Exam 1- Endocrine Flashcards
What is the first line medication for diabetes?
- metformin
- met Forman is strongly associated with improved long-term outcomes for adults with type two diabetes and should almost always be started first
What are some other options of medication to start after metformin?
- sulfonylureas
- thiazoldinediones
- DPP4 inhibitors
- SGLT2 inhibitors
- injectables ( GLP 1 agonist)
What are examples of when another medication other than metformin should be started on diabetic patients?
- if there is a contraindication to metformin like renal impairment or diabetic ketoacidosis
- intolerance to metformin ( nauseous, vomiting, diarrhea, stomach pain)
What are the medications you would have to add as the second agent in diabetic patients with cardiovascular or kidney disease
- semaglutide, empaglifozin, canagliflozin, dapagliflozin
( -glifozin = diabetic cardio patients)
When should insulin be added in conjunction with metformin?
- insulin in conjunction with metformin should be initial therapy for patient with a very high A1c ( more than 9)
What is the major cause of morbidity in diabetic patients?
Cardiovascular disease
Medication management for diabetic patients with hypertension
- different first line anti-hypertensive meds can be used like ACE inhibitors, ARBS, and calcium channel blockers
Oral anti-diabetic meds are just for which type of diabetes?
- type 2!!
( type 1: insulin dependent so only get insulin
Type 2 : can be given insulin or oral antidiabetic agents)
What is a key side effect in a lot of oral anti diabetic medication
Hypoglycemia
( can go down too low)
What are examples of sulfonyuera medications? How does it work? Side effects and patient education?
- glipizide, glyburide
- brings blood sugar down by increasing release of insulin from pancrease
- side effects: hypoglycemia ( blood sugar goes down too much)
- take 30 min before meals
Can cause photosensitivity- wear sunscreen when going outside
• think glip = slide= going down ( BS down) . Slides are in the park outside = photosensitivity
Metglitinides ( example, side effects, education)
- ex: repaglinide
- helps increase insulin release from the pancreas
- side effects: hypoglycemia, angina
- education: take 3 times a day and eat within 30 min of taking med
• think pag= pageant= pageant queen having angina
What medication class is metformin?
Biguanides
Bye guy, I’m taking metformin
Metformin ( how does it work, side effects, pt education)
- decreases glucose production in the liver by increasing uptake of glucose in the body cells
- side effects: GI upset, metallic taste, lactic acidosis ( dizziness, diarrhea, bradycardia, hypotension )
- education: take with meals if procedure with contrast, diet or needs to be NPO= discontinue metformin 48 hours before procedure
• think metFORMIN= foreman= foreman going to construction site with a metal bottle, drinks it and has the metallic taste in mouth and starts to feel dizzy and have diarrhea 
What anti-diabetic meds can cause weight gain/ loss?
- weight gain: insulin, sulfonlyureas ) glip, gly) thiazolodinediones ( TZD) ( ex. Pioglitazone, rosiglitazone)
- weight loss: GLP1 receptors ( end in glutide) ( semaglutide aka ozempic), SGLT Inhibitors ( end in flozin. Ex: empagliflozin aka jardiance)
Which antidiabetic meds can cause hypoglycemia?
- sulfonylureas ( glipizide, glyburide, glimepride)
- meglitinides ( repaglinide, nateglinidine)
- regular insulin, insulin lispro, insulin aspart
How does metformin work?
Decreases glucose production in the liver by increasing uptake of glucose by the body cells
Side effects of metformin?
- GI upset, metallic taste, lactic acidosis ( dizziness, diarrhea, hypotension, bradycardia)
Metformin is contraindicated in patients with glomerular rates ( eGFR) less than…
30
Metformin should be avoided in patients with…
Liver disease
Differences in ADA/ AACE recommendations for glycemic targets
ADA : less than 7%
AACE: less than 6.5%
Why is metformin considered an essential component in type 2 diabetes?
- because of its effectiveness, safety people, and long term beneficial effects
- metformin doesn’t cause hypoglycemia
- weight neutral
- lowers A1C by 1-2% which is better than other oral anti-diabetic meds
Thiazolidinediones ( TZDs)
- medication examples,
- when to avoid TZDs
- ex: pioglitazone, rosiglitazone ( end in litazone)
- avoid in patients with cardiovascular disease!!! Associated with increased CV and edema. May provide fluid retention and edema
Incretin mimetics are associated with…
- weight loss. ( May be desirable in obese patients)
- incretin mimetics are agents that act like incretin hormones like GLP1 ( end in - tide)
When is metformin contraindicated?
- renal impairment ( eGFR less than 30)
- DKA
- lactic acidosis ( any condition associated with increased risk of lactic acidosis like severe infection, shock, hypoxemia)
- liver disease ( can increase risk of lactic acidosis)
- heart failure
- alcoholism
- use in caution with older adults
When should insulin be considered in type 2 diabetes?
- when patients aren’t achieving their glycemic targets despite use of oral anti-diabetic medications or when there is a rapid and significant reduction in blood glucose levels
-over time, patients with type 2 diabetes may need insulin to better control blood glucose
DDP 4 inhibitors ( med examples?)
- End in lipton ( ex sitaglipton, linaglipton)
Think DDP always has the tea( Lipton)
How should insulin be initiated so the patient doesn’t experience hypoglycemia?
- basal insulin should be initiated first ( usually 10 units once daily )
- adjust the dose based on fasting blood glucose levels. Common titration strategy: increase the dose by 2-4 units every 3-7 days until the fasting blood glucose in the target range - discontinue oral secretagogues
- start with long acting insulin if a basal is not used
SGLT2 ( med examples)
- end in flozin ( canagliflozin, dapagliflozin)
What type medication would be good for a diabetic patient with cardiovascular problems?
- SGLT2 inhibitors ( - flozin). SGLT2s regardless of type of heart failure. They are approved to include cardiovascular benefits.
GLP 1 ( glucagon like peptide 1) med examples and good for weight…
- weight loss ( part of incretins)
- examples: end in tide
Which med class would you NOT want to use in diabetic patients with heart failure?
- thiazolidinediones ( TZD) ( ex pioglitazone/ actos)
Can produce fluid retention and meds= contraindicated in heart failure. Can cause weight gain
Cholesterol control in diabetic patients.. what type of meds should every diabetic patient be on
- statin ( atorvastain, others that end in statin). Lowers cholesterol
Cholesterol control in diabetic patients.. what type of meds should every diabetic patient be on
- statin ( atorvastain, others that end in statin). Lowers cholesterol
What kind of meds should a diabetic patient be on with hypertension?
-ACE ( - pril)
-ARBs ( end in sartan)
- calcium channel blockers
• ACE and ARB are also first line for patients with with renal or kidney disease
Diabetic meds that cause weight gain
- sulfonylureas ( glipizide, glyburide) and metglitinides ( repaglinide)
SGLT2 side effects
( end in flozin)
- side effects: UTI, fungal infections, hyperkalemia
GLP1 side effects and contraindications
( end in tide)
- weight loss
- contraindications: hx of thyroid cancer, pancreatis
Insulin ( how many non insulin options before switching to insulin?
3
Starting insulin therapy, what meds to stop?
When you start with fast acting insulin, stop sulfonylureas ( metformin and GLP can continue)
Insulin can cause weight…
Gain
Hypothyroidism vs hyperthyroidism levels
T4 is what you should look at ( low= hypo). TSH is the opposite
- hypothyroidism: low T4, high TSH
- hyperthyroidism: high T4, low TSH
TSH normal range
0.5-4.5
What is the drug of choice for hypothyroidism?
Levothyoxine. Take in AM on empty stomach!!
( synthetic LT4- mimics the normal physiology of the thyroid gland. Stable and well tolerated)
Patients don’t need frequent monitoring since it’s stable, just need monitoring of TSH levels
Hypothyroidism and pregnancy
- hypothyroidism during pregnancy has a lot of adverse effects. Increased rate of miscarriage and decreased intelligence in baby
- pregnant women need more levo, TSH levels need to be monitored every 4-6 weeks
What’s the cause of hypothyroidism?
- hashimotos
- iodine deficiency or excess
What’s the cause of hyperthyroidism?
- Graves’ disease
- hyperthyroidism: exophthalmus ( bulging eyes)
What are the 4 types of insulin?
- rapid acting
- short acting
- intermediate
- long lasting
What are the onset, peaks, and durations of the diff types of insulin?
- rapid acting ( lispro, aspart) : onset 15 min, peak 1 hr, duration 2-4 hrs
- short acting ( regular insulin Humulin R or novolin R): onset 30 min, peak 2-3 hrs, duration 3-6 hrs
- intermediate ( NPH) onset 2-4 hrs, peak 4-12 hrs, duration 12-18 hrs
- long acting ( glargine, determir) : onset 3-4 hrs, NO PEAK, Duration 24 hrs
What’s example of rapid acting insulin ?
Insulin Lispro( humalog) and aspart ( novolog) . Onset 15 min, peak 1 hr, duration 2-4 hrs . Since its rapid onset, make sure their food is right in front of them
• think logs rolling rapidly down hill
What’s examples of short acting insulin?
Regular insulin ( humulin R or Novolin R)
Onset: 30 min
Peak: 2-3 hrs
Duration: 3-6 hrs
What’s an intermediate insulin?
- NPH
onset: 2-4 hrs
Peak: 4-12 hrs
Duration: 12-18 hrs
• think of actor Neil Patrick Harris (NPH) , when you call him he will be on set in 2-4 hrs and stays for a duration up to 18 hrs
What are examples of long lasting insulin?
- glargine ( lantus) think large= long
- determir ( levemir) think detemir lasts a year
Onset: 3-4 hrs
NO PEAK
Duration 24 hrs
Think of old guys= reached their peak (no peak) and don’t mix well ( don’t mix long lasting insulin)
With insulin, draw up…
Clear before cloudy
When should insulin in conjunction with metformin be considered as initial therapy?
- When a patient has a very high A1C greater than 9%
- usually basal insulin is the first insulin added
What is thyrotoxicosis
- signs and symptoms associated with high T3 and T4 that are excessive for the individual ( hyperthyroidism)
What is the medication used for hyper thyroidism?
- propylthiouracil ( PTU) and methimazole ( MMI)
Graves’ disease and pregnancy medication dosage
Graves ( hyperthyroidism)
PTU at the lowest possible dose then switch to MMI for 2nd and 3rd trimester
What is a serious adverse effect of hyperthyroid meds? ( PTU and MMI)
Agranulocytosis ( decrease in granulocytes which is a type of white blood cell)
NTI ( narrow therapeutic index) and levo
Small NTI so small changes can result in significant change in hormone levels
