Exam 3 lecture 3 Flashcards
What is the somogyi effect
Nocturnal hypoglycemia and their body rebounds as hyperglycemia in the morning.
We rule this out by checking hypoglycemia in the middle of the night.
How to treat somogyoi effect
Move NPH from dinner to bedtime or add a bedtime snack
What to do on sick days as a diabetic
Let someone know you are feeling sick
continue insulin even if food intake decreases
maintain fluid intake
Test BG every 1-4 hours
Test urine for ketone
When to switch to concentrated for?
When there is leakage or 200-300 TDD dose
What are some non-insulin agents
Metformin, SGLT-2 Inhibitors, GLP-1, DPP 4, TZD, sulfonylurea
Which non insulin drugs increase insilin secretion
Increased by sulfonylureas
meglitinides
Incretins
Which non insulin drugs decrease glucagon secretion
Incretins and amylin
Hepatics glucose output is decreased by
Metformin and TZDs
Glucose uptake and utilization is increased by
TZDs and metformin
Glucose reabsorption is decreased by
SGLT-2 inhibitors
mechanism of action of metformin
Decreases hepatic glucose production
increases glucose utilization
increases GLP-1 secretion
Increases uptake and utilization by muscles
When to use metformin? Uses of metformin?
On type 2 patients and obese type 1 pts. Decrease CV risk.
Metformin CV risk? hypoglycemia risk? effect on weight? Price? Lipid levels?
lowers risk for CV event
minimal risk for hypoglycemia
neutral effect on weight
not expensive
decrease LDL
A1c reduction by metformin
1.5-2% (not as efficacious as insulin, but better than other non-insulin meds)
metformin might cause_____ which can be a disadvantage
lactic acidosis
Who is at risk for developing lactic acidosis when taking metformin
Alcoholics, HF patients, Post MI and COPD, decreased renal function
What do we consider when dosing metformin
eGFR
MEtformin and surgery?
Dx metformin before and a little after surgery
Metformin can cause what deficiency
B12
What side effects does metformin have
GI side effects (food helps decrease side effects)
(nausea, diarrhea)
gets better with time
titrate from 500 per day to 2000 grams
dosing for metformin based of EGFR
> 60- Monitor Scr annually, no problems
between 45 and 60- safe to start therapy, monitor scr every 3-6 months
between 30 and 45- starting metformin not recommended, decrease dose by 50% if already taking. Monitor every 3 months
below 30- do not start
stop if already taking
How do SGLT2 inhibitors work?
They lead to renal glucose excretion via urine.
What is the initial therapy for type 2 diabetics
SGLT-2 inhibitors or GLP-1 inhibitors with or without metformin
What other conditions does SGLT-2 inhibitors affect
Used in type 2 at risk for CVD, HF and CKD.
Can SGLT-2 inhibitors be used in HF patinets
Yes
Efficacy of sglt-2 inhibitors
Weaker than GLP-1 and metformin in reduction of A1c
Lowers weight
Lowers BP
very effective at post prandial reduction
What drugs are good for BP reduction
SGLT-2 inhibitors
Side effects of SGLT2 inhibitors
UTIs (because of sugar in urine) and genital fungal infections (yeast infection)
hypotension
Can increase cholesterol
FDA warnings for SGLT2 inhibitors
-DKA (seen in type 2 patients with elevated bs, caused by dehydration or lowering of insulin) (do not give pt SGLT-2 with hx of DKA)
bone fractures (especially in canagliflozin)
-acute kidney injury
-foot amputations (becareful in pts with acute foot infections)
-fourniers gangrene (seek immediate medical attention if soreness or pain in taint area)
How long before a surgery should we hold SGLT2?
3 days
4 days for ertugliflozin
restart after baseline food/oral intake is back to normal
Can you use SGLT2 inhibitors on dialysis?
No, you can not pee it out.
when not to start SGLT2 inhibitors based on eGFR
<30
Of already on it, monitor
name SGLT-2 drugs
Canagliflozin
dapagliflozin
empagliflozin
HF an kidney disease patients with diabetes should use
SGLT2 inhibitors, these drugs are expensive
Name GLP-1 antagonist drugs
Liraglutide, dulaglutide, semaglutide
what do GLP-1 drugs do?
promote insulin secretion by stimulating basal cell growth
inhibits glucagon secretion, delays gastric emptying, decreases apetite
Hypoglycemic risk with GLP-1 inhibitors
very low because insulin is only released when glucose is elevated
Initial treamment with type 2 diabetes?
SGLT 2 or GLP 1 inhibitors with or without metformin
GLP can reduce risk for
CV risk, CKD, HF
WHy is insulin +GLP 1 recommended?
Efficacy is incredible with both of these.
efficacy of GLP-1
Lowers A1c better than SGLT-2 but not as good as metformin
Massive weight loss
Which GLP-1 inhibitors have a bigger effect on PPG? which ones of fasting BG?
Short acting affect PPG
long affect fasting
What are some adverse effects of GLP-1 agonists
nausea in half of the users
Which type of patients is GLP-1 never used in
pancreatitis and thyroid cancer
What new warning id there for GLP-1 pts
Gall bladder disease (ask pt for FH), dx if there is FH
Avoid GLP-1 is pts with _________ and _________
gastroparesis and retinopathy
What are the 4 contraindications that we should look out for when giving out GLP-1s
Retinopathy, gall bladder issues, pancreatitis, thyroid cancer
What are the dosings of some popular GLP-1s
Trulicity- once weekly
Victoza- daily
Ozempic- Weekly
oral semaglutide name
Rybelus
Dosing for rybelus
Start at 3 mg po x 30 days
increase dose to 7 mg, can increase to 14 mg if neededs
side effects of rybelus
lots of nausea
How to prevent nausea from rybelus
Take 30 mins before food
Other than improving diabetes, what other uses do GLP-1 agonists have
CV benefits and renal benefits
Which drug has dual action as GLP-1 and GIP RA
Mounjaro (tirzepatide)
Does mounjaro act in a glucose dependent manner?
Yes, it reduces glucagon in a glucose dependent manner. It also delays gastric emptying and increases satiety, causing weight loss.
efficacy of mounjaro
reduces A1c comparable to metformin.
leads to massive weight loss and lowering of FBG
Mounjaro adverse effects
Ask about retinopathy, gall bladder, thyroid cancer and pancreatitis.
tachycardia
Dosing mounjaro
Start at 2.5 mg per week
adjust by 2.5 every week until 15 mg/week
