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DB Therapeutics > Lecture 4 (T2DM Management) > Flashcards

Lecture 4 (T2DM Management) Flashcards

1
Q

MOA of Metformin

A

lowers hepatic glucose production
can also enhance sensitivity
increase glucose utilization via action in the gut

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2
Q

What dosing levels from metformin?

A

start slow - initiate 250-500 mg
desired 850-1000 mg BID
max dose 850 mg TID

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3
Q

What is the efficacy of metformin?

A

reduce A1C to 1.5%
decrease TG and LDL

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4
Q

List DI with metformin

A

Cimetidine
Dolutegravir
alcohol
contrast media

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5
Q

Common AE metformin

A

GI (Diarrhea, N, general abdominal discomfort)

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6
Q

Less Common AE metformin

A

metallic taste
vitamine B12 deficiency with long term use
hypoglycemia

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7
Q

Precautions for Metformin

A

lactic acidosis –> caused by decrease in arterial pH
Sx weakness, malaise, myalgias, heavy labored breathing

this can be a rare SE of metformin

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8
Q

Major CI of metformin R

A

renal impairment with ClCr < 60 ml/min

if 45-59 1500mg/d
if 30-44 1000mg/d
CI when <30

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9
Q

Other CI of metformin

A

History of lactic acidosis
Severe liver disease
Alcohol abuse
Radiologic procedures (iodinated contrast)
Acute illness (severe infection, trauma)
Severe dehydration

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10
Q

When combining with metformin if the pt has
degree of hyperglycemia, addition will have

A

BG lowering efficacy & durability

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11
Q

When combining with metformin if the pt has
risk of hypoglycemia, add will have

A

risk of inducing hypoglycemia

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12
Q

When combining with metformin if the pt has
weight, the add will have

A

effect of weight

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13
Q

When combining with metformin if the pt has
clinical CVD, addition will have

A

effect on CV outcomes

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14
Q

When combining with metformin if the pt has
comorbidities (renal,CHF,hepatic) addition will have

A

CI and S/E

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15
Q

When combining with metformin if the pt has
access to treatment, agent needs to have

A

cost and coverage

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16
Q

MOA of Sulfonylureas

A

they enhance the secretion of insulin by binding to SU receptors on the beta cells of the pancreas
This leads to closing of K+ channels and opening of calcium channels which stimulates insulin secretion
they stimulate both basal and meal-stimulated insulin release

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17
Q

List some of the 2 gen of SUs

A

glyburide
gliclazide
glimepiride

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18
Q

When is glyburide CI? R

A

<60 ml/min

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19
Q

What is the CI for gliclazide? R

A

> 30 ml

Caution with 30-60

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20
Q

Efficacy of SUs

A

reduce A1C –> 1 to 1.5%
works quickly

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21
Q

Common AE of SU

A

hypoglycemia
weight gain

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22
Q

Uncommon AE of SUs

A

nausea, rash, photosensitivity

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23
Q

CI of SUs

A

pregnancy and breastfeeding
CI for both hepatic and renal impairment

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24
Q

DI of SUs

A

Sulfonamides, salicylates, warfarin
alcohol
cimetidine
clarithromycin
fluconazole
NSAIDs
beta-blockers
MAOIs

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25
Q

Drugs in Meglitinides

A

repaglinide

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26
Q

MOA of meglitinides

A

binds to a site adjacent to the SU receptor, resulting in stimulation of the secretion of insulin from the pancreas

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27
Q

Efficacy of meglitinides

A

lowers A1C 1-1.5%

works primarily to decrease PPG

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28
Q

AE of repaglinide

A

hypoglycemia
weight gain
similar to SU but less SE

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29
Q

DI of repaglinide

A

increase 3A4 inhibitors (cyclosporine, grapefruit)
increase 2C8 (gemfibrozil, clopidogrel)
decrease 3A4 inducers (carbamazepine)

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30
Q

What drugs are alpha-glucosidase inhibitors?

A

acarbose

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31
Q

MOA of acarbose

A

α-Glucosidase enzymes in the small intestine are responsible for the breakdown of polysaccharides into absorbable glucose
Acarbose inhibits these enzymes, hence there is a delay in the rate of digestion of CHO’s and glucose absorption

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32
Q

Efficacy of acarbose

A

reduce AC1 0.5-0.8%
reduce PPG levels

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33
Q

Main AE of acarbose

A

flatulence and diarrhea

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34
Q

Other AE of acarbose

A

bloating, abdominal pain
hypoglycemia

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35
Q

DI of Acarbose

A

digestive enzyme preparations
may decrease digoxin effect

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36
Q

What pts to be cautious with acarbose?

A

IBD or GI conditions

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37
Q

CI with acarbose R

A

<25 ml/min or severe liver disease

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38
Q

What drugs are in thiazolidinediones?

A

rosiglitazone
pioglitazone

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39
Q

MOA of thiazolidinediones

A

bind to PPAR-y receptors which are primarily found in adipose tissue
enhance insulin sensitivity at muscle, liver, and fat tissues

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40
Q

Efficacy of thiazolidinediones

A

lower A1C 1-1.5%

TG - P decrease, ros is neutral
LDL - P neutral, ros is increase
HDL - both increase

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41
Q

DI of thiazolidinediones

A

anything metabolized by CYP 2C8
increase with inhibitors (TMP)
decrease with inducers (rifampicin)

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42
Q

What is the caution with thiazolidinediones? R

A

<60m/min
mainly metabolized by liver (liver disease)

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43
Q

AE of thiazolidinediones

A

peripheral edema
new-onset/worsening of HF
weight gain
increase distal fractures in postmenopausal women

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44
Q

Rare AE of thiazolidinediones

A

Macular edema: report any blurred vision, loss of sight
Anemia: not very common; long-term side effect
Pio: possible ↑ bladder cancer risk?…dont use if history of
Rosi: possible ↑ MI

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45
Q

Cardiovascular safety of TZDs

A

there was a study that showed that there is an increase risk of MI
but there was another study that disproved it
because of this all new diabetes meds require a CV outcome trial to show that these meds are not bad for the heart

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46
Q

List the examples of GLP-1 receptor agonists

A

semaglutide
exenatide (daily and weekly)
liraglutide
dulaglutide
lixisenatide

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47
Q

List the examples of DPP-4 inhibitors

A

linagliptin
sitagliptin
saxagliptin

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48
Q

MOA of DPP4 inhibitors

A

block the enzyme DPP4 which rapidly hydrolyzes incretins, thus enhancing the action of endogenous incretins

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49
Q

Efficacy of DPP4 inhibitors

A

decrease A1C 0.7

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50
Q

Dosing for Sitagliptin (normal and renal adjustment)

A

100 mg Once daily

30-44 –> 50 mg Once daily

<30 –> 25 mg Once daily

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51
Q

Dosing for saxagliptin (normal and renal adj.)

A

5 mg Once daily

30-44 –> 2.5 mg Once daily

<30 –> use with caution

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52
Q

CI for saxagliptin

A

avoid in ESRD, dialysis

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53
Q

Dosing for linagliptin (normal and renal adj.)

A

5 mg Once daily

no dose adjustment needed

54
Q

Dosing for alogliptin (normal and renal adj.)

A

25 mg Once daily

30-44 –> 12.5 mg Once daily

<30 –> 6.25 mg Once daily

55
Q

Most common AE of DPP4i

A

overall, well tolerated meds
no hypo on their own
weight neutral

headache
nasopharyngitis
URTI

56
Q

Rare AE of DPP4i

A

hypersensitivity rxn
bullous pemphigoid
joint pain
pancreatitis

57
Q

Cautions with DPP4i

A

history of pancreatitis

58
Q

DI for DPP4i

A

combined SU or insulin –> increase hypoglycemia

avoid GLP1RA (similar MOA)

59
Q

DI for saxagliptin

A

clearance is reduced / enhanced with strong CYP 3A4 inhibitors and inducers

60
Q

DI for linagliptin

A

clearance is enhanced with strong 3A4 inducers

61
Q

MOA of GLP1RA

A

stimulate insulin secretion in a glucose-dependent manner
lowers glucagon, slow gastric emptying
increase satiety

62
Q

Storage requirements for GLP1RAs

A

in the fridge for most of the time
at home most can be out of the fridge for 2-4 wks

semaglutide –> always room temp

63
Q

Which GLP1RAs are short acting?

A

exenatide
lixisenatide

64
Q

Which GLP1RAs are long acting?

A

liraglutide
exenatide
liraglutide
semaglutide

65
Q

What is the formulation of oral semaglutide?

A

po bioavailable, when co formulated with SNAC
but only 1% makes the journey

66
Q

Renal dosing considerations for dulaglutide

A

<15

67
Q

Renal dosing considerations for liraglutide

A

<15

68
Q

Renal dosing considerations for semaglutide SC

A

<15

69
Q

Renal dosing considerations for semaglutide PO

A

<30

70
Q

Renal dosing considerations for exenatide QW

A

CI <30
caution in 30-50

71
Q

Renal dosing considerations for exenatide

A

CI <30
caution in 30-50

72
Q

Renal dosing considerations for lixisenatide

A

CI < 30
limited data

73
Q

Efficacy of GLP1RAs

A

decreases A1C about 1-1.5%
longer are more potent than short acting
works on both FPG and PPG

74
Q

Common AE for GLP1RAs

A

N/V/D (nausea)

75
Q

Some tips to minimize nausea for GLP1RAs

A

tell pt what to expect
stop eating when full
eat smaller portions and eat slowly
consider end of day dosing
stay hydrated and drink cold water when nauseous

76
Q

Rare AE of GLP1RAs

A

acute gallstone disease
acute pancreatitis
increase cancer risk
retinopathy

77
Q

GLP1RAs affect on weight

A

weight loss
amount various
was not due N/V/D

78
Q

DI with GLP1RAs

A

since these drugs decrease gastric emptying
oral contraceptives
antibiotics
narrow TI drugs

79
Q

T/F
GLP1RAs help with glucose but not CV or renal

A

False it has been shown to help all of those and HF

80
Q

MOA SGLT2 Inhibitors

A

tends to be overexpressed in those with T2DM
responsible for glucose reabsorption from the kidneys

81
Q

Effects on BG for SGLT2i

A

decrease A1C by 0.5-0.8% as an add on agents
works on both FPG and PPG

82
Q

What is the limiting factor for SGLT2i?

A

they work in the kidneys so the pt. will have to have functioning nephrons to work

83
Q

What are the effects on weight for SGLT2i?

A

~2-3kg weight loss

84
Q

Dosing for SGLT2i

A

the lower dose works also just as well as the higher (very little benefit for more)

85
Q

What is the renal dosing for SGLT2i?

A

if renal is <45, it will not be very beneficial
but some will stay on because they have a renal protection

86
Q

What is a caution with SGLT2i and renal?

A

there will be a lower of eGFR of about 5 after the start of this medication

87
Q

Most common AE for SGLT2i?

A

increase urination
increase thirst
can cause mycotic genital infections (will have once)

88
Q

What is the management and prevention of genital mycotic infections?

A

recommended to pee, rinse and then wipe

89
Q

What are some rare AE for SGLT2i?

A

DKA (caused by dehydration)
can happen without low blood sugar

90
Q

Other effects on levels with SGLT2i?

A

mild increase in LDL and HDL
decrease in TGs
mild decrease in BP (SBP/DBP)

91
Q

DI with SGLT2i

A

watch for diuretics

92
Q

What are some rare AE for canagliflozin?

A

Might be amputation (with other risk)
might be increase risk of bone fracture (also other risks)
fournier’s gangrene

93
Q

What is fournier’s gangrene?

A

very rare condition that involves pain, swelling, tenderness in genital region

94
Q

What is the link between Empagliflozin?

A

decrease CVD
has CV protection
superior for MACE

95
Q

List the SGLT2i

A

dapagliflozin
canagliflozin
empagliflozin

96
Q

What is the link between SLGT2i with renal disease?

A

helps with decrease ERSD
decrease in renal or CV death
renal protective (not just for DM can work for normal pt too)

97
Q

What is the link between SLGT2i with heart failure?

A

decrease in hospitalization (both DM or not)
Cardiac protection
decrease hHF or CV death

98
Q

What is the link between SLGT2i with secondary prevention?

A

Empa and Cana decrease MACE

99
Q

What is the link between SLGT2i with primary prevention?

A

Dapa did not decrease MACE but others did make a difference

100
Q

Does T1DM or T2DM use mixed insulin more often?

A

T2DM tends to use mixed more often

101
Q

What are some barriers to insulin for the pt?

A

More complexity
Sense of failure
Fear of hypo
Needle phobia
Fear/denial of disease progression
“my aunt went on insulin and lost her foot”

102
Q

What are some barriers to insulin for the HCPs?

A

More complexity
Fear of hypo
Patient’s cognitive ability to handle it

103
Q

What are the benefits to premixed insulins?

A

less injections
easier to understand

104
Q

What are the three major options for T2DM starting insulin?

A

Basal insulin + antihyperglycemic
Basal and bolus
biphasic (premixed) insulin

105
Q

What is the benefit to only initiated with basal?

A

simplicity
minimization of weight gain and hypoglycemia
keeping oral meds on board helps with insulin sensitization

106
Q

Define overbasilization

A

basal insulin has a ceiling effect
they over take insulin and it stops helping as much
need to switch to have both basal and bolus

107
Q

What happens if basal insulin / oral/SC pharmacotherapy is not doing the trick?

A

evaluate/add another antihyperglycemics

basal insulin/GLP1RAs combo products

go to basal and bolus

108
Q

If patients are willing to do MDI, start by introducing 1 prandial insulin at a time, explain the process

A

Start with largest meal; 2-4U
Titrate by 1-2U/week until FPG and PPG at target
As insulin gets added, consider removing secretagogues
Monitor for effectiveness (BG targets) as well as hypoglycemia

109
Q

List some factors that are used to choose a second line drug after metformin

A

Clinical CV disease?
Hypoglycemia
Affect on weight
Renal function
Degree of hyperglycemia
Other comorbidities (i.e. heart failure)
Cost
Patient preference

110
Q

MOA of Tirzepatide

A

a GIP and GLP1 dual agonist

It enhances the secretion of insulin in response to food (increase in BG) and reduces glucagon (in a glucose dependent manner)

111
Q

Common AE for Tirzepatide

A

GI (N/D/V)

dyspepsia, constipation and abdominal pain
hypo

112
Q

Efficacy of Tirzepatide

A

Decrease A1C between 1.8-2.5%

113
Q

Affect on Weight with Tirzepatide

A

average was losing around 25.8 lb

114
Q

DI of Tirzepatide

A

gastric emptying –> BC or similar medication

115
Q

CI for Tirzepatide

A

GLP1RAs

116
Q

What is the new thinking of treatment strategy?

A

instead of treating to fail

try to be preemptive and help with things early before it gets really bad

117
Q

Should we use antiglycemic agents in T1DM?

A

no as they might be beneficial but it does not outway the risks (mainly hypo)

118
Q

When is preconception care essential?

A

for women with pre-existing DB to optimize pregnancy outcomes

119
Q

What are the A1C goals for the different stages of pregnancy?

A

pre <7
during <6.5

120
Q

What are some increase risks with poorly controlled DB and pregnancy?

A

risk of miscarriage, stillborn and malformations

121
Q

What is the disease monitored for during pregnancy for a DB?

A

retinopathy
HTN
CKD

122
Q

What meds can you still take for T2DM and pregnancy?

A

metformin, glyburide or insulin

123
Q

What meds should you stop take for T2DM and pregnancy?

A

ACEi /ARB
Statins

124
Q

What drugs are used for gestational DB?

A

insulin is the drug of choice
but can use metformin and glyburide

125
Q

What is the first line tx for GDM?

A

diet and exercise (for about 2 wks)
if it is not working after 2 wks then they go on meds

126
Q

What makes DB in children more complicated?

A

Psychological risks
Eating disorders
Insulin omission
Need access to a dietician
Smoking cessation
Contraception

127
Q

What is the targets for T1DM?

A

A1C targets of <7 or 7.5% for all children <18 yo
FPG - 4-8 mmol/L
2hr PPG - 5-10 mmol/L

more relaxed as worried about hypo is higher

128
Q

When a child/adolescent is diagnosised with T2DM, what is the plan?

A

the whole family is talked to, as it is more a situation more than just the child

129
Q

What is first line for T2DM in adolescents?

A

metformin
or metformin + basal insulin
or metformin + liraglutide

130
Q

What is needed to be considered for T2DM in elderly?

A

higher risk of hypo
limited use of SUs, TZDs
DPP4i over SU

when using insulin, use basal analogues

more relaxed targets

131
Q

What is the A1C targets based on for the elderly?

A

mainly the level of independent

DB Therapeutics (5 decks)

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