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Therapeutics 2 - Exam 3 > non-insulin treatments pg 1-17 > Flashcards

non-insulin treatments pg 1-17 Flashcards

kania pt 3

1
Q

what is the brand name(s) of metformin?

A

glucophage
fortamet
glumetza

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2
Q

metformin MOA

A

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

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3
Q

why is metformin recommended by the ADA in all T2DM pts if tolerated?

A

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

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4
Q

what are some off-label uses of metformin?

A

T1DM management in pts who are overweight and low risk of ketoacidosis
PCOS – increases ovulation, lowers androgen

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5
Q

what is the efficacy profile of metformin?

A

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

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6
Q

why is metformin d/c while in hospital?

A

may cause lactic acidosis in combination with medications

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7
Q

when should metformin use be cautioned?

A

in pts with renal dysfunction (needs adjustment)
acute decompensated hospitalized HF pts, unstable HF pts, or HF with severe renal/hepatic disease (AVOID)
alcoholics

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8
Q

what are some disadvantages of metformin?

A

lactic acidosis
GI effects (NVD flatulence)
vit B12 deficiency
controversial study of dementia risk

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9
Q

what is the normal dosing for metformin?

A

start at 500 mg BID wm
titrate weekly or bi-weekly by 250-500mg/day to avoid SE
max of 2gm/day

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10
Q

what is the dosing for metformin in renal insufficiency?

A

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

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11
Q

what is the brand name(s) of canagliflozin?

A

invokana

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12
Q

what is the brand name(s) of of dapagliflozin?

A

farxiga

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13
Q

what is the brand name(s) of empagliflozin?

A

jardiance

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14
Q

what is the MOA of SGLT2 inhibitors?

A

inhibition of SGLT2 (transports renal glucose to increase glucose reabsorption) –> leads to renal glucose excretion

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15
Q

when is SGLT2 inhibitors recommended as initial therapy?

A

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

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16
Q

what is the efficacy profile of SGLT2 inhibitors?

A

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)

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17
Q

what are common SE of SGLT2 inhibitors?

A

UTIs
female/male genital mycotic infections
increased urination
hypotension
hyperkalemia
increased cholesterol

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18
Q

if a pt is UTI free for the past year, are they ok to start SGLT2 inhibitors?

A

yes

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19
Q

can SGLT2 inhibitors be considered for pts with h/o of GMIs?

A

yes if uncomplicated or rectified complicated
counsel on s/s
counsel on good perineal hygiene
d/c if infections

20
Q

what are the FDA warnings for SGLT2 inhibitors?

A

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)

21
Q

what is the recommendation for SGLT2 inhibitors near surgery?

A

hold three days before (4 if ertugliflozin)
restart once back to baseline due to increased risk of DKA

22
Q

what is the dosing for canagliflozin?

A

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

23
Q

what is the dosing for dapagliflozin?

A

if eGFR > 45 –> 5mg, max of 10 mg qd
if eGFR < 25 –> do not start, if on monitor

24
Q

what is the dosing for empagliflozin?

A

if eGFR > 30 –> 10mg, max of 25
if eGFR < 30 –> do not start, monitor if on

25
Q

what are the benefits of SGLT2 inhibitors?

A

reducing the composite of worsening renal function, ESRD, or renal death by 45%
overall CV benefits
decreased weight, decreased BP, osmotic diuresis

26
Q

what is the brand name of liraglutide?

A

victoza

27
Q

what is the brand name of dulaglutide?

A

trulicity

28
Q

what is the brand name of semaglutide?

A

ozempic
rybelsus

29
Q

what drugs are GLP-agonists?

A

liraglutide
dulaglutide
semaglutide

30
Q

what is the MOA of GLP-1 agonists?

A

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

31
Q

when should GLP-1s be use as an initial therapy?

A

same as SGLT2 inhibitors
in pts with ASCV, high risk of atherosclerotic CV disease, HF, and CKD

32
Q

what is the efficacy profile of GLP-1?

A

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)

33
Q

what type of GLP-1s are CI in severe renal disease?

A

short-acting ones (exenatide/lixisenatide)

34
Q

what are AE of GLP-1s?

A

NVD
acute pancreatitis (sometimes fatal)

35
Q

what is the warnings for GLP-1?

A

black box –> thyroid c-cell tumors
regular –> gall bladder disease, pts with gastroparesis, and retinopathy

36
Q

when are GLP-1s CI?

A

personal or family h/o of MTC or in MEN 2
caution –> pre-existing gallbladder disease

37
Q

what are some preventative measures to protect against gallbladder disease in GLP-1s?

A

low fat diet
good hydration
physical activity

38
Q

what is the SUSTAIN 6 trial?

A

rates of retinopathy complications were higher in semaglutide group rather than placebo
may be from the magnitude and speed of A1c reduction

39
Q

are needles included in GLP-1s?

A

yes in trulicity and ozempic
no in victoza, byetta, adylyxin

40
Q

what are some counseling tips of dulaglutide?

A

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

41
Q

what are some counseling tips of semaglutide (ozempic)?

A

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

42
Q

what are some counseling tips of liraglutide?

A

0.6mg SQ qw, then increase to 1.2mg qd up to 1.8mg
only prime prior to first injection

43
Q

what are some counseling tips of oral semaglutide?

A

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

44
Q

what is the LEADER trial?

A

showed CV (primary outcomes only) and renal benefits with liraglutide

45
Q

what is the SUSTAIN-6?

A

showed CV (primary outcomes, nonfatal MI, and nonfatal stroke) and renal benefits with semaglutide

46
Q

what is the REWIND trial?

A

showed CV and renal benefits with dulaglutide

Therapeutics 2 - Exam 3 (10 decks)

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