches to albumin
3-5 day SS, no other insulin has this!!!
Inhaled regular insulin
Afrezza –> bolus insulin
BBW: acute bronchospasm
approved for 18y/o+
What dosage is blue afrezza?
4 units
what dosage is green afrezza?
8 units
what dosage is gold afrezza?
12 units
Insulin ADES
HYPOGLYCEMIA
- allergy extremely rare
- injection site
- lipohypertrophy
- cough (Afrezza only)
Using AACE guidelines, what insulin dosage should someone with an A1C < 8% get?
TDD: 0.1-0.2U/kg
Using AACE guidelines, what insulin dosage should someone with an A1C > 8% get?
TDD: 0.2-0.3U/kg
Using AACE guidelines, pt is on basal insulin and you want to add bolus insulin, how do you do this?
start 1 bolus shot/day
start: 10% of basal dose
Using AACE guidelines, you want to start basal and bolus insulin , how do you do this?
- start bolus before each meal
- if not on basal: 0.3-0.5U/kg/day
- if on basal: 50% of basal dose divided by 3 for each meal
Using ADA guidelines, you want to start bolus insulin in a patient already on basal insulin, how do you do this?
10% of basal dose injected once a day at largest meal of day
Using ADA guidelines, you want to start basal insulin in a patient, how much do they get?
0.1-0.2U/kg/day
insulin drug interactions
- TZDs
- ACEi, MAOi
- thiazide diuretics
- hormones (estrogens/androgens/thyroid)
- beta blockers
- alpha-glucosidase inhibitors
insulin monitoring
- FBG/PPG
- hypoglycemia
- weight gain
- injection site rxns
- cough (afrezza only)
Whats the MDD for insulin?
there is none
does insulin cause weight gain or loss?
weight gain
Whats absorbed faster, injectable or nasal insulin?
injectable
What SQ injection site has fastest absorption?
abdomen > arms > thighs > buttocks
What SQ injection depth has fastest absorption?
IV > IM > SQ
Regional blood flow is affected by?
- exercise
- skin temp.
- hydration status
- local heat
Insulin glargine + Lixisenatide
(Soliqua)
- MDD: 60units/20mcg
- admin. 1hr before breakfast
- no thyroid C-cell tumor BBW
insulin degludec + liraglutide
xultophy
- MDD: 50U/1.8mg
- pen delivers doses between 10-50U
- admin. anytime once daily without regard to food
Are sulfonylureas PO or SQ?
PO
What drugs are SUs?
(-ide)
Glyburide, Glipizide, Glimepiride
How often are SUs dosed?
QD-BID
What is the MDD for glyburide?
20mg
what is the MDD for glipizide?
IR: 40mg
ER: 20mg
What is the MDD for glimepiride?
8mg
what is the MOA for SUs?
stimulate insulin release from beta cells
- “insulin secretagogues”
What is the SOA for SUs?
beta cells in the pancreas
What are CIs of SUs?
hypersensitivity
T1DM
DKA
When is glyburide CI?
CrCl < 50
When is glipizide CI?
CrCl < 10
when is glimepiride CI?
CrCl < 15
What SUs are CI if pregnancy-near term?
Glyburide and Glipizide
What are ADEs of SUs?
hypoglycemia
N/V
weight gain
What SUs are on the BEERs list?
glyburide and glimepiride
When should you take SUs?
Take with breakfast or first meal of the day
Exception: Glipizide should be taken 30 min before a meal
What should you ask about at every refill for SUs?
hypoglycemia and weight gain
What efficacy is SUs?
high efficacy
What cost is SUs?
low cost
What durability are SUs?
low durability –> become less efficacious over time
SUs may blunt ___?
may blunt myocardial ischemia preconditioning
What is the ASCVD risk of SUs?
neutral
What is the HF risk of SUs?
neutral
What is the CKD risk of SUs?
neutral
Do SUs cause weight gain or loss?
weight gain
What do you monitor in SUs?
Hypoglycemia
FBG
A1C
allergic rxns, sun sensitivity
How long until SUs reach peak effect?
4-6 weeks
What drugs are meglitinides?
(-glinide)
Repaglinide
Nateglinide
Are meglitinides PO or SQ?
PO
What is the MDD for Nateglinide when A1C < 8%?
4mg
What is the MDD for Nateglinide when A1C > 8%?
16mg
What is the MOA for meglitinides?
- stimulate insulin release from beta cells
- insulin secretagogues
What is the SOA for meglitinides?
beta cells in pancreas
What are DDI with Repaglinide?
NPH insulin –> inc. risk of MI
Gemfibrozil –> inc. Repaglinide levels
What are DDI with Nateglinide?
Mifepristone (abortificant): do not use within 14 days
Pazopanib (cancer agent) –> inc. nateglinide levels
What are meglitnides CI in?
hypersensitivity
T1DM
DKA
What are precautions with meglitnides?
severe renal disease
impaired liver fx
use with insulin
What are ADEs of meglitinides?
hypoglycemia (less common than SUs)
GI disturbances
weight gain
headache
When do you administer meglitinides?
before meals
- skip meal, skip dose
When do you take repaglinide?
15-30mins before meals
When do you take nateglinide?
1-30min before meals
Meglitinides are the short acting form of?
SUs
What should you ask about at every Meglitinide refill?
hypoglycemia and weight gain
What efficacy are meglitnides?
low efficacy
What cost are meglitnides?
intermediate cost
What is the ASCVD risk of meglitnides?
neutral
What is the HF risk of meglitnides?
neutral
What is the CKD risk of meglitnides?
neutral
Do meglitnides require renal dosing?
no
Meglitnides work specifically on?
PPG, so if pt with high PPG these might be good meds
What do you monitor for Meglitnides?
PPG
hypoglycemia
A1C
weight gain
How long until meglitnides reach peak effect?
4-6 weeks
Do meglitnides cause weight gain or loss?
weight gain
What drugs are biguanides?
metformin
Are biguanides PO or SQ?
PO
How is IR Metformin dosed?
850-1000mg BID
How is ER metformin dosed?
1000-2000mg QD
What is minimal effective dose for metformin?
500mg
What is the primary MOA of biguanides?
dec. glucose output from liver
what is the secondary MOA of biguanides?
inc. peripheral muscle glucose sensitivity
What is the SOA of biguanides?
liver and peripheral muscle
When are biguanides CI?
eGFR < 30
Acute Renal Failure
When should you dec. biguanides dose?
eGFR 30-45 = 1/2 dose
What are DDIs with biguanides?
radiopaque contrast dyes!!!
d/t 24hrs prior and 48hrs after admin.
What are ADEs of biguanides?
GI
weight loss
lactic acidosis
cardio protection
vit. B12 deficiency
What is a rule of biguanides?
titrate SLOWLY to avoid GI ADEs
How should you take biguanides?
take with food to dec. GI effects
start low, go slow
What should you ask about for every biguanide refill?
GI upset, weight loss, S/Sx of lactic acidosis (SOB, muscle cramping, tachycardia)
What efficacy are biguanides?
high
Do biguanides cause hypoglycemia?
no
What cost are biguanides?
low cost
What ASCVD risk do biguanides have?
potential benefit
What HF risk do biguanides have?
neutral
What CKD risk do biguanides have?
neutral
What do you monitor for biguanides?
- renal fx (eGFR) –> check 6 weeks after initiation, then annually, most providers do Q3-6months
- GI intolerance
FBG/PPG
- A1C –> Q3months
- B12 levels
- weight loss
- s/sx of lactic acidosis
When do biguanides reach peak effect?
6-8 weeks
Do biguanides cause weight gain or loss?
weight loss
What drugs are Thiazolidinediones?
(-glitazone)
Rosiglitazone
Pioglitazone
Are TZDs PO or SQ?
PO
How often are TZDs dosed?
QD
What is the MDD of Rosiglitazone?
8mg
What is the MDD of pioglitazone?
45mg
What is the primary MOA of TZDs?
inc. peripheral muscle glucose sensitivity
What is the secondary MOA of TZDs?
dec. glucose output from the liver
What is the SOA of TZDs?
liver and peripheral muscle
What DDI does Rosiglitazone have?
insulin, nitrates
What DDI does Pioglitazone have?
oral contraceptives, progestins, pazopanib
What are CI of TZDs?
hypersensitivity
T1DM
DKA
ALT > 2.5xULN
NYHA Class 3-4
Symptomatic CHF
ACS
What is a CI of pioglitazone?
active bladder cancer
What are precautions for TZDs?
NYHA class 1-2
edema
impaired liver fx
insulin/SU use
bladder cancer hx
fracture risk
MI –> rosiglitazone has higher risk
females –> can induce ovulation
What is the BBW for TZDs?
CHF
What is the BBW specific to Rosiglitazone?
MI
What are ADEs of TZDs?
edema –> may worsen CHF
weight gain
hepatotoxicity
fractures
What is an ADE specific to Pioglitazone?
Bladder cancer
How are TZDs dosed?
QD; same time each day
report weight gain &/or swelling of legs immediately
What should you ask about for every refill of TZDs?
edema and weight gain
What efficacy are TZDs?
high
Do TZDs cause hypoglycemia?
no
what cost are TZDs?
low cost
What ASCVD risk do TZDs have?
potential benefit with pioglitazone
What HF risk do TZDs have?
inc. risk
What CKD risk do TZDs have?
neutral
Do TZDs require renal dose adjustment?
no
What do you monitor in TZDs?
LFTs
edema
weight gain
cholesterol panel
FBG/PPG
A1C
How long until TZDs reach peak effect?
6-8 weeks
What drugs are alpha-glucosidase inhibitors (AGIs)?
acarbose
miglitol
Are AGIs PO or SQ?
PO
How are AGIs dosed?
TID; dosed with every meal –> take with first bite of each meal
skip meal, skip dose
start low, go slow
they have a v short half life
What is the MDD of Acarbose?
50mg
What is the MDD of Miglitol?
100mg
What is the MOA of AGIs?
dec. breakdown of sucrose and complex carbs in the brush border of the SI
What is the SOA of AGIs?
gut
What are the CIs of AGIs?
hypersensitivity
T1DM
DKA
IBS
Crohn’s disease
colonic ulceration
intestinal obstruction
SCr > 2.0
What are precautions of AGIs?
impaired renal fx
What are ADEs of AGIs?
GI: abdominal pain, diarrhea, flatulence, bloating –> ADEs more intense than metformin
When on AGI, when should you contact a MD?
if severe diarrhea or vomiting occur
What should you ask about for every refill of a AGI?
GI upset and meal timing
What efficacy are AGIs?
high
Do AGIs cause hypoglycemia?
no
What are the cost of AGIs?
intermediate cost
What ASCVD risk are AGIs?
neutral
What HF risk are AGIs?
neutral
What CKD risk are AGIs?
neutral
What ASCVD risk are AGIs?
no
Do AGIs cause weight gain or weight loss?
no weight change
What do you monitor in AGIs?
PPG, A1C
GI intolerance
How long until AGIs reach peak effect?
4-6 weeks
What drugs are Gliptins/DPP4is?
(-gliptin)
Sitagliptin
Linagliptin
Saxagliptin
Alogliptin
Are DPP4s PO or SQ?
PO
What is the dose of Sitagliptin?
100mg daily
What is the dose of Linagliptin?
5mg daily
What is the dose of saxagliptin?
5mg daily
What is the dose of Alogliptin?
25mg daily
What is the MOA of DPP4s?
potentiate the effects of incretin hormones (which are involved in the physiologic regulation of glucose homeostasis)
What is the SOA of DPP4s?
suppresses glucagon secretion
slows gastric emptying
dec. food intake
promotes beta cell proliferation
What DPP4 inhibitor is does not have a renal dose adjustment?
linagliptin
What is a DDI with Saxagliptin?
conivaptan
What is a DDI with Linagliptin?
carbamazepine
Efavirenz
phenytoin
rifampin
St. John’s Wort
What is a DDI with Sitagliptin?
none
What is a DDI with Alogliptin?
none
What are CIs are DPP4s?
hypersensitivity
T1DM
DKA
What is a precaution of DPP4s?
impaired renal & hepatic fx
What is a precaution specific to Saxagliptin and Alogliptin?
HF –> FDA warning
What drug class should you never use with DPP4 inhibitors?
GLP-1 RA
What are ADEs of DPP4s?
nasopharyngitis
URI
abdominal pain
N/V/D
headache
edema
hepatotoxicity
How should you take DPP4s?
take QD; same time each day
can be taken with or without food
What should you ask about at every refill for a DPP4?
nasopharyngitis and URI
What efficacy are DPP4s?
intermediate
Do DPP4s cause hypoglycemia?
no
What cost are DPP4s?
high cost
What ASCVD risk do DPP4s have?
neutral
What HF risk do DPP4s have?
potential risk with saxagliptin and alogliptin
What CKD risk do DPP4s have?
neutral
Do DPP4s require renal dosing?
Yes except Linagliptin!!!
What should you monitor for DPP4s?
FBG, PPG
A1C
URI Sx
GI intolerance
What drugs are SGLT2 inhibitors?
(-flozin)
Canagliflozin
Dapagliflozin
Empagliflozin
Ertugliflozin
Are SGLT2s PO or SQ?
PO
How are SGLT2 inhibitors dosed?
QD; same time each day
What is the MOA of SGLT2s?
by inhibiting SGLT2, reabsorption of filtered glucose is dec. and the renal threshold for glucose (glucose reabsorption) is lowered, thereby inc. urinary glucose excretion
How long until DPP4s reach peak effect?
6-8 weeks
Do DPP4s cause weight gain or loss?
no weight change
What is the SOA of SGLT2i?
proximal renal tubules
What are CIs of SGLT2s?
eGFR < 30 (renal failure)
dialysis
ESRD
What are DDIs with SGLT2s?
UGT enzyme inducers
Rifampin
Ritonavir
Phenytoin
Phenobarbital
watch for hypotension if pt on: ACE/ARB/diuretic
may alter digoxin levels
What are precautions of SGLT2s?
hypotension
genital mycotic infections
UTIs
AKD
ketoacidosis
hyperkalemia
bladder cancer
amputations
What are ADEs of SGLT2s?
genital mycotic infections
UTIS
inc. urination
hypotension
weight loss
ketoacidosis: stay hydrated
Fournier’s Gangrene
What ADEs are specific to Canagliflozin?
lower limb amputations
bone fractures
hyperkalemia
What ADEs are specific to Dapagliflozin?
bladder cancer
What should you discuss in women who are taking an SGLT2i?
yeast infections/UTIs
What should you discuss in men who are taking na SGLT2i?
circumcision status
UTIs
penile discharge
What efficacy are SGLT2s?
high
Do SGLT2s cause hypoglycemia?
no
What cost are SGLT2s?
high cost
What ASCVD risk do SGLT2s have?
benefit with Canagliflozin, dapagliflozin, empagliflozin
What HF risk do SGLT2s have?
benefit with Canagliflozin, dapagliflozin, empagliflozin
What CKDrisk do SGLT2s have?
benefit with Canagliflozin, dapagliflozin, empagliflozin
Do SGLTs require renal dosing?
yes
Do SGLT2s have weight gain or loss?
weight loss
Do SGLT2s have studies in. black pts for ASCVD, HF and CKD benefits?
no
What do you monitor in SGLT2s?
FBG/PPG
A1C
eGFR
hydration status
UTI & yeast infection sx
BP, weight
LDL cholesterol
How long until SGLT2s reach peak effect?
4-6 weeks
What drugs are GLP-1 RAs?
(-tide)
Liraglutide
Dulaglutide
Lixisenatide
Semaglutide
Exenatide
Are GLP-1s PO or SQ?
SQ
How do you dose Liraglutide?
SQ QD
How do you dose Dulaglutide?
SQ weekly
How do you dose Lixisenatide?
SQ QD, take within 60min of first meal of day
What GLP-1 is PO and SQ?
Semaglutide
How do you dose PO Semaglutide?
PO QD, take 30min prior. to first meal of day
How do you dose SQ Semaglutide?
SQ weekly
How do you dose ER Exenatide?
SQ weekly, must be reconstituted
How do you dose IR Exenatide?
SQ BID, taken 60min before meals
What is the MOA of GLP-1s?
slows gastric emptying
promotes beta cell proliferation
What CI is specific to Exenatide?
CI if CrCl < 30
What GLP-1 has a BBW?
Lixasenatide!!! Thyroid C-cell tumo
What DDIs with GLP-1s cause hypoglycemia?
androgens
insulins/SUs
pegvisomant
What DDIs with GLP-1s cause hyperglycemia?
corticosteroids
danazol
LHRH
somatropin
thiazide diuretics
What are CIs for GLP-1s?
severe GI diseases (IBS, Crohn’s, gastroparesis, etc.)
hypoglycemia
pancreatitis
renal impairment
What are ADEs of GLP-1s?
hypoglycemia
N/V/D
GERD/dyspepsia
injection site rxns
jitteriness
headache
URI/cough
pancreatitis
cholethiasis
How should you store GLP-1s prior to initial use?
store in refrigerator
How should you store GLP-1s after initial use?
may be stored at room temp.
What should you ask about for every refill of a GLP-1?
GI upset and timing of doses
What efficacy are GLP-1s?
high
What cost are GLP-1s?
high cost
Do GLP-1s cause hypoglycemia?
no
Do GLP-1s cause weight gain or loss?
weight loss
What ASCVD risk do GLP-1s have?
benefit with liraglutide, SQ semaglutide, dulaglutide
What HF risk do GLP-1s have?
neutral
What CKD risk do GLP-1s have?
improved renal outcomes with liraglutide and dulaglutide
Do GLP-1s require renal dosing?
only exenatide
What GLP-1s have significant data to support use in blacks?
liraglutide and semaglutide
What do you monitor in GLP-1s?
renal fx
FBG, PPG ,A1C
GI Sx
patient use of device
How long until GLP-1s reach peak effect?
6-8 weeks depending on titration schedule
What is more dangerous, hyperglycemia or hypoglycemia?
Hypoglycemia
