Exam 3 lecture 5 Flashcards by Matti Daniel

Name DPP-IV inhibitors

Sitagliptin, Saxagliptin, Linagliptin, Alogliptin

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What does DPP IV do as an enzyme?

Breaks down GLP-1 and GIP. DPP inhibitors stop this breakdown.

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describe GLP and GIP

they are incretin hormones that are released from the gut and help enhance insulin secretion in response to food.

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What do GLPs and GIPs do?

stimulate insulin response in glucose dependent manner (prevent hypoglycemia)

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DPP IV inhibitor efficacy

reduces A1c 0.5-1% (not as effective as GLPs)

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DPP IV inhibitor effect on weight?

weight neutral

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DPP IV dosing strategy

Excreted renally so dose should be adjusted in renal dysfunctions

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side effects on DPP IV inhibitors

Nasopharyngitis
pancreatitis
upper respiratory infections

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FDA warning for DPP IV inhibitors

Joint pain
HF risk

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Which DPP IV inhibitor has no increased risk for CV events

Sitagliptin

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sitagliptin dosing

100 mg qd
CRCL 30-50- 50 mg

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Saxagliptin dosing

2.5-5 mg
crcl 30-50- 2.5 mg

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What is the only DPP IV inhibitor not renally eliminated

Linagliptin (no renal adjustments needed)

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Linagliptin dose

5 mg

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alogliptin dosing

25 mg
CRCL 30-50- 12.5 mg
less than 30 CRCL- 6.25

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sulfonylurea MOA

Stimulates insulin release from B cells
increases binding between insulin and receptor and also increases the number of receptors

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What type of pts in sulfonylureas used in?

type 2 pts

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name suulfonylurea drugs

Glyburide, glipizide, glimepride

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Which sulfonylurea is preferred in renally impaired pts? why?

Glipizide

It is metabolized without active metabolites

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side effects of sulfonylurea

Risk for hypoglycemia

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glipizide dosing?
glipizide XL dosing?

starting 2.5-5
increase dose every 1-2 weeks until 20 mg (until 10 mg in glipizide XL)

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glyburide dosing?

starting 1.25-5, max is 10 mg

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Who are the best candidates for sulfonylureas

No type 1 pts
FBS<250

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TZDs MOA

bind to PPAR-gamma on fat cells to allow us to decrease insulin resistance and decrease hepatic glucose production

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TZD drug name

pioglitazone

Benefits of TZDs

Pioglitazones can decrease TG by 10-20% (make LDL fluffy and they do not stick together)

What are things we should monitor when taking pioglitazine

LFT (liver function test)

Adverse effects of TZDs

Hepatotoxicity increases fracture risk weight gain and edema

when to dx pioglitazone

when LFT is 3x normal

Which drugs exacerbate HF

TZDs (pioglitazone, metformin, DPP IV inhibitors (except sitagliptin)

Which drugs are good in HF pts

SGLT-2 inhibitors

dosing of pioglitazone

initial- 15-30 mg max- 30-45 titrate dose every 12 weeks

Can pioglitazone be used for MI/stroke pts?

Yes, not in HF pts

T/F In patients with T2DM, a GLP-1 is preferred to insulin when possible

True

When should we consider adding insulin (basal bolus) to GLP-1 agonists

evidence of weight loss, polyuria, dipsia and phagia. BG readings are >300, a1c>10%

When to add bolus insulin to basal insulin

If basal dose= 0.5 units/kg/day

Can we use DPP IV inhibitors and GLP 1 together?

goal A1c for women with diabetes that are planning to concieve

<6%

Glycemic targets in pregnancy

fasting-70-95 1h ppg- 110-140 2 h ppg- 100-120 a1c<6% use CGMs

What are some changes to insulin physiology in pregnancy

In early pregnancy, insulin sensitivity is enhanced, leading to hypoglycemia. By 16 weeks resistance increases exponentially

When is there an increased risk of hypoglycemia in pregnancy

Early pregnancy.

Pregnancy is a ______ state

Ketogenic DKA can increase still births

What happens to insulin sensitivity after baby is delivered

insulin sensitivity increases

what meds need to be dx at pregnancy

statins, ACE-I, ARBs,

type 2 pregnant patients BP goal

110-135/85

what type of pregnancy loss is more common in T1DM? What about T2DM?

T1DM- first trimester T2DM- Third trimester

Insulin dose requirements during pregnancy

Increases. drops after delivery

Dose of insulin for gestational diabetes

0.7-1 units/kg/day as basal-bolus

What should be used in gestational diabetes if patient can not take insulin

metformin. If taking for PCOS, dx by the end of 1st trimester

T/F GDM is associated with risk of diabetes at 50-75% after 15-25 yrs

true

How is type 2 in children different from type 2 in adults

Children have a more rapid decline in B cell function

type 1 treatment

Insulin

what is the honeymoon phase in type 1 DM

The body responds really well to insulin 1st few months of therapy so only 1 dose a day can be sufficient. This will eventually stop

for type 2 diabetic children with A1C<8.5%, what is the initial therapy

metformin

for type 2 diabetic children with A1c >8.5%, what is initial therapy

basal insulin+metformin

In children with type 2 diabetes already on basal insulin and metformin that are not controlled, what do we add to therapy

GLP-1 RAs on children 10 or above

What are some GLP 1 RAs approved in children

Liraglutide exenatide

What do we add to type 2 children that are not at goal on metformin, basal and GLP1 RAs

Bolus insulin

If a patient presents with DKA we treat with

SQ or IV insulin

diabetes goals in older patients with very few coexisting conditions

A1c-7-7.5 Fasting- 80-130 bedtime- 80-180 BP<130/80

diabetes goals in older patients with complex/intermediate chronic illnesses

A1c<8% fasting- 90-150 bedtime-100-180 BP<130/80

Diabetes goals in pts with older pts very poor health

control hyper/hypo glycemia BP<140/90

Medication causes for elevated BS

Glucocorticoids (prednisone) reahces peak plasma levels at around 4-6 hours.

How do we adjust Insulin when taking prednisone

Since BG peaks in 4-6 hours on prednisone, it peaks at the same time as NPH, addition of NPH can help this. Morning dose of prednisone= more insulin in morning

How do we adjust insulin when taking dextromethorphan

Long acting insulin is increased because dextromethorphan is long acting

peri operative management in diabetuiucs

BG target- 100-180 reduce basal insulin the evening before surgery by 25% Hold all bolus insulin once patient becomes NPO metformin should be held the day of surgery SGLT-2 should be held 3 days before (4 days for empagliflozin) hold allogliptin the morning of surgery Give half NPH dose

GB target before surgery

100-180

basal insulin perioperative

reduce basal insulin by 25%

bolus insulin perioperative

hold all bolus insulin once patient becomes NPO

Metformin perioperative

metformin should be held the day of surgery

SGLT2 perioperative

should be stopped 3 days before surgery (4 for empagliflozin)

Allogliptin perioperative

should be stopped the morning of surgery

NPH perioperative

give half dose the morning of surgery