non-insulin treatments pg 1-17 Flashcards
kania pt 3
what is the brand name(s) of metformin?
glucophage
fortamet
glumetza
metformin MOA
decrease hepatic production of glucose
increase intestinal glucose utilization –> decrease glucose uptake into circulation
can increase GLP-1 secretion
modest effect on increasing tissue uptake and utilization of glucose by muslces
why is metformin recommended by the ADA in all T2DM pts if tolerated?
shown to reduce risk of mortality and CV death
extensive experience
efficacious with minimal hypoglycemia
positive and/or neutral effects on weight
widely available and inexpensive
what are some off-label uses of metformin?
T1DM management in pts who are overweight and low risk of ketoacidosis
PCOS – increases ovulation, lowers androgen
what is the efficacy profile of metformin?
A1c –> decrease by 1.5-2%
FBG –> decrease by 60-80 mg/dL
TG/LDL –> decrease by 8-15%
Weight –> decrease by 2-3 or neutral
why is metformin d/c while in hospital?
may cause lactic acidosis in combination with medications
when should metformin use be cautioned?
in pts with renal dysfunction (needs adjustment)
acute decompensated hospitalized HF pts, unstable HF pts, or HF with severe renal/hepatic disease (AVOID)
alcoholics
what are some disadvantages of metformin?
lactic acidosis
GI effects (NVD flatulence)
vit B12 deficiency
controversial study of dementia risk
what is the normal dosing for metformin?
start at 500 mg BID wm
titrate weekly or bi-weekly by 250-500mg/day to avoid SE
max of 2gm/day
what is the dosing for metformin in renal insufficiency?
above 60 –> no change
45-60 –> safe to start and continue but monitor 3-6months
30-45 –> do not start, reduce 50% if taking already, monitor 3 months
<30 –> do not start, d/c if taking
what is the brand name(s) of canagliflozin?
invokana
what is the brand name(s) of of dapagliflozin?
farxiga
what is the brand name(s) of empagliflozin?
jardiance
what is the MOA of SGLT2 inhibitors?
inhibition of SGLT2 (transports renal glucose to increase glucose reabsorption) –> leads to renal glucose excretion
when is SGLT2 inhibitors recommended as initial therapy?
with T2DM patients that have
- ASCVD
- high risk for atherosclerotic CV disease (over 55y with at least 2: HTN, HLD, obesity, smoking, or albuminuria)
- HF
- CKD
what is the efficacy profile of SGLT2 inhibitors?
A1c –> decrease by 0.5-1.0%
FBG –> decrease by 25-35 mg/dL
PPG –> decrease by 40-60 mg/dL
Weight –> decrease by 1-5kg
BP –> decrease by 3-6mmHg (SBP) and 2-3 mmHg (DBP)
what are common SE of SGLT2 inhibitors?
UTIs
female/male genital mycotic infections
increased urination
hypotension
hyperkalemia
increased cholesterol
if a pt is UTI free for the past year, are they ok to start SGLT2 inhibitors?
yes
can SGLT2 inhibitors be considered for pts with h/o of GMIs?
yes if uncomplicated or rectified complicated
counsel on s/s
counsel on good perineal hygiene
d/c if infections
what are the FDA warnings for SGLT2 inhibitors?
DKA
bone fractures and decreased BMD in patients (specifically canagliflozin)
AKI (specifically in canagliflozin and dapagliflozin)
increased risk of leg and foot amputations (specifically canagliflozin but removed in 2020)
what is the recommendation for SGLT2 inhibitors near surgery?
hold three days before (4 if ertugliflozin)
restart once back to baseline due to increased risk of DKA
what is the dosing for canagliflozin?
if eGFR > 60 –> 100 mg, max of 300mg qd
if eGFR 30-60 –> 100 mg if no albuminuria
if eGFR < 30 –> do not start, if already taking may use 100 mg daily if albuminuria > 300 mg/d
what is the dosing for dapagliflozin?
if eGFR > 45 –> 5mg, max of 10 mg qd
if eGFR < 25 –> do not start, if on monitor
what is the dosing for empagliflozin?
if eGFR > 30 –> 10mg, max of 25
if eGFR < 30 –> do not start, monitor if on
what are the benefits of SGLT2 inhibitors?
reducing the composite of worsening renal function, ESRD, or renal death by 45%
overall CV benefits
decreased weight, decreased BP, osmotic diuresis
what is the brand name of liraglutide?
victoza
what is the brand name of dulaglutide?
trulicity
what is the brand name of semaglutide?
ozempic
rybelsus
what drugs are GLP-agonists?
liraglutide
dulaglutide
semaglutide
what is the MOA of GLP-1 agonists?
inhibits glucagon secretion delays gastric emptying
decreases appetite
increases in both first and second-phase insulin secretion after meals occur
leads to insulin release only in presence of elevated BS
inhibits B-cell death
potentiates glucose-dependent insulin secretion by stimulating B-cell growth and differentiation/insulin gene expression
when should GLP-1s be use as an initial therapy?
same as SGLT2 inhibitors
in pts with ASCV, high risk of atherosclerotic CV disease, HF, and CKD
what is the efficacy profile of GLP-1?
A1c –> decreases 0.7-1.6%
short acting (exenatide/lixisenatide) more effect on PPG/eliminated in the kdiney vs long-acting more effect on FBG
weight –> decreases by 1.5-3 kg (may be up to 6 depending on dose)
what type of GLP-1s are CI in severe renal disease?
short-acting ones (exenatide/lixisenatide)
what are AE of GLP-1s?
NVD
acute pancreatitis (sometimes fatal)
what is the warnings for GLP-1?
black box –> thyroid c-cell tumors
regular –> gall bladder disease, pts with gastroparesis, and retinopathy
when are GLP-1s CI?
personal or family h/o of MTC or in MEN 2
caution –> pre-existing gallbladder disease
what are some preventative measures to protect against gallbladder disease in GLP-1s?
low fat diet
good hydration
physical activity
what is the SUSTAIN 6 trial?
rates of retinopathy complications were higher in semaglutide group rather than placebo
may be from the magnitude and speed of A1c reduction
are needles included in GLP-1s?
yes in trulicity and ozempic
no in victoza, byetta, adylyxin
what are some counseling tips of dulaglutide?
0.75mg SQ qw up to 4.5mg
use caution in ESRD
wait for second click before removing pen for admin
available in single dose pen
what are some counseling tips of semaglutide (ozempic)?
start at 0.25mg SQ qw x4w then 0.5mg SQ qw and titrate up to 2 mg
flow must be checked with each new pen –> prime it
what are some counseling tips of liraglutide?
0.6mg SQ qw, then increase to 1.2mg qd up to 1.8mg
only prime prior to first injection
what are some counseling tips of oral semaglutide?
3mg po qd x30 then increase to 7mg qd
take 30 minutes before first food, beverage, or other oral medication with no more than 4 oz of plain water –> not good option if pt needs cup of coffee in the morning
inject 0.5 mg SQ = 7 mg PO
what is the LEADER trial?
showed CV (primary outcomes only) and renal benefits with liraglutide
what is the SUSTAIN-6?
showed CV (primary outcomes, nonfatal MI, and nonfatal stroke) and renal benefits with semaglutide
what is the REWIND trial?
showed CV and renal benefits with dulaglutide
