Module 8: Unit A Diabetes Flashcards
Short Duration, Rapid Acting Insulin examples
lispro (Humalog)
aspart (Novolog)
glulisine (Apidra)
Rapid-acting inhaled insulin
(Afrezza)
Indication short duration, rapid acting insulins
Used for postprandial glycemic control
Preferred insulin for pumps for bolus and basal glycemic control
Prandial glycemic control
BBW affrezza
Risk of acute bronchospasm in patients with chronic lung disease
Onset, peak and duration of rapid acting insulin (Humalog, Novalog, etc.)
O: 5-15 minutes
P: 0.75-3 hours
D: 3-5 hours
Risks with insulin
Hypoglycemia
D2D with insulins
Enhance hypoglycemia: anti-diabetic medications, beta-blockers, MAOIs, SSRIs, salicylates, quinolones, androgens, alcohol.
Raise glucose: Thiazide diuretics, glucocorticoids, and sympathomimetics. requiring an adjustment of insulin dosage.
Beta-blockers can delay and/or mask symptoms of hypoglycemia AND potentiate hypoglycemia by ↓ glycogenolysis.
Short Duration, Short-Acting Insulin examples
regular insulin (Humulin R, Novolin R)
regular insulin (Humulin R, Novolin R) uses
Given 30 m before meals to control postprandial hyperglycemia
Also used in insulin pumps for basal glycemic control (less expensive than rapid-acting, but slower onset)
Safety with regular insulin
Higher risk of hypersensitivity due to the presence of protamine (foreign particle can trigger an allergic reaction)
Onset Peak Duration: Regular insulin
15-30 minutes
2-4 hours
5-8 hours
Intermediate-Acting Insulin
NPH- neutral protamine (Humulin-N)
Hagedorn (Novolin N)
NPH neutral protamine (Humulin-N) and Hagedorn (Novolin N) uses
Glycemic control between meals and overnight.
Intermediate insulin (NPH (Humulin-N and Novolin N) onset, peak, duration
O: 1-2 hr
P: 4-12 hr
D: 18-24hr
Considerations with intermediate insulin
Much less expensive than long-acting/basal insulin but requires dosing 2-3 times/day along with short-acting insulin for postprandial glycemic control
Long and ultra-long
-acting (basal)
Long duration
glargine U-100 (Lantus)
detemir (Levemir)
Ultra-long duration
glargine U-300 (Toujeo)
degludec (Tresiba)
Use for long and ultra-long duration insulin
Basal coverage
glargine U-100 (Lantus) OPD
O: 1-2
P: none
D: 24 h
detemir (Levemir) OPD
detemir (Levemir)
O: 1-2 h
P: 4-8
D: 24 hr (varies by dose)
glargine U-300 (Toujeo) OPD
O: 3 h
P: none
D: up to 48 hours
degludec (Tresiba) OPD
degludec (Tresiba)
O: 30-90 m
P: none
D: >24 h
Intermediate-Acting/Combination Preparations
70% NPH/30% regular (Humulin 70/30, Novolin 70/30)
50% NPH/50% regular (Humulin 50/50)
70% aspart protamine/30%aspart (Novolog Mix 70/30)
75% lisproprotamine / 25% lispro (Humalog Mix 75/25)
50% lisproprotamine 50% lispro (Humalog Mix 50/50)
Mixed insulin OPD
Onset: 30 minutes,
Peak: 0.5-12 hours,
Duration: up to 24 hours
Basal bolus strategy:
Combination of a long or ultra-long acting insulin for basal coverage and short insulin for meal coverage
Insulin Pump:
Rapid-acting insulin (preferred) provides a steady (hourly) SQ infusion (units/hr) along with preprogrammed boluses for meal and snack coverage
Sulfonylureas examples
glyburide (DiaBeta)
glimeperide (Amaryl)
glipizide (Glucotrol)
Indication sulfonylureas
DM2
MOA Sulfonylureas (glyburide, etc.)
Promotes insulin secretion by the pancreas and may ↓ insulin resistance/ ↑ tissue response to insulin
Safety sulfonylureas
hypoglycemia- dose-dependent
weight gain
↑ effects of alcohol
Pregnancy safety with sulfonylureas
contraindicated during pregnancy
Biguanides:
metformin (Glucophage, Fortamet)
metformin (Glucophage, Fortamet) indication
T2DM glycemic control
Prevention of T2DM
Off label:
Gestational DM
PCOS
MOA metformin
↓ hepatic gluconeogenesis, ↑ tissue response to insulin, ↓ absorption of glucose in the gut (small effect)
Safety, D2D with metformin
GI s/s, nausea, cramping, diarrhea, ↓ appetite.
lactic acidosis
D2D: cimetidine (Tagamet), resulting in an increase in metformin blood levels
Excessive Alcohol can cause lacitic acidosis
BBW metformin
Lactic acidosis. ↑ accumulation of metformin. Highest risk with renal impairment
Monitoring metformin
↓ absorption of vitamin B12 and folic acid
Renal funciton
Thiazolidinediones (-Glitazones) examples
pioglitazone (Actos)
rosiglitazone (Avandia)
indication pioglitazone (Actos) and rosiglitazone (Avandia)
T2DM
Often added to metformin
Pioglitazone (Actos) and rosiglitazone (Avandia) MOA
↓ insulin resistance, ↑ glucose uptake by cells, ↓ hepatic gluconeogenesis
Safety Pioglitazone (Actos) and Rosiglitazone (Avandia)
Contraindicated with HF and hypersensitivity
hypoglycemia (ONLY in the presence of insulin)
edema
HF, bladder CA, fracture (↑ women), promotes ovulation
Some reports of hepatic injury (rare)
BBW Thiazolidinediones (GLITAZONES)
cause or exacerbate congestive heart failure (CHF
Monitoring Thiazolidinedines (-GLIZAZONES)
LFTs
Alpha-glucosidase inhibitors example
acarbose (Precose)
acarbose (Precose) use
T2DM adjunctive therapy
acarbose (Precose) MOA
Delays CHO digestion and absorption which slows postprandial glucose elevations
acarbose (Precose) side effects
GI s/s flatulence, cramps, abd. distention, and borborygmus (technical term for rumbling and gurgling sounds in belly)
Tx for hypoglycmeia with Precose
If hypoglycemia develops (acarbose PLUS a hypoglycemic agent), sucrose metabolism is ↓ by acarbose, so GLUCOSE must be used to treat.
SGLT2 Inhibitors
“-Gliflozins”
canagliflozin (Inovkana)
dapaglifozin (Farxiga)
MOA SGLT2 INhibitors (-Gliflozins)
↑ glucose excretion in urine by inhibiting SGLT-2 (↓ glucose reabsorption in tubules) which lowers circulating glucose and weight loss 2° less calories (glucose excreted in urine)
Safety and D2D SGLT2 (-Gliflozins)
Genital mycotic infections (female >male), UTI, ↑ urination
orthostatic hypotension
rifampin, phenytoin, phenobarbital and similar inducers can ↓ efficacy
Additional benefit of SGLT2 (-Gliflozins)
Cardioprotective
DPP-4 inhibitors
-GLIPTINs
sitagliptin (Januvia)
linagliptin (Tradjenta)
Indication DPP-4 inhibitors (-GLIPTINs)
T2DM
Safety DPP-4 Inhibitors (-GLIPTINs)
pancreatitis, hypersensitivity
URI, HA, inflammation of the throat and nasal passages
hypersensitivity
hypoglycemia (with other agents)
GLP-1 Receptor Agonist
incretin mimetics
-TIDEs exenatide (Byetta) exenatide ER (Bydureon) semaglutide (Ozempic) liraglutide (Victoza) dulaglutide (Trulicity)
Indications GLP-1 receptor agonsit (-TIDES)
T2DM
weight loss
GLP-1 (-TIDE) Receptor Agonist safety
pregnancy: risk of fetal harm
Hypersensitivity
hypoglycemia (dose-dependent), GI s/s nausea, vomiting, diarrhea, constipation, pancreatitis, renal insufficiency, increased risk for CA: medullary thyroid and theoretical risk with multiple endocrine neoplasms (MENs)
BBW GLP-1 Receptor Agonist
Risk of thyroid C-cell tumors.
Semaglutide is contraindicated in patients with a personal or family history of MTC or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
other use for semaglutide
Semaglutide is gaining popularity as an anti-obesity medication
