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CDCES Exam > Level 1 - Meds for Type 2 (Class 3) > Flashcards

Level 1 - Meds for Type 2 (Class 3) Flashcards

DiabetesEd

1
Q

Which factors are most important to consider matching meds to individuals?

A. Insurance coverage
B. Heart and kidney health
C. Willingness to take meds
D. Person’s values and preferences
E. All of the above

A

E.

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2
Q

Define ‘person centered approach.’

A

“providing care that is respectful of and responsive to individual patient preferences, needs, values - ensuring that patient values guide all clinical decisions.”

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3
Q

What is the first line medication? Why?

A

Metformin

-Longstanding evidence
-High efficacy and safety
-Inexpensive ($12 for 3 mos)
-Weight neutral

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4
Q

If their A1c is above 8.5% what medication should be considered?

A

Combination therapy

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5
Q

If they have ASCVD, HF, CKD, or high risk for ASCVD, what medications should be considered?

A

Use SGLT-2i or GLP-1 RA

with, or without metformin

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6
Q

What are qualities of an ideal diabetes medication?

A. No weight gain or some weight loss.
B. Increases UACR and decreases GFR.
C. Only causes hypoglycemia once a week.
D. Reduce cardiorenal risk.
E. A & D.

A

E.

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7
Q

59 year old with T2DM, with BMI of 29, A1c 8.4%, GFR 62. Their formulary covers the following medications. What first class of medication would you suggest?

A. Sulfonylureas.
B. Biguanides
C. DPP-IV Inhibitors
D. Insulin
E. TZD (Actos)

A

B. Metformin

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8
Q

How do biguanides work?

A

They decrease hepatic glucose output.

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9
Q

What are contraindications for Metformin?

A

1) GFR less than 30 (do not start Metformin).
2) Binge drinking

Metformin is cleared by the kidneys, so we need to monitor the GFR

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10
Q

What are the doses of metformin (glucophage)?

A

500 - 2550 mg (usually BID with meals)

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11
Q

What is Riomet?

A

Liquid metformin

500-2550 mg (with 500 mg in 5 mL)

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12
Q

What are the names of the XR versions of metformin?

A

Glucophage XR (dose: 500 - 2000 mg)
Glumetza (dose: 500 - 2000 mg)
Fortamet (dose: 500 - 2500 mg)

Taken once daily with dinner meal

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13
Q

What the GFR guidelines when starting and using metformin? **

A
  • If GFR < 30, do not use **

-If GFR < 45, do not start **

-If patient on metformin and GFR falls to 30-45, evaluate risk vs. benefit, consider decreasing dose.

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14
Q

What are the benefits of biguanide?

A

1) Lowers LDL cholesterol
2) No risk of hypo
3) No weight gain, possible slight weight loss
4) Inexpensive
5) Approved for PEDS, 10 y/o and older
6) Lowers A1c by 1.0-2.0%
7) Cancer protective (breast, studies ongoing)
8) Decreases risk of cellular aging, may increase longetivity

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15
Q

What is biguanide derived from?

A

Goats Rue, Galega officinalis, French lilac

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16
Q

Does metformin? **

-Cause hypoglycemia?
-Cause weight gain?
-Affordable?
-Lowers CV risk?
-Can most people tolerate/use it?

A

-Cause hypoglycemia? NO
-Cause weight gain? NO
-Affordable? YES
-Lowers CV risk? YES*
-Can most people tolerate/use it? YES&NO (monitor GI upset and GFR)

*Lowers LDL cholesterol

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17
Q

Which of the following groups of meds for a month supply are cheapest? Select multiple.

A. Actos & Avandia
B. Glipizide, Glyburide, Glimepiride
C. Metformin & Metformin XR
D. Januvia, Tradjenta
E. Exenatide, Semaglutide
F. Empagliflozin, SGLT-2i
G. Tirzepatide (Mounjaro)

A

A. Actos & Avandia ($5, $348)
B. Glipizide, Glyburide, Glimepiride ($10 x 3 mos)
C. Metformin & Metformin XR ($10 x 3 mos)
D. Januvia, Tradjenta ($657, $630)
E. Exenatide, Semaglutide ($964, $1123)
F. Empagliflozin, SGLT-2i ($408-$718)
G. Tirzepatide (Mounjaro) ($982)

Actos, B, C

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18
Q

What is UACR?

A

Urinary Albumin Creatinine Ratio

Assessed with an urinary spot collection; then either sent to the lab or can be done via dipstick

It evaluates the ratio of albumin/creatinine in mg/g

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18
Q

What is the target range for UACR?**

A

LESS THAN 30 MG/G**

< 30 mg/g

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18
Q

What factors can influence the UACR?

A

Exercise
Stress
Body weight loss

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18
Q

(TRUE or FALSE)

If a UACR is positive, recommend repeating the test to verify.

A

TRUE

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18
Q

What do the UACR ranges below represent:

< 30 mg/g
30-299 mg/g
>300 mg/g

A

< 30 mg/g = normal or mild increase level

30-299 mg/g = moderately increased (kidneys are struggling)

> 300 mg/g = severely increased

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19
Q

When is it recommended to check UACR?

A

At diagnosis in T2DM and within 5 years of being diagnosed in T1DM

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19
Q

What are the target ranges for GFR?

A

> 60 mg/dL

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20
Q

What do the GFR ranges below indicate:

90+
89-60
59-45
44-30
29-15
14-0

A

90+ = Stage 1, normal
89-60 = Stage 2
59-45 = Stage 3a, mild to moderate loss
44-30 = Stage 3b, moderate to severe loss
29-15 = Stage 4
14-0 = Stage 5, kidney failure

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21
Q

(TRUE or FALSE)

GFR can be improved by getting patients on the correct medications, lowering A1c, and controlling blood pressure.

A

TRUE

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22
Q

69 year old with BMI of 26, T2DM for the past 3 years. Has been trying to manage diabetes with diet and exercise. GFR 32, UACR 46 mg/g. Most recent A1c 8.4%. Has limited income, pays cash for medications.

What class of meds would you consider?

A

SGLT-2, but too expensive

Recommend sulfonylureas

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23
Q

What is the mechanism of action of sulonylureas?

A

Tells beta cells in pancreas to release insulin all day* (whether the person is eating or not!)

**Therefore, they are AT RISK FOR HYPOGLYCEMIA

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24
Q

How effective are sulfonylureas, in regards to FBG and A1c?

A

Decreases FBG by 60-70 mg/dL

Reduces A1c by 1.0 to 2.0%

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25
Q

How are sulfonylureas dosed?

A

1-2x per day BEFORE MEALS

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26
Q

Based hypoglycemia, what other adverse effects can sulfonylureas cause?

A

Weight gain
Monitor renal function

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27
Q

(TRUE or FALSE)

Sulfonylureas are expensive.

A

FALSE

Low-cost, $12 for a 3 month supply

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28
Q

(TRUE or FALSE)

Sulfonylureas can help with glucose toxicity.

A

TRUE

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29
Q

What are the specific sulfonylurea medications?

A

1) Glyburide
2) Glipizide
3) Glimepiride

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30
Q

Which sulfonylurea medication is the most associated with hypoglycemia?

A

Glyburide - so we tend to avoid it

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31
Q

Which are the two best sulfonylurea meds? What is the starting dose?

A

Glipizide (2.5 mg) and Glimepiride (1.0 mg)

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32
Q

Glucotrol and glucotrol XL are also known as

A

Glipizide

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33
Q

What is the brand name of glimepiride?

A

Amaryl

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34
Q

What is the max dose of Glucotrol?

A

40 mg

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35
Q

What is the max dose of Glucotrol XL?

A

20 mg

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36
Q

What is the max dose of Amaryl?

A

8 mg

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37
Q

How are sulfonylureas eliminated?

A

Through the kidney

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38
Q

What are the effects of sulfonylureas? **

A

1) Hypoglycemia
2) Weight gain
3) Cleared by the kidney, use caution in those with renal disease
4) Cheap
5) Can be helpful in the presence of glucose toxicity

**KNOW FOR EXAM

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39
Q

Does sulfonylureas? **

-Cause hypoglycemia?
-Cause weight gain?
-Affordable?
-Lowers CV risk?
-Can most people tolerate/use it?

A

-Cause hypoglycemia? YES
-Cause weight gain? YES (about 3-5 lbs)
-Affordable? YES
-Lowers CV risk? NO
-Can most people tolerate/use it? YES/NO

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40
Q

LR is transgender, 44 years old on metformin and sulfonylurea with an A1c of 8.4%, struggling with weight gain. What are possible next options?

A. Refer to RDN
B. Suggest the addition of GLP-1 agonist
C. Increase dose of sulfonylurea
D. Suggest starting metformin
E. A & B

A

E. Refer to RDN and start GLP-1

Hormone therapy can increase or decrease insulin resistance

41
Q

How do GLP-1s work?

A

1) Brain: Promotes satiety and reduces appetite
2) Stomach: helps regulate gastric emptying
3) Alpha cells: lowers post-prandial glucagon secretion
4) Liver: lowers glucagon reduces hepatic glucose output
5) Beta cells: enhances glucose-dependent insulin secretion

42
Q

(TRUE or FALSE)

GLP-1 is degraded by DPP-4 within 4 minutes.

A

TRUE

43
Q

Exenatide (Byetta) and Liraglutide (Victoza) are not commonly seen, why?

A

Byetta = requires a twice daily injection

Victoza = once daily injection

Both administered via pen, which requires an rx for needles

44
Q

Which two GLP-1s are approved for PEDS?

A

10-17 years old

1) Exenatide XR (Bydureon)

Once weekly injection without the site of needles via pen

2) Dulaglutide (Trucility)

45
Q

Which 3 GLP-1s reduce the risk for ASCVD?

A

1) Liraglutide (Victoza)
2) Semaglutide (Ozempic)
3) Dulaglutide (Trucility)

46
Q

Which GLP-1 reduces A1c?

A

Semaglutide (Ozempic)

47
Q

What side effects would require you to stop the GLP-1?

A

1) Acute pancreatitis
2) Intestinal blockage (ileus)

48
Q

What does “incretin mimetic” mean?

A

-Increases insulin release with food
-Slows gastric emptying
-Promotes satiety
-Suppresses glucagon

49
Q

Which semaglutide is available in an oral form?

A

Rybelsus

50
Q

What are the doses of rybelsus?

A

3, 7, and 14 mg daily

Take daily with at least 30 minutes before first food, beverage, and other oral meds

Do not crush tablets
Take with no more than 4 oz water

51
Q

Which GLP-1 RAs have been approved for weight loss?

A

1) Saxenda (3 mg) and Victoza (1.8 mg) - same active ingredient (liraglutide) at different doses (daily injection)

2) Wegovy (2.4 mg) & Ozempic (2 mg) - same active ingredient (semaglutide) at different doses (weekly injection)

52
Q

Who would be appropriate for a GLP-1 for weight loss?

A

Adults, with

BMI > 30, or
BMI > 27 with HTN, T2DM, or dyslipidemia

53
Q

GIP

A

Glucose-dependent insulinotropic

54
Q

How effective is tirzepatide (Mounjaro) in lowering A1c and weight loss?

A

Lowers A1c by 1.8 - 2.4%

7-13% body weight loss at max dose

55
Q

How effective is semaglutide and liraglutide in lowering A1c and weight loss?

A

Lowers A1c by 0.5 - 1.6%

4-6% body weight loss

56
Q

GLP-1

A

Glucagon like peptide 1

57
Q

Tirzepatide was approved for weight loss only under what brand name?

A

Zepbound

With same qualifying criteria as Mounjaro

58
Q

What are the 6 benefits of GLP-1 RA and GIP/GLP-1 RA?

A

1) Lowers A1c
2) Substantial weight loss
3) CVD benefits
4) Decreased appetite
5) Lowers post-meal glucose
6) Easy to use (weekly, preloaded pen)

59
Q

RT is taking tirzepatide (Mounjaro) once weekly for 3 months. Which side effect should they report immediately?

A. Muscle aches
B. Feeling jittery
C. Headaches
D. Sudden abdominal pain

A

D

60
Q

A history or family history of what condition is a contraindication to GLP-1 and GLP-1/GIP?

A

Medullary thyroid cancer

61
Q

What are some counseling points for GLP-1 & GLP-1/GIP?

A

1) Eat SFMs to reduce nausea
2) Avoid high fat meals
3) Reconsider feelings of nausea, as feelings of fullness (this could be the first time they are actually feeling satiated).
4) Store extra pens in fridge
5) Avoid in combination with DPP-4 inhibitors
6) Report any sudden abdominal pain, pancreatitis, or ileus
7) Ask about recent eye exam (there is a potential increase in diabetes retinopathy)

62
Q

Do Incretin Mimetics? **

-Cause hypoglycemia?
-Cause weight gain?
-Affordable?
-Lowers CV risk?
-Can most people tolerate/use it?

A

-Cause hypoglycemia? NO
-Cause weight gain? NO
-Affordable? NO
-Lowers CV risk? YES
-Can most people tolerate/use it? YES/NO (monitor GI)

63
Q

72 year old, BMI 24, food insecure, lives alone, A1c 7.3%, history of stroke. “Diet controlled.” GFR is 42, UACR is 89 mg/g. Most meds are covered under insurance. What is the best next action?

A. Start Metformin
B. Consider SGLT-2i
C. Start low dose glipizide
D. Continue current strategy and ongoing monitoring
E. Consider DPP-IV Inhibitor

A

B. because it will lower glucose and protect against heart attack and stroke

Why are metformin and glipizide not good options?

64
Q

What does ‘glucoretic’ mean?

A

Decreases renal reabsorption in the proximal tubule of the kidneys (reset renal threshold and increase glucosuria).

aka - allows glucose to leave via the urine

65
Q

SGLT-2i are considered what?

A

Glucoretics

(Decreases renal reabsorption in the proximal tubule of the kidneys (reset renal threshold and increase glucosuria))

66
Q

What risks are associated with SGLT-2is?

A

Ketoacidosis and Fournier’s gangrene, especially for those on insulin

67
Q

What are the 3 most commonly recommmended SGLT-2is? Why?

A

1) Canagliflozin (Invokana)

2) Dapagliflozin (Farxiga)

3) Emphagliflozin (Jardiance)

*Because of CVD benefits

68
Q

What are the 6 benefits of SGLT-2is?

A

1) Lowers A1c
2) Weight loss (3-5 lbs)
3) CVD benefits
4) Renal benefits
5) HF benefits
6) Lowers BP (typically their BP medication dose is decreased when starting on a SGLT-2i)

69
Q

When should SGLT-2s be used?

A

If CKD and GFR > 20

70
Q

(TRUE or FALSE)

SGLT-2s are approved for PEDS?

A

TRUE, 10 years and older

71
Q

How much do SGLT-2s lower A1c?

A

0.6 to 1.5%

72
Q

What adverse effects must be managed in SGLT-2s?

A

1) Good hygiene to reduce risk of genital mycotic infections
2) DKA and Euglycemia DKA risk (use caution when reducing insulin dose; recommend ketone sticks to monitor urine on a regular basis).
3) Monitor BP
4) Increased risk of UTI
5) Check feet daily (Canagliflozin - amputations)
6) Monitor renal function, potassium

73
Q

Do SGLT-2 inhibitors? **

-Cause hypoglycemia?
-Cause weight gain?
-Affortable?
-Lowers HF risk?
-Lowers CKD risk?
-Lowers CVD risk?

A

-Cause hypoglycemia? NO
-Cause weight gain? NO
-Affortable? NO ($600 cash pay)
-Lowers HF risk? YES
-Lowers CKD risk? YES
-Lowers CVD risk? YES

74
Q

Which class of medications are considered ‘incretin enhancers?’

A

DPP-4 inhibitors

75
Q

What is the mechanism of action of DPP-4 inhibitors?

A

1) Increase insulin release with meals
2) Suppress glucagon

They stop the DPP-4 enzymes from breaking down your gut hormones

76
Q

How effective are DPP-4 inhibitors at lowering A1c?

A

Decreases A1c by 0.6 - 0.8%

lowest effective in A1c compared to other medication classes

77
Q

What are the 3 medications that are DPP-4 inhibitors?

A

1) Sitagliptin (Januvia)

2) Linagliptin (Tradjenta)

3) Alogliptin (Nesina)

78
Q

Why are DPP-4 inhibitors not very commonly used?

A

They are very expensive, with fewer benefits

79
Q

What side effect do DPP-4 inhibitors have?

A

Can cause sudden severe joint pain

80
Q

Which DPP-4 inhibitor increases risk of HF?

A

Alogliptin (Nesina)

81
Q

Do DPP-4 inhibitors? **

-Cause hypoglycemia?
-Cause weight gain?
-Affordable?
-Lowers CVD risk?
-Can most tolerate/use?

A

-Cause hypoglycemia? NO
-Cause weight gain? NO
-Affordable? NO
-Lowers CVD risk? NO
-Can most tolerate/use? YES

82
Q

What class of medications is pioglitazone (Actos)?

What is the mechanism of action?

A

Thiazolidinediones

Which increase insulin sensitivity

83
Q

The ADA recommends Actos for patients with what conditions?

A

NAFLD or a history of stroke

84
Q

What are side effects to monitor for in thiazolidinediones?

A

Edema and weight gain

It also may increase the risk of peripheral fracture risk and bladder cancer

85
Q

(TRUE or FALSE)

Thiazaolidinediones are appropriate for those with HF.

A

FALSE

It may cause or worsen CHF

86
Q

What class of medication is acarbose (Precose)? What is the mechanism of action?

A

Glucosidase inhibitors

Which delays carbohydrate absorption

87
Q

What are side effects in glucosidase inhibitors?

A

Increase in gas

88
Q

What class of medication is repaglinide (Prandin) and nataglinide (Starlix)?

What is the mechanism of action?

A

Meglitinides

Which stimulates rapid insulin burst

89
Q

When are meglinides taken?

A

Take before meals

90
Q

What are side effects of meglinides?

A

Hypoglycemia and weight gain

91
Q

How is repaglinide (Prandin) metabolized?

A

Metabolized by the liver and mostly excreted in the feces (some renal)

92
Q

(TRUE or FALSE)

Repaglinide (Prandin) is not appropriate for those with renal failure.

A

FALSE

It is safe for those with renal failure, as many other medications are cleared by the kidneys

93
Q

Which medication is like ‘an oral insulin?’

A

Repaglinide (Prantin)

-decreases peak post-prandial glucose
-decreases plasma glucose 60-70 mg/dL
-reduces A1c by 1.0 - 2.0%

94
Q

When are combination meds appropriate?

A

If an A1c is 8.5% or higher, because they are cheaper than two separate medications and easier to take/manage

95
Q

What is a common combination medication?

What meds does it include?

A

Trijardy XR - 3 in 1 pill

1) Empagliflozin (SGLT-2)
2) Linagliptin (DPP-4)
3) Metformin XR (Biguanides)

96
Q

65 year old, BMI 25, on max dose of Metformin/Exenatide XR. Hx of HF. A1c 8.9%. GFR 63, UACR 37 mg/g. What is the next best choice?

A. Add a once weekly GLP-1 RA
B. Start basal insulin
C. Add SGLT-2 inhibitor
D. Start bolus insulin

A

C.

He is already on a GLP-1 RA (Exenatide XR)

97
Q

An A1c of X% would indicate insulin or sulfonylurea?

A

10%

98
Q

(TRUE or FALSE)

Before starting insulin, consider GLP-1 RA first.

A

TRUE

99
Q

What is the starting dose for basal insulin?

A

10 units, or 0.1 - 0.2 units/kg/day

100
Q

How is basal insulin titrated?

A

Increase by 2 units every 3 days, until FBG is at goal

101
Q

If someone is on insulin and they are having hypoglycemia, how much should their basal insulin be decreased?

A

By 20%

102
Q

What is considered ‘over-basalization?’

A

Basal insulin of 0.5 units/kg/day

103
Q

When someone is at the max for basal insulin, what would be the next step?

A

Adding bolus insulin

104
Q

What is the starting dose for bolus insulin?

A

Start with 4 units bolus at the largest meal; or

Start with 1-2 injections with 10% of basal; or

Switch to basal/bolus combo (like 70/30)

105
Q

67 year old male, BMI 25, weighs 90 kg, takes metformin 1000 mg BID, bydureon 2mg once weekly, and empagliflozin (Jardiance) 25 mg. A1c 9.5%, GFR 63, UACR 37 mg/g. What would you recommend next?

A

Start with 10 units glargine (basaglar)

see insulin/injectable pocket card

106
Q
A

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