medications Flashcards
1
Q
What is the mechanism of action of biguanides?
A
Increase insulin sensitivity
Decreases liver glucose production
Reduces GI glucose absorption
2
Q
What are biguanides?
A
Metformin
Glucophage
ends in phage
3
Q
What is the first line tx for T2DM?
A
ILI + Metformin
4
Q
What are the benefits of biguanides?
A
- Lower LDL & TG
- weight neutral
- potentially CA protective
- no HYPO
- Decrease CVD risk
- Affordable
5
Q
What meds are approved for peds?
A
Metformin & liraglutide, have to be 10 years old
6
Q
eGFR recs for metformin
A
Do not initiate <45
STOP <30
7
Q
Side effects of metformin
A
- GI: bloating, diarrhea, abdominal pain
- B12 deficiency & worsening neuropathy with LT use
- Lactic acidosis of prescribed wrong
8
Q
how to reduce diarrhea in metformin
A
- XR form
- Gradual dose titration
9
Q
Sulfonylureas
A
end in ide
glyburide, glimepiride, glipizide
10
Q
Side effects of sulfonylureas
A
Hypo esp. in reduced kidney/liver function
- weight gain
- does not lower CVD risk
- doesn’t work as well after 5 years
11
Q
How do sulfonylureas work
A
- IDE- insulin down easy
- secretors
- stimulates sustained insulin release
- effective at lowering BG
12
Q
Meglinitinides
“ide”
how do they work?
A
stimulate rapid insulin burst
aka secretors
Insulin Down Easier
13
Q
Side effects of meglinides
A
- Cause HYPO
- better for inconsistent meals d/t shorter 1/ 2 life
- weight gain
14
Q
SGLT-2 i
ends in __________
how does it work
A
flozin
increase urination
decreases renal glucose reabsorption
15
Q
s/s of SGLTi-2
A
- Glycosuria- high glucose in urine
- Increase UTIs & candida/yeast infections
- Fournier’s gangrene (genital infection)
- osmotic diuresis –> increased urination, dehydration, hypotension
- Potential for DKA
16
Q
benefit of SGLT-2
A
Good luck for
- reducing CVD risk
- Preserves kidney function
17
Q
GLP-1
mechanism of action
A
- tide
- imitate GI incretin hormone, GLP-1
- Suppress glucagon secretion
- increase insulin secretion
- delays gastric emptying
- reduce appetite
- changes tide in gut
- INJECTIBLE
18
Q
Benefits of GLP-1
A
- weight loss
- reduce risk of CV events
- beta cell protective factor
19
Q
disadvantages of GLP-1
A
- black box warning for thyroid tumor
- report s/s of pancreatitis
- nausea when starting
- $$$$$$$$
20
Q
Dpp-4 inhibitors
ends in _________
A
liptin
21
Q
DPP-4 inhibitor mechanism of action
A
inhibit DPP-4 enzyme that breaks down GI incretin hormone GLP-1
- extend duration of GLIP-1
- first hits your lips then your gut
22
Q
s/s of dpp-4 i
A
DISABLING joint pain- tell MD immediately
headache/flu like s/s
increase risk of HF
increase risk of pancreatitis
23
Q
benefit of dpp4-i
A
no weight gain
no hypo
24
Q
TZD
ends in ________
mechanism of action
A
end in zone
increase insulin sensitivity
puts your cells in the zone
25
benefit of TZD
decrease FFA
26
s/s of TZD
- increase fracture risk esp in elderly
- may worsen/cause CHF
- monitor for edema/wt gain
- does not lower CVD risk
27
Bolus insulin is ________
fast acting
28
Name the bolus insulins and their duration
```
Gary Loves Red Apples
Glulisine <5 H
Lispro <5 H
Regular (human insulin) 5-8 H
Aspart 3-5 H
```
29
Name the basal insulins and their duration
```
Nancy Does Good Deeds
NPH (human) 12 H
Detemir 24 H
Glargine 24 H
Degludec 42 H
```
30
What's recommended if HF or CKD predominates?
1st- SGLT2 i
| 2nd- GLP-1
31
IF pt has HF what should be avoided?
TZD
| NO saxagliptin
32
When does CKD predominate?
UACR >30 or esp >300
| eGFR 30-60
33
When does HF predominate?
HFrEF (LVEF<45%)
34
When does ASCVD predominate?
age >55 w/ coronary, carotid, or lower extremity artery stenosis >50%
35
What's recommended if ASCVD predominates?
1. GLP-1 RA
| 2. SGLT2i
36
What insulins have demonstrated CVD safety
Degludec
| U100 glargine
37
Which SGLTi2 are most effective?
canagliflozin
empagliflozin
dapagliflozin
38
What meds are good if you need to minimize hypo risk?
- Metformin
- Dpp-4
- GLP-1
- SGLT2i
- TZD
39
What meds are good if you need to minimize risk of wt gain? or promote wt loss?
- Metformin
- GLP-1 RA
- SGLT2-I
- then DPP-4i
40
If cost is a major barrier, recommend:
- Metformin
- SU
- TZD
41
Which GLP-1 is best?
Semaglutide --> Liraglutide --> dulaglutide --> exenatide --> lixisenatide
42
What should be considered before insulin in T2DM?
GLP-1 RA
43
What to do w/ insulin if hypoglycemia occurs?
- try to determine cause
| - lower dose by 10-20%
44
In T2DM, how to start basal insulin
10 U/day
| 0.1-0.2 IU/kg/d
45
When to start prandial insulin in T2DM
reached basal dose >0.5 IU/kg
| if A1c is above target but fasting goal is met
46
How to start prandial insulin in T2DM
- 4 IU/day or 10% of basal at largest meal
- if A1c <8%, can lower basal by 4 IU or 10%
- titrate by increase dose 1-2 IU or 10-15% twice weekly
47
If wanting to switch from bed time NPH to 2x/day NPH
- decrease total dose to 80%
| - 2/3 AM, 1/3 PM
48
When should insulin be considered in T2DM right away?
- s/s catabolism
- A1c >10%
- BG >/=300
- T1DM v. T2DM is being ?
49
T1DM insulin recommendations
- multiple prandial + basal or pump
- rapid acting insulin analog to reduce hypo risk
- match prandial insulin dose to CHO intake, pre-prandial BG and predicted PA
50
DCCT of 7% reduce microvascular complications by ____%
50
51
What are human insulins
Regular (short acting)- Humulin/novolin R's
NPH (intermediate) Humlin N, Novolin N
Premix 70/30 (Humulin 70/30 or Novolin 70/30)
52
Timing
| T1DM
Basal- longer duration, more consistent plasma concentration
Rapid acting quicker onset and peak, shorter duration v. human insulin
53
proper storage of insulin
- no extreme heat/cold
- never in freezer, direct sunlight, glovebox
- never expired
- open- can be stored at room temp; usually good for 28 days
- unopened- in fridge
54
T1DM insulin recs
50% basal, 50% bolus
based on wt in kg
0.4-1 u/kg/day
higher during puberty, illness, pregnancy
55
what does basal insulin do
regulate overnight, fasting BG
56
what does bolus insulin do
regulate postprandial BG
| CHO counting can help with this
57
where to inject insulin
abdomen
thigh
butt
upper arm
58
how to inject insulin
- rotate sites to avoid lipohypertrophy (accumulation of subq fat)
- NOT in muscle
- use short needle 4 mm
59
If someone w/ T1DM used SGLT2 i what could happen?
2-4x increase risk of DKA
| small improvement in A1c/weight when used with insulin
60
What is pramlinitide
- only FDA approved oral med for T1DM
- reduce A1c by 0-0.3%
- reduce wt 1-2 kg
61
When should pancreas islet transplantation be considered?
- total pancrectomy
- renal transplant
- recurrent DKA
- severe HYPO, ongoing
62
Why is pancreas islet transplant seldom used?
- need to be on immunosuppressive tx for life
| - CGM's and closed loop pump-sensor systems are available
63
Why would pancreas islet transplant even be considered?
can normalize BG
| reduce microvascular complications
64
In T2DM, how long should Metformin be used for?
- as long as tolerated, not contraindicated
| - can be used along w/ insulin
65
when choosing oral meds for T2DM what should be considered?
- pt preference
- risk of hypo
- CVD comorbidities
- impact on wt
- cost
- side effects
66
how often to re-evaluate meds regimen in T2DM
q 3-6 months
67
When should metformin be started?
At time of T2DM dx
68
how long is monotherapy effective in T2DM
usually only a few years before additional tx needed
69
Each new med added to Metformin lowers HgbA1c by?
0.7-1%
70
Which GLP-1 is available in oral medication form? What's the s/s?
```
Oral semaglutide
robust WL
lower risk of hypo
increase GI side effects
$$$$$$$$$$$$
```
71
goal of basal insulin in T2DM
- restrain hepatic GLU production
| - limit HYPER overnight & b/w meals
72
How to reduce risk of HYPO overnight w/ T2DM on insulin
Long-acting analog instead of NPH
73
A person w/ T2DM on insulin may benefit from NPH & regular human insulin when
- relax A1C goal
- low rates of HYPO
- significant insulin resistance
- cost concerns
74
When to use concentrated insulin in T2DM
- high insulin resistance
75
U500 is x times more concentrated than U100
5x
| ]*has a special tiny syringe that MUST be used
76
a 3 mL pen of U500 has how many units of insulin? how long is it good for?
1,500 units
| 3 days
77
a 20 mL vial of U500 has how many units of insulin? good for how long?
10,000 units
| good for 40 days
78
What is benefit of GLP-1 over basal insulin in T2DM?
less hypo, less wt gain
79
combination injectable therapy
| what is it?
insulin glargine + lixisenatide
| insulin degludec + liraglutide
80
what is nasal glucagon
who can use it
how much does it raise BG
Basquimi
age 4+
nasally absorbed
67-73 pt rise
81
```
glucagon
who is it approved for
how much does it raise BG
how is it administered
what are the types
```
age 2+
20-30 pts and it's short lived; need CHO immediately after
subq
Gvoke pre-filled syrings or Gvoke hypo pen
82
how to dose glucagon injection
adults and kids 2-12 who are >/=45 kg take 1 mg
kids 2-12 <45 kg take 0.5 mg
83
Glucagon emergency kit
approved for what ages
how to dose
how to administer
```
all ages
adults- 1 mg
kids <6 or <25 kg- 0.5 mg
kids >/= 6 or >25 kg- 1 mg
subq or IM
MUST mix the glucagon powder with filled syringe to reconstitute it
```
84
How much do Initial meds reduce A1c
O.5-2%
85
Each new added class of meds has what effect on A1C
0.7-1%
