ENDO-DMRX

Question 1

What is the 1st line medical management for type 2 DM

Answer 1

Biguanides: metformin (Glucophage, Glucophage XR, Glumetza, Fortamet)

Question 2

What is the MOA of Biguanides

Answer 2

DEC hepatic glucose production
may improve glucose utilization in periphery.
Insulin must be present

SE-diarrhea, lactic acidosis with liver or renal impairment

Question 3

What is MOA of Thiazolidinediones (TZD) (Zones)
rosiglitazone (Avandia),
pioglitazone (Actos)

Answer 3

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.

Question 4

What is the MOA, ADR of Sulfonylureas-( RIDE)
glyburide (Micronase, Diabeta, Glynase)

glipizide (Glucotrol, Glucotrol XL),

glimepiride (Amaryl)

Answer 4

INC first-phase beta cell insulin secretion

ADR-Hypoglycemia and weight gain

Question 5

What are the 1st generation and ADR Sulfonylureas

Answer 5

tolbutamide (Orinase) rare

Short acting requires multiple daily dosing.

Question 6

What are the MOA, ADR of Meglitinides (NIDES)
repaglinide (Prandin)
nateglinide (Starlix)

Answer 6

Non-sulfa insulin secretogogues
rapid onset
short duration, so less post meal hypoglycemia.

hypoglycemia, weight gain

Question 7

What inhibits enzyme alpha glycosidase and causes gas?

Answer 7

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.

Question 8

What binds to beta cells in response to food?

Answer 8

glucagon like peptide-1 (GLP-1)
GLP-1 is released from the cells in the gut
stimulating insulin release

Question 9

What are the MOA ,ADRs of Incretin mimetics (Injectables) (TIDE)

1 exenatide (Byetta), (Bydureon), 
2 liraglutide (Victoza) albigultide (Tanzeum),
3] dulaglutide, (Trulicity)

Answer 9

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

Question 10

What enzyme inactivates incretin hormones, which are involved in the physiologic regulation of glucose homeostasis.

Answer 10

dipeptidyl peptidase-4

DPP-4 enzyme

Question 11

Describe the MOA of dipeptidyl peptidase-4 (DPP-4) inhibitors

Answer 11

inhibiting DPP-4, prolongs incretin:
increases insulin release
decreases glucagon in a glucose-dependent manner.

comparable to placebo, pancreatitis

Question 12

What drugs are in the dipeptidyl peptidase-4 (DPP-4) inhibitors class? (TIN)

Answer 12

TIN-
sitagliptin phosphate (Januvia), 

saxagliptin (Onglyza),

linagliptin (Tradjenta),

alogliptin (Nesina)

Question 13

What is a lipid lowering polymer?

Answer 13

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

Question 14

Dosing of Colesevelam hydrochloride (Welchol)

Answer 14

Dosing: 3.8 g/day (either 6 625mg tabs/d or OS)

Question 15

What is a dopamine receptor agonist assoc with insulin resistance?

Answer 15

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.

Question 16

Describe the dosing of bromocriptine mesylate (Cycloset)

Answer 16

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

Question 17

What med inhibit glucose reabsorption from renal tubules?

Answer 17

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)

Question 18

Describe the use of Insulin and Symlin to treat DM

Answer 18

Typically at much higher doses and in combination with oral medications.

Insulin- safe if dosed appropriately 
#1DOC for renal or hepatic impairment.

Question 19

What drugs are recommended for initial monotherapy

Answer 19

1] Metformin,

2] GLP 1 RA,

3] SGLT-21,

4] DPP-4 Inhbitor,

5] AGI

Question 20

When is step up therapy recommended?

Answer 20

If goal NOT met in 3 months

Question 21

How is dual therapy?

Answer 21

Met + 1st line monotherapy drug or

MET + Colesevelam, Bromocriptine, AGI

Question 22

What is triple therapy for DM2?

Answer 22

Met + 2- 1st line monotherapy drug or

MET+ Colesevelam, Bromocriptine, or AGI

Question 23

When should insulin be started?

Answer 23

Pt on dual therapy BUT A1c 8, FBS 130,

titrate

Question 24

What should be considered when starting insulin?

Answer 24

D/C or reducing sulfonyureas

Question 25

Describe the initial dosing for insulin in type II management

Answer 25

1- A1C <8% 0.1-0.2 u/kg,

2] A1c >8% 0.2-0.3 u/kg

Question 26

What are the glycemic goals

Answer 26

1] AACE- HbA1c goal of <6.5%,
ADA HbA1c goal is <7%,

2] 2 hour post prandial <140mg/dl,

3] BP <130/80