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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
What do the GFR ranges below indicate: 90+ 89-60 59-45 44-30 29-15 14-0
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
21
(TRUE or FALSE) GFR can be improved by getting patients on the correct medications, lowering A1c, and controlling blood pressure.
TRUE
22
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?
SGLT-2, but too expensive Recommend sulfonylureas
23
What is the mechanism of action of sulonylureas?
Tells beta cells in pancreas to release insulin all day* (whether the person is eating or not!) **Therefore, they are AT RISK FOR HYPOGLYCEMIA
24
How effective are sulfonylureas, in regards to FBG and A1c?
Decreases FBG by 60-70 mg/dL Reduces A1c by 1.0 to 2.0%
25
How are sulfonylureas dosed?
1-2x per day BEFORE MEALS
26
Based hypoglycemia, what other adverse effects can sulfonylureas cause?
Weight gain Monitor renal function
27
(TRUE or FALSE) Sulfonylureas are expensive.
FALSE Low-cost, $12 for a 3 month supply
28
(TRUE or FALSE) Sulfonylureas can help with glucose toxicity.
TRUE
29
What are the specific sulfonylurea medications?
1) Glyburide 2) Glipizide 3) Glimepiride
30
Which sulfonylurea medication is the most associated with hypoglycemia?
Glyburide - so we tend to avoid it
31
Which are the two best sulfonylurea meds? What is the starting dose?
Glipizide (2.5 mg) and Glimepiride (1.0 mg)
32
Glucotrol and glucotrol XL are also known as
Glipizide
33
What is the brand name of glimepiride?
Amaryl
34
What is the max dose of Glucotrol?
40 mg
35
What is the max dose of Glucotrol XL?
20 mg
36
What is the max dose of Amaryl?
8 mg
37
How are sulfonylureas eliminated?
Through the kidney
38
What are the effects of sulfonylureas? **
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
39
Does sulfonylureas? **** -Cause hypoglycemia? -Cause weight gain? -Affordable? -Lowers CV risk? -Can most people tolerate/use it?
-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
40
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
E. Refer to RDN and start GLP-1 Hormone therapy can increase or decrease insulin resistance
41
How do GLP-1s work?
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
(TRUE or FALSE) GLP-1 is degraded by DPP-4 within 4 minutes.
TRUE
43
Exenatide (Byetta) and Liraglutide (Victoza) are not commonly seen, why?
Byetta = requires a twice daily injection Victoza = once daily injection Both administered via pen, which requires an rx for needles
44
Which two GLP-1s are approved for PEDS?
10-17 years old 1) Exenatide XR (Bydureon) Once weekly injection without the site of needles via pen 2) Dulaglutide (Trucility)
45
Which 3 GLP-1s reduce the risk for ASCVD?
1) Liraglutide (Victoza) 2) Semaglutide (Ozempic) 3) Dulaglutide (Trucility)
46
Which GLP-1 reduces A1c?
Semaglutide (Ozempic)
47
What side effects would require you to stop the GLP-1?
1) Acute pancreatitis 2) Intestinal blockage (ileus)
48
What does "incretin mimetic" mean?
-Increases insulin release with food -Slows gastric emptying -Promotes satiety -Suppresses glucagon
49
Which semaglutide is available in an oral form?
Rybelsus
50
What are the doses of rybelsus?
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
Which GLP-1 RAs have been approved for weight loss?
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
Who would be appropriate for a GLP-1 for weight loss?
Adults, with BMI > 30, or BMI > 27 with HTN, T2DM, or dyslipidemia
53
GIP
Glucose-dependent insulinotropic
54
How effective is tirzepatide (Mounjaro) in lowering A1c and weight loss?
Lowers A1c by 1.8 - 2.4% 7-13% body weight loss at max dose
55
How effective is semaglutide and liraglutide in lowering A1c and weight loss?
Lowers A1c by 0.5 - 1.6% 4-6% body weight loss
56
GLP-1
Glucagon like peptide 1
57
Tirzepatide was approved for weight loss only under what brand name?
Zepbound With same qualifying criteria as Mounjaro
58
What are the 6 benefits of GLP-1 RA and GIP/GLP-1 RA?
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
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
D
60
A history or family history of what condition is a contraindication to GLP-1 and GLP-1/GIP?
Medullary thyroid cancer
61
What are some counseling points for GLP-1 & GLP-1/GIP?
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
Do Incretin Mimetics? **** -Cause hypoglycemia? -Cause weight gain? -Affordable? -Lowers CV risk? -Can most people tolerate/use it?
-Cause hypoglycemia? NO -Cause weight gain? NO -Affordable? NO -Lowers CV risk? YES -Can most people tolerate/use it? YES/NO (monitor GI)
63
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
B. because it will lower glucose and protect against heart attack and stroke Why are metformin and glipizide not good options?
64
What does 'glucoretic' mean?
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
SGLT-2i are considered what?
Glucoretics (Decreases renal reabsorption in the proximal tubule of the kidneys (reset renal threshold and increase glucosuria))
66
What risks are associated with SGLT-2is?
Ketoacidosis and Fournier's gangrene, especially for those on insulin
67
What are the 3 most commonly recommmended SGLT-2is? Why?
1) Canagliflozin (Invokana) 2) Dapagliflozin (Farxiga) 3) Emphagliflozin (Jardiance) *Because of CVD benefits
68
What are the 6 benefits of SGLT-2is?
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
When should SGLT-2s be used?
If CKD and GFR > 20
70
(TRUE or FALSE) SGLT-2s are approved for PEDS?
TRUE, 10 years and older
71
How much do SGLT-2s lower A1c?
0.6 to 1.5%
72
What adverse effects must be managed in SGLT-2s?
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
Do SGLT-2 inhibitors? ** -Cause hypoglycemia? -Cause weight gain? -Affortable? -Lowers HF risk? -Lowers CKD risk? -Lowers CVD risk?
-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
Which class of medications are considered 'incretin enhancers?'
DPP-4 inhibitors
75
What is the mechanism of action of DPP-4 inhibitors?
1) Increase insulin release with meals 2) Suppress glucagon They stop the DPP-4 enzymes from breaking down your gut hormones
76
How effective are DPP-4 inhibitors at lowering A1c?
Decreases A1c by 0.6 - 0.8% lowest effective in A1c compared to other medication classes
77
What are the 3 medications that are DPP-4 inhibitors?
1) Sitagliptin (Januvia) 2) Linagliptin (Tradjenta) 3) Alogliptin (Nesina)
78
Why are DPP-4 inhibitors not very commonly used?
They are very expensive, with fewer benefits
79
What side effect do DPP-4 inhibitors have?
Can cause sudden severe joint pain
80
Which DPP-4 inhibitor increases risk of HF?
Alogliptin (Nesina)
81
Do DPP-4 inhibitors? ** -Cause hypoglycemia? -Cause weight gain? -Affordable? -Lowers CVD risk? -Can most tolerate/use?
-Cause hypoglycemia? NO -Cause weight gain? NO -Affordable? NO -Lowers CVD risk? NO -Can most tolerate/use? YES
82
What class of medications is pioglitazone (Actos)? What is the mechanism of action?
Thiazolidinediones Which increase insulin sensitivity
83
The ADA recommends Actos for patients with what conditions?
NAFLD or a history of stroke
84
What are side effects to monitor for in thiazolidinediones?
Edema and weight gain It also may increase the risk of peripheral fracture risk and bladder cancer
85
(TRUE or FALSE) Thiazaolidinediones are appropriate for those with HF.
FALSE It may cause or worsen CHF
86
What class of medication is acarbose (Precose)? What is the mechanism of action?
Glucosidase inhibitors Which delays carbohydrate absorption
87
What are side effects in glucosidase inhibitors?
Increase in gas
88
What class of medication is repaglinide (Prandin) and nataglinide (Starlix)? What is the mechanism of action?
Meglitinides Which stimulates rapid insulin burst
89
When are meglinides taken?
Take before meals
90
What are side effects of meglinides?
Hypoglycemia and weight gain
91
How is repaglinide (Prandin) metabolized?
Metabolized by the liver and mostly excreted in the feces (some renal)
92
(TRUE or FALSE) Repaglinide (Prandin) is not appropriate for those with renal failure.
FALSE It is safe for those with renal failure, as many other medications are cleared by the kidneys
93
Which medication is like 'an oral insulin?'
Repaglinide (Prantin) -decreases peak post-prandial glucose -decreases plasma glucose 60-70 mg/dL -reduces A1c by 1.0 - 2.0%
94
When are combination meds appropriate?
If an A1c is 8.5% or higher, because they are cheaper than two separate medications and easier to take/manage
95
What is a common combination medication? What meds does it include?
Trijardy XR - 3 in 1 pill 1) Empagliflozin (SGLT-2) 2) Linagliptin (DPP-4) 3) Metformin XR (Biguanides)
96
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
C. He is already on a GLP-1 RA (Exenatide XR)
97
An A1c of X% would indicate insulin or sulfonylurea?
10%
98
(TRUE or FALSE) Before starting insulin, consider GLP-1 RA first.
TRUE
99
What is the starting dose for basal insulin?
10 units, or 0.1 - 0.2 units/kg/day
100
How is basal insulin titrated?
Increase by 2 units every 3 days, until FBG is at goal
101
If someone is on insulin and they are having hypoglycemia, how much should their basal insulin be decreased?
By 20%
102
What is considered 'over-basalization?'
Basal insulin of 0.5 units/kg/day
103
When someone is at the max for basal insulin, what would be the next step?
Adding bolus insulin
104
What is the starting dose for bolus insulin?
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
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?
Start with 10 units glargine (basaglar) see insulin/injectable pocket card
106

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