Exam 1 Flashcards
Sulfonylureas
MOA:
Stimulate insulin release from Beta cells (Pancreas)
“Insulin secretagogues”
Oral.
What meds are SUs?
Glyburide (DiaBeta, Micronase) BEERS list
Glipizide (Glucotrol)
Glimepiride (Amaryl) BEERS list
SU dosing
Glyburide 1.25-20 daily
Glipizide 2.5-20, 1-2 times daily
Glimepiride 1-4mg daily
SU side effects
Hypoglycemia
N/V
Weight gain
Use w/ caution in elderly
SU Drug interactions
Alcohol
Displaced protein binding
Decreased renal secretion
SU Contraindications
DKA Hypersensitivity T1DM CrCl<50 for glyburide Near-term pregnancy (hlyburide/glipizide)
SU counseling points
Take 1st thing in morning with 1st meal, with food if upset stomach.
Avoid alcohol.
Ask about hypoglycemia and weight gain
SU Monitoring
Hypoglycemia FBG A1c Weight gain Allergies Sun sensitivity 4-6 weeks for full effect
Meglitinides
MOA:
Stimulate insulin release from Beta cells (Pancreas)
Insulin secretagogues, short acting.
(same MOA as SUs, but shorter acting)
Which meds are Meglitinides?
Repaglinide (Prandin)
Nateglinide (Starlix)
Meglitinides dosing (Multiple times a day, since short acting)
Nateglinide 60-120 b4 meals
Repaglinide 0.5-2 mg b4 meals
Meglitinides side effects
Hypoglycemia
GI disturbances
Weight gain
Headache
Meglitinides DI
Repaglinide and NPH insulin : increased risk of MI
Repaglinide and gemfibrozil : avoid
Meglitinides Contraindications
Hypersensitivity
T1DM
DKA
Meglitinides Precautions
Severe renal disease
Impaired liver function
Use with insulin
Meglitinides counseling points
Administer before meal
Repaglini
Meglitinides monitoring
PPG
Hypoglycemia
A1c
Weight gain
Biguanides Primary MOA
Decrease glucose output from the liver (hepatic glucose production)
- Liver
Biguanides Secondary MOA
Increase peripheral
muscle glucose sensitivity (glucose uptake and
utilization)
- Muscles
Which meds are Biguanides?
Metformin
Biguanides dosing
Initial 500 BID or 850 daily
Optimal dosing 1000 BID
titrate slowly
Biguanides Renal dosing
- eGFR 30-45 mL/min: half dose, up to 1,000mg/day
- eGFR ≤ 30 mL/min: Discontinue
- ARF: Discontinue until reversed
Biguanides Side effects
GI trouble (N/V/D) Weight loss
Biguanides DI
Radiopaque contrast dyes (Stop Metformin 24hrs before and 48hrs after)
Biguanides CI
(Dehydration, Sepsis,Surgery ) All sick day issues. Medication should be stopped until resolution
Biguanides Precautions
Elderly
Excessive alcohol
CHF with drug therapy
Biguanides counseling points
Take with food to decrease GI effects
Start low, go slow
Avoid alcohol use
GI upset/diarrhea should decrease over time
Ask about: GI upset, weight loss, Lactic acidosis
Biguanides Monitoring
Renal function ( 6 weeks, then annually)
6-8 weeks to max effect
A1c Q3months
Thiazolidinediones (TZD)
Primary MOA: Increase peripheral
muscle glucose sensitivity (glucose uptake and
utilization)
- Muscles
Thiazolidinediones (TZD)
Secondary MOA
Decrease glucose output from the liver (hepatic glucose production)
- Liver
Which meds are TZDs?
Rosiglitazone (Avandia)
Pioglitazone (Actos)
TZD dosing
Pioglitazone (Actos) 15-30 PO daily
TZD Side effects
Edema (major) Bladder cancer Weight gain Hepatotoxicity Fractures
Pioglitazone DI
(Actos)
Oral contraceptives
Progestins
Pazonib
TZD CI
Active bladder cancer
Hypersensitivity/T1DM/DKA
CHF (symptomatic)
ACS
TZD Precautions
CHF Edema MI (Rosiglitazone) Isulin/SU Bladder cancer history Females (ovulation) Fracture risk
TZD BBW
Can exacerbate CHF (monitor for Sx: weight gain, dyspmea, edema)
MI for Rosiglitazone
Rosiglitazone DI
Insulin
Nitrates
TZD counseling points
Take once a day at the same time each day
Avoid alcohol
Report weight gain or swelling immediately
Do not use in CHF Class 3-4
TZD monitoring
LFTs Edema Weight gain Cholesterol FBG/PPG A1c 6-8 weeks to max effect
Alpha-Glucosidase inhibitors (AGI) MOA
Decreases breakdown of sucrose and complex carbs in brush border of the small intestine (GI)
Which meds are AGIs?
Acarbose (Precose)
Miglitol (Glyset)
AGI dosing
Acarbose: 25 PO TID
Miglitol 25 PO TID
AGI Side effects
GI upset:
- Abdominal pain
- Diarrhea
- Flatulence
- Bloating
AGI CI
Hypersensitivity/DKA
Cirrhosis
IBS and other gut problems
SCr > 2.0
AGI Precautions
Impaired renal function
AGI counseling points
- Start low, go slow (cause GI effects)
- Take with the 1st bite of each meal (Skip meal, skip dose as well)
- Call MD if severe diarrhea or vomiting
AGI Monitoring
PPG
A1c
GI intolerance
4-6 weeks to max effects
Gliptins/DPP4-i MOA
Potentiate the effects of incretin hormones (involved in regulation of glucose homeostasis)
Which meds are DPP4s/Giptins
- Sitagliptin (Januvia)
- Linagliptin (Tradjenta)
- Saxagliptin (Onglyza)
- Alogliptin (Nesina)
DPP4 dosing
Dosed daily.
Sita, Saxa, Alo need renal adjustments
Lina does not
DPP4s/Gliptins Side effects
- Nasopharyngitis
- URI
- Pancreatitis
- Heart failure (Saxa, Alo)
Gliptins/DPP4 CI
Hypersensitivity/T1DM/DKA
Gliptins/DPP4 Precautions
- Impaired renal /hepatic function
- History of pancreatitis
- HF (Saxa, Alo)
- Avoid use with GLP-1
DPP4s counseling points
- Take once a day, same time
- With or without food
- Avoid alcohol
DPP4s/Gliptins Monitoring
- FBG/PPG
- A1c
- URI Sx
- GI intolerance
6-8 weeks to max effects
sglt-2i MOA
Inhibits SGLT2 thus reabsorption of filtered glucose is reduced and the renal threshold for glucose is lowered.
- Urinary glucose excretion increases.
Which drugs are SGLT2i?
Canagliflozin (Invokana)
Farxiga (Dapagliflozin)
Jardiance (Empagliflozin)
Steglatro (Ertugliflozin)
SGLT2i dosing
PO daily All contraindicated if eGFR<30 mL/min Canagliflozin (Invokana) NO if GFR<45 Farxiga (Dapagliflozin) NO if GFR<60 Jardiance (Empagliflozin) NO if GFR<45 Steglatro (Ertugliflozin) NO if GFR <60
SGLT2i side effects
- Genital mycotic infections
- Increased urination
- UTIs
- Weight loss
- Ketoacidosis
- ## gangrene
Canagliflozin (invokana) specific side effects
- Lower limb amputation/bone fractures
- Hyperkalemia
Dapagliflozin (Farxiga) Specific side effects
Bladder cancer
SGLT2i DI
UGT enzyme inducers
Rifampin, Ritonavir, Phenytoin. Phenobarbital
Hypotention with ACE/ARB/diuretic
Monitor digoxin levels
SGLT2i CI
- Dialysis
- Renal failure (GFR<30)
- ESRD
SGLT2 precautions
- Hypotension
- Infections (UTI, genital)
- AKI
- Ketoacidosis
- Hyperkalemia (Cana)
- Amputation (Cana)
- Bladder cancer (Dapa)
SGLT2i counseling points
Once a day at the same time
- Hydrate (ketoacidosis)
- Hyperkalemia Hx
- Bladder cancer Hx
- Renal Fx
Which SGLT2 have ASCVD and HF benefits?
Cana
Empa
Dapa
SGLT2 monitoring
FBG/PPG
(all the side effects)
LDL cholesterol
4-6 weeks to max effect
GLP-1 RA MOA
- Suppresses glucagon secretion (glucagon increases blood sugar)
- Increases insulin secretion
- slows gastric emptying
- Promotes b-cell proliferation
GLP-1 RA dosed weekly
- Bydureon (Exenatide ER)
- Trulicity (Dulaglutide)
- Ozempic (Semaglutide)
GLP-1 RA dosed daily
- Byetta (Exenatide IR)
- Victoza (Liraglutide)
- Adylxin (Lixisenatide)
- Rybelsus (Semaglutide) ORAL
GLP-1 RA side effects
- Hypoglycemia
- Nausea/Vomitting/Diarrhea
- Pancreatitis
GLP- 1 DIs that cause HYPOglycemia
- Androgens
- Insulin/SU
- Pegvisomant
GLP-1 DIs that cause HYPERglycemia
- Corticosteroids
- Danazol
- LHRH
- Somatropin
- Thiazide diuretic
GLP-1 RA CI
- Thyroid tumors (Medullary thyroid carcinoma, multiple endocrine neoplasia)
- Severe GI disease
- Pancreatitis
- Renal impairment
- —-ESRD or CrCl <30 (Exenatide -Bydureon, Byetta-)
GLP-1 RA counseling point
- Upset stomach
- Eat smaller meals more frequently
- Refrigerate before initial use
- Ask about GI upset and timing at refills
What counseling point is specific to Rybelsus (Semaglutide)?
Take EXACTLY 30 minutes before eating first meal.
With minimal water (4 oz)
GLP-1 RA monitoring
- Renal Fx
- FBG
- PPG
- GI Sx
- Proper use of device
6-8 weeks to max effects
