Exam 3 lecture 5 Flashcards
Name DPP-IV inhibitors
Sitagliptin, Saxagliptin, Linagliptin, Alogliptin
What does DPP IV do as an enzyme?
Breaks down GLP-1 and GIP. DPP inhibitors stop this breakdown.
describe GLP and GIP
they are incretin hormones that are released from the gut and help enhance insulin secretion in response to food.
What do GLPs and GIPs do?
stimulate insulin response in glucose dependent manner (prevent hypoglycemia)
DPP IV inhibitor efficacy
reduces A1c 0.5-1% (not as effective as GLPs)
DPP IV inhibitor effect on weight?
weight neutral
DPP IV dosing strategy
Excreted renally so dose should be adjusted in renal dysfunctions
side effects on DPP IV inhibitors
Nasopharyngitis
pancreatitis
upper respiratory infections
FDA warning for DPP IV inhibitors
Joint pain
HF risk
Which DPP IV inhibitor has no increased risk for CV events
Sitagliptin
sitagliptin dosing
100 mg qd
CRCL 30-50- 50 mg
Saxagliptin dosing
2.5-5 mg
crcl 30-50- 2.5 mg
What is the only DPP IV inhibitor not renally eliminated
Linagliptin (no renal adjustments needed)
Linagliptin dose
5 mg
alogliptin dosing
25 mg
CRCL 30-50- 12.5 mg
less than 30 CRCL- 6.25
sulfonylurea MOA
Stimulates insulin release from B cells
increases binding between insulin and receptor and also increases the number of receptors
What type of pts in sulfonylureas used in?
type 2 pts
name suulfonylurea drugs
Glyburide, glipizide, glimepride
Which sulfonylurea is preferred in renally impaired pts? why?
Glipizide
It is metabolized without active metabolites
side effects of sulfonylurea
Risk for hypoglycemia
glipizide dosing?
glipizide XL dosing?
starting 2.5-5
increase dose every 1-2 weeks until 20 mg (until 10 mg in glipizide XL)
glyburide dosing?
starting 1.25-5, max is 10 mg
Who are the best candidates for sulfonylureas
No type 1 pts
FBS<250
TZDs MOA
bind to PPAR-gamma on fat cells to allow us to decrease insulin resistance and decrease hepatic glucose production
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?
No
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
