Glycemic control

Question 1

Metformin

Answer 1

M: inhibits hepatic gluconeogenesis
Start: 500 mg
CI: GI symptoms

Preop: Hold AM of surgery

NB: initial therapy for asymptomatic, non-catabolic DM2

Question 2

SLGT2 inhibitors “–GLIFOZIN”

Canagliflozin (Invokana)
Empaglifozin (Jardiance)
Dapaglifozin- (Forxiga)

Answer 2

M: Sodium-Glucose Co-transporter 2 inhibitor decreases glucose re-uptake in the PCT, increasing urinary excretion of glucose.

PreOp: Major inpatient surgery: Stop 3 days prior (inc. risk of UTI and hypovolemia)
Minor surgery: Hold on AM of sx

AE: Risk of Hypoglycemia: modest. Osmotic diuresis & dehydration.

Ind: coexisting cardiovascular disease

CI: low carb diet pre-op: discontinue (Bariatric)

Question 3

DPP-4 Inhibitors “–GLIPTIN”

(dipeptidylpeptidase-4 inhibitor)

Saxagliptin (Onglyza)
Sita- (Januvia)

Answer 3

M: prevent degradation of Glucagon-like peptide-1, increasing insulin secretion

PreOp: Hold AM of sx

AE: GI effects

Question 4

GLP-1 receptor agonists “–TIDE”

(glucagon-like peptide receptor)

Long-acting: Liraglutide (Victoza) IM; Semaglutide (Wegovy), IM or PO

Short: Exenatide (Byetta)

Answer 4

M: Stimulates insulin secretion. Native GLP-1 is secreted by small intestine in response to glucose/nutrient load; acts on beta cells to stimulate insulin secretion.

Preop: Hold on AM of sx

SE: Does not cause hypoglycaemia unless combined with insulin or sulfonylureas or glinides

Question 5

SULFONYLUREAS “–IDE”

LA: Glyburide
SA: Glicazide (DiaBeta), Glipizide
Glimepiride (Amaryl), Glibenclamide

Answer 5

M: K-ATP channel inhibitor on beta-cells. Raises resting potential to increase beta-cell sensitivity to meals and increase insulin secretion.

PreOp: Hold on AM of sx

AE: hypoglycemia (after exercise, missed meal, hospitalization, cardiac or renal impairment, malnourished, long-acting)
Weight gain

Question 6

MEGLITINIDES “–glinide”

Repaglinide (GlucoNorm)

Answer 6

M: K-ATP channel inhibitor on b-cells, increasing insulin secretion after meals. Especially useful in pts with CKD

PreOp:

AE: Hypoglycemia (modest)

Question 7

THIAZOLIDINEDIONES
“–glitazone”

pioglitazone (Actos)
rosiglitazone (Avandia)

Answer 7

M:increases adipocyte, myocyte, endothelial glucose utilization. PPAR-alpha and PPAR-gamma pathway activation increases sensitivity to insulin.

Pre-Op: Hold on AM of sx

AE: hypoglycaemia if used with insulin or sulfonylureas, fluid retention (incr risk of CHF), fractures, weight gain,

Question 8

Insulin Long-acting

Answer 8

Onset, duration
Lantus
Humulin U
Levemir

Question 9

Insulin Short-acting

Answer 9

Onset, duration
Humalog, Novalog
Humulin R, Novolin R
Apidra

Question 10

Insulin intermediate-acting

Answer 10

Onset, duration
Humulin L or N
Novolin L or N