ENDO-DMRX Flashcards
What is the 1st line medical management for type 2 DM
Biguanides: metformin (Glucophage, Glucophage XR, Glumetza, Fortamet)
What is the MOA of Biguanides
DEC hepatic glucose production
may improve glucose utilization in periphery.
Insulin must be present
SE-diarrhea, lactic acidosis with liver or renal impairment
What is MOA of Thiazolidinediones (TZD) (Zones)
rosiglitazone (Avandia),
pioglitazone (Actos)
DED insulin resistance in the periphery and to a small degree in the liver.
INC TGs, LDL
Edema (caution w/ CHF), weight gain, elevate LFTs.
What is the MOA, ADR of Sulfonylureas-( RIDE)
glyburide (Micronase, Diabeta, Glynase)
glipizide (Glucotrol, Glucotrol XL),
glimepiride (Amaryl)
INC first-phase beta cell insulin secretion
ADR-Hypoglycemia and weight gain
What are the 1st generation and ADR Sulfonylureas
tolbutamide (Orinase) rare
Short acting requires multiple daily dosing.
What are the MOA, ADR of Meglitinides (NIDES)
repaglinide (Prandin)
nateglinide (Starlix)
Non-sulfa insulin secretogogues
rapid onset
short duration, so less post meal hypoglycemia.
hypoglycemia, weight gain
What inhibits enzyme alpha glycosidase and causes gas?
Alpha glucosidase Inhibitors
acarbose (Precose),
miglitol (Glyset)
MOA- Inhibits digestion of glucose. competitive inhibitors of the enzyme in the brush border of small intestine needed to digest carbohydrates.
ADR- lack of to complex CHO not breaking down in small intestine, when reaches colon bacteria will digest cause GI effects such as ***flatulence and diarrhea.
start low dose and INC dose slowly.
What binds to beta cells in response to food?
glucagon like peptide-1 (GLP-1)
GLP-1 is released from the cells in the gut
stimulating insulin release
What are the MOA ,ADRs of Incretin mimetics (Injectables) (TIDE)
1 exenatide (Byetta), (Bydureon), 2 liraglutide (Victoza) albigultide (Tanzeum), 3] dulaglutide, (Trulicity)
cause glucose-dependent stimulation of insulin secretion, suppression of glucagon
reduction of appetite
delay of food absorption,
resistant to breakdown DPP-4
ADRs- n/v/d, dizziness, headache, weight loss, hypoglycemia (worse with a sulfonylurea)
**pancreatitis (medullary thyroid cancer in rats
What enzyme inactivates incretin hormones, which are involved in the physiologic regulation of glucose homeostasis.
dipeptidyl peptidase-4
DPP-4 enzyme
Describe the MOA of dipeptidyl peptidase-4 (DPP-4) inhibitors
inhibiting DPP-4, prolongs incretin:
increases insulin release
decreases glucagon in a glucose-dependent manner.
comparable to placebo, pancreatitis
What drugs are in the dipeptidyl peptidase-4 (DPP-4) inhibitors class? (TIN)
TIN- sitagliptin phosphate (Januvia),
saxagliptin (Onglyza),
linagliptin (Tradjenta),
alogliptin (Nesina)
What is a lipid lowering polymer?
Colesevelam hydrochloride (Welchol)
non-absorbed, binds to bile acids in the intestine, impeding its reabsorption.
exact mechanism for glycemic control is unknown.
ADRS-Constipation, nasopharyngitis, dyspepsia (indigestion) hypoglycemia, N, HTN
Dosing of Colesevelam hydrochloride (Welchol)
Dosing: 3.8 g/day (either 6 625mg tabs/d or OS)
What is a dopamine receptor agonist assoc with insulin resistance?
bromocriptine mesylate (Cycloset)
reverses metabolic changes associated with insulin resistance/obesity.
(ME-IF happy, reward, can reverse insulin, SAD-cortisol, dont eat LIVER, SUGAR-makes us feel good, visous cycle)
ADRs- N/V/D dizziness, fatigue, headache constipation.
Describe the dosing of bromocriptine mesylate (Cycloset)
1.6 to 4.8 mg Q w/in 2 hours after waking.
Taper-Initiate 1 tablet (0.8 mg) and increased by 1 tab/wk Goal-maximum daily dose of 6 tablets (4.8 mg) or until the maximal tolerated number d/t SE
What med inhibit glucose reabsorption from renal tubules?
Sodium glucose co-transporters 2 (SGLT2) inhibitors promoting urinary glucose excretion
dec. plasma glucose
improve weight in patients with T 2DM.
DEC BP d/t diuretic action
ADRs- Vaginal yeast infections, UTI F>M, uncircumcised, euglycemic DKA.
1] canagliflozin (Invokana) if eGFR <60 dose reduction
DO NOT use if <45,
2] dapagliflozin, (Farxiga) DO not use if egfr <60,
empagliflozin (Jardiance)
Describe the use of Insulin and Symlin to treat DM
Typically at much higher doses and in combination with oral medications.
Insulin- safe if dosed appropriately #1DOC for renal or hepatic impairment.
What drugs are recommended for initial monotherapy
1] Metformin,
2] GLP 1 RA,
3] SGLT-21,
4] DPP-4 Inhbitor,
5] AGI
When is step up therapy recommended?
If goal NOT met in 3 months
How is dual therapy?
Met + 1st line monotherapy drug or
MET + Colesevelam, Bromocriptine, AGI
What is triple therapy for DM2?
Met + 2- 1st line monotherapy drug or
MET+ Colesevelam, Bromocriptine, or AGI
When should insulin be started?
Pt on dual therapy BUT A1c 8, FBS 130,
titrate
What should be considered when starting insulin?
D/C or reducing sulfonyureas
Describe the initial dosing for insulin in type II management
1- A1C <8% 0.1-0.2 u/kg,
2] A1c >8% 0.2-0.3 u/kg
What are the glycemic goals
1] AACE- HbA1c goal of <6.5%,
ADA HbA1c goal is <7%,
2] 2 hour post prandial <140mg/dl,
3] BP <130/80
