Lecture 14 - DM Treatment Flashcards
When treating a DM patient, what are you goals?
blood glucose control
prevent acute complications (DKA, infection)
CV disease risk reduction
treat/prevent chronic complications
What are the glycemic targets for a “typical” adult?
HbA1C <7% (eAG <154 mg/dl)
Pre-prandial capillary glucose 80-130
Peak post prandial glucose <180
What is the HgA1C level goal for complex/intermediate pt?
<8.0%
U -100
refers to the insulin concentration: 100 units/mL
Basal Insulin
intermediate or long acting insulin or pump
suppress glucose production between meals and overnight
continuously active
Bolus Insulin
mealtime or prandial
rapid or short acting insulin
controls post prandial hyperglycemia
sharp peak effect
Basla Bolus
Giving both rapid acting and long acting insulin
What are the first line oral agents for type 2 DM?
Metformin
Sulfonylureas (glyburide, glipizide, glimepiride)
Dipeptidylpeptase IV inhibitors (DPP4-I)
Sodium glucose cotransporter 2 inhibitors (SGLT2-I)
Pioglitazone
Metformin MOA and SE
suppresses hepatic glucose production
GI side effects common
potential vitamin B12 deficiency
Contraindicated in GFR <30 ml/min
Sulfonylureas MOA and SE
stimulates insulin secretion
risk of hypoglycemia
not recommended in GFR <50 ml/min
DDP-4 Inhibitors MOA and SE
inhibit inactivation of endogenous GLP-1
enhances incretin actions
cost $$$
potential risk of acute pancreatitis and CHF
SGLT2 Inhibitors MOA and SE
increases renal clearance of glucose
$$$
not recommended with GFR <30-60
Canagliflozin BBW for risk of ampuation
risk of bone fx
risk of DKA (class effect) increase LDL cholesterol
Pioglitazone MOA and SE
fat cell actions (??)
can cause weight gain –esp if in combo with insulin
BBW: CHF
risk of bone fx, bladder ca, fluid retention
Metformin + sulfonylurea advantages and disadvantages
+
good efficacy
low cost
- risk of hypoglycemia
tachyphylaxis
Metformin + SGLT-2 advantages and disadvantages
+
good efficacy
low risk of hypoglycemia
weight neutral
- $$$
Metformin + DDP-4I advantages and disadvantages
+
low risk of hypoglycemia
weight neutral
- fair efficacy
Metformin + piglitazone advantages and disadvantages
low dose of piglitazone
+
low risk of hypoglycemia
low cost
- weight gain
control about thiazolidinediones
Should you use DPP-4 inhibitors in pts with high HbA1c?
no
What are the IV antihyperlycemia agents for Type 2 DM?
GLP-1 RA
Insulin
GLP-1 RA
Glucagon-like peptide-1 receptor agonists
IV
high efficacy
no risk of hypoglycemia
weight loss
$$$
BBW - risk of medullary thyroid cancers
GI SE upon initiation —will go away
Insulin IV
highest efficacy
risk of hypoglycemia
weight gain
analog cost higher than human
lower insulin dose as GFR decreases
Metformin + GLP1RA advantages and disadvantages
+
efficacy
low risk of hypoglycemia
weight neutral
- $$$
GI SE
Metformin + SGLT2I + GLP1RA advantages and disadvantages
+
efficacy
low risk of hypoglycemia
weight neutral
- $$$
SE
Metformin + basal insulin advantages and disadvantages
+
very good efficacy
low cost (NPH insulin)
-
weight gain
risk of hypoglycemia
cost if insulin analog
