Oral, Diabetes Pharm

Question 1

Metformin

Answer 1

Biguanides

MOA: activates AMPK, increases insulin sensitivity
-decreases cholesterol, TG, and FA synthesis
-increases glucose uptake in skm

AE: DAAMN B
-GI (dia/nausea/abd. dis./metallic taste/low B12)
-Lactic acidosis (rare)

Question 2

Biguanides (Metformin) Important Considerations

Answer 2

1. First line choice (w. lifestyle changes)
2. To minimize GI AEs, take with food, start with low dose, and titrate slowly
3. Contraindicated in patients with predisposing factors to lactic acidosis: (bad kid/LD/alc/HF/inf)
4. Temp. discontinue metformin in pts at risk of developing lactic acidosis (dehydration/sepsis/IV iodinated contrast)

Question 3

Pioglitazone, Rosiglitazone

Answer 3

Thiazolidinediones (TZDs),“Glitazones”

MOA: PPARy agonist (nuclear rec.) - gene transcription
-increase AMPK/sensitivity/gluc uptake
-decrease glucose production

AE: HII WE
-Hepatotoxicity
-Na/water retention = edema
-Weight gain
-Increase bone fractures
-Increase bladder cancer risk (PIO)

Question 4

Glitazones: Important Considerations

Answer 4

1. Relatively slow effects
2. Baseline LFTs/Check LFTs
3. Monitor for signs of HF (*higher risk if with insulin)
4. Contraindications:
   -HF
   -Bladder cancer (past/present)
   -Risk of fractures
   -Active liver disease

Question 5

Glimepiride, Glipizide, Glyburide
and Nateglinide, Repaglinide

Answer 5

Sulfonylureas and NON-sulf

MOA: bind to sulf rece subunit, increase Ca ch, increase insulin secretion

AE:
-Hypoglycemia (palp/tremor/sweat/anx/hunger/cns)
-Weight gain

Question 6

SUs and Non-SUs Considerations

Answer 6

1. Risk factors for hypoglycemia
   -after exercise, missed meal, high dose, alcohol, impaired renal/liver
2. Will not work in T1 DM pts (no beta cells)

Question 7

Exenatide, Lixisenatide, Liraglutide, Dulaglutide, Semaglutide

Answer 7

glutes = GG

MOA: activates GLP1 receptors

AE:
-GI (nausea/vomit/diarrhea)

Question 8

Glutides: Important Considerations

Answer 8

SO MEN P

1. Administer SC
2. Off label use in T1 DM
3. CI in pts with thyroid cancer or multiple endocrine neoplasia (MEN)
4. Caution if pancreatitis hx

Question 9

Sitagliptin, Linagliptin, Saxagliptin, Alogliptin

Answer 9

MOA: inhibits DPP4, increases GLP1 effects

AE: JARR (clip a jar)
-Increase risk of respiratory infection
-Rash
-Angioedema
-Joint pain

Question 10

Gliptin Important Considerations

Answer 10

1. Use with caution in patients with history of or risk factors for HF = increase hospitalization for HF

Question 11

Canagliflozin, Dapagliflozin, Empagliflozin

Answer 11

MOA: inhibits SGLT2 in PT

AE: HA LEG off a cliff (gliff)
-Genitourinary infections
-Hypotension
-AKI
-Euglycemic DKA
-Increase risk of lower limb amputations (Cana)

Question 12

Gliflozins Important Considerations

Answer 12

FRON
1. Off label for T1 DM
2. Pt ed about infections (gen)
3. Drink plenty of fluids
4. Risk factors for AKI (caution nsaids/acei/arb)
5. CI: severe renal impair
6. Renal monitoring
7. Risk factors for euglycemic DKA
8. Caution in pts with neuropathy, PAD, foot deformities

Question 13

A1c lowering

Answer 13

*High (>1.5%): metformin, SUs/non-SUs, GLP-1 agonists

*Medium (1-1.5%): TZDs

*Low (< 1%): DPP-4 inhibitors, SGLT2 inhibitors

Question 14

Weight Loss

Answer 14

GLP-1 agonists, SGLT2 inhibitors, metformin

Question 15

Weight Neutral

Answer 15

DPP-4 inhibitors, metformin

Question 16

Weight Gain

Answer 16

TZDs (glitazones), SUs, non-SUs

Question 17

Decrease CV risk

Answer 17

GLP-1 agonists, SGLT2 inhibitors

Question 18

Cancer Concerns

Answer 18

*Bladder cancer: pioglitazone

*Medullary thyroid cancer: GLP-1 agonists

Question 19

High Hypoglycemia Risk

Answer 19

SUs/non-SUs

Question 20

Metabolic Acidosis Risk

Answer 20

*Lactic acidosis: metformin

*“Euglycemic” DKA: SGLT2 inhibitors (glifs)

Question 21

Renal Considerations

Answer 21

-Metformin

-SGLT2 inhibitors (glifs)

-SUs/non-SUs