Oral medications for diabetes Flashcards
What is a post-prandial glucose (PPG)?
Glucose level taken 2 hours after eating
What is the goal glucose level for a PPG?
< 140 mg/dL
What is PPG level dependent on?
Upon the amount of food eaten
Overeating exacerbates glucose spikes
When do plasma glucose concentrations peak in nondiabetics?
~ 60 min after start of a meal (rarely > 140) & return to pre-prandial levels within 2-3 hrs
Oral diabetic meds can only be used for which type of DM?
Type 2
Oral diabetic meds supplement what?
Lifestyle changes (diet & exercise)
Used when diet & exercise alone are insufficient for disease management
Choice of oral diabetic med is dependent on what?
Comorbidities & patient needs
Non-insulin management of diabetes should start with what two things?
1) diet
2) exercise
Glycemic targets (ADA)
Individualized to person
A1C → < 7%
FPG → 80-130 (as close to normal as possible)
PPG → < 140
What drug class does metformin (Glucophage) fall into?
Biguanides
Metformin is considered a first line Tx for?
Type 2 DM
Can be used for pre-diabetics if diet/ exercise fail
How does metformin work? Hint: 5
1) Decreases absorption of carbs
2) Decreases glucose production in liver
3) Decreases appetite
4) Can be given alone or in combo w/ other meds
5) improves how insulin works in body (insulin sensitizer)
Additional benefits of metformin use HInt: 3
1) Off-label use for weight loss (due to appetite suppression)
2) can lower lipid levels
3) decreases PLT aggregation (reduces viscosity)
List 5 common GI side effects of Biguanides (metformin)
1) bloating
2) diarrhea
3) abdominal pain
4) nausea
5) metallic taste
Biguanides increase risk of _____ deficiency
Vitamin B12
Is risk of hypoglycemia high or low when using biguanides?
Low when used alone, can increase if combined with poor diet
Biguanides are contraindicated in what patients?
Patients with renal/ hepatic impairment & heart failure
Precautions in using Biguanides
IV contrast dye (CT scans) → Hold for 48 hrs before & after to prevent acute kidney injury & lactic acidosis
How can you reduce GI side effects from Biguanides?
Take the med with food
What is the most commonly prescribed oral diabetic med?
Sulfonylureas
How do sulfonylureas work?
1) stimulate beta cells to secrete insulin
2) decrease glucose production by the liver
What two meds can give sulfonylureas be given with?
Metformin or insulin
List 4 side effects of sulfonylureas
1) hypoglycemia
2) weight gain
3) GI side effects
4) increase risk of sunburn
Precautions/ contraindications of sulfonylureas Hint: 6
1) Renal & hepatic impairment
2) Allergies to sulfa drugs
3) Pregnant/ lactating clients
4) Pts on a beta blocker
5) Avoid alcohol
6) take with food
Onset & peak of sulfonylureas
Onset → 90 min
Peak → 2-3 hrs
Drug interactions of sulfonylureas Hint: 5
1) oral anticoagulants
2) NSAIDs
3) H2 blockers
4) Warfarin
5) beta blockers
Sulfonylureas may have decreased concentrations from what three meds?
1) thiazides
2) steroids
3) TB meds
List 3 examples of sulfonylurea meds
1) Glipizide (Glucotrol)
2) Glyburide (DiaBeta)
3) Glymepride (Amaryl)
How do metglinides work?
Stimulate beta cells to produce more insulin
less hypoglycemia risk than sulfonylureas
What oral diabetic med can be given to those with sulfa allergies?
Metglinides
Metglinides can be used alone or in combo with _____
metformin
List 2 examples of metglinide meds
1) Repaglinide (Prandin)
2) Nateglinide (Starlix)
When should you take metglinides?
with the first bite of food
Precautions to using metglinides
1) must eat within 15 min of taking med
2) skip the dose if skipping a meal (NPO patients need their dose held)
List 3 side effects of Metglinides
1) weight gain
2) angina
3) hypoglycemia
How do Thiazolidinediones work? Hint: 2
Similar to metformin
1) Improve the effectiveness of insulin by decreasing insulin resistance in adipose & muscle cells
2) blocks heaptic gluconeogenesis
slow onset
How can thiazolidinediones be used/ taken?
1) alone or in combo
2) taken with or without food
list 4 side effects of thiazolidinediones
1) weight gain
2) fluid retention
3) edema
4) osteopenia
Thiazolidinediones are considered what line of Tx?
second or third line
Give an example of a Thiazolidinedione
Pioglitazone (actos)
Thiazolidinediones are contraindicated in those with?
Heart failure or hepatic impairment
What lab test should be monitored when taking Thiazolidinediones?
LFTs (before & during use)
Pioglitazone causes possible risk of?
bladder cancer
Alpha Glucosidase inhibitors are also known as ____ ____
Starch blockers
How do alpha glucosidase inhibitors work?
Inhibit alpha-glucosidase, b delaying the absorption of glucose in the SI after a meal; does not increase insulin secretion
Slows glucose entry into bloodstream, reducing postprandial glucose spikes
When should alpha glucosidase inhibitors be taken?
With the first bite of food
List 3 side effects of alpha glucosidase inhibitors
1) anemia
2) GI → diarrhea, distention, flatulence
3) hypoglycemia (esp. when used in combo)
List 2 medications considered to be alpha glucosidase inhibitors
1) Acarbose (precose)
2) miglitol (Glyset)
Alpha glucosidase inhibitors should be avoided in patients with ____ _____
renal impairment
Alpha glucosidase inhibitors are contraindicated in what type of patients?
Patients with GI problems
Alpha glucosidase inhibitors can be used in combo with what type of meds?
Glucose lowering meds
What lab study should be monitored for patients on alpha glucosidase inhibitors?
LFTs
Glucagon-like peptide (GLP-1) receptor agonists are considered _____
incretin
List 5 mechanisms of action of GLP-1 receptor agonists
1) enhances secretion of insulin
2) blocks glucagon secretion
3) delay gastric emptying
4) decreased appetite; increased feeling of fullness
5) promotes growth & development of beta cells
How are GLP-1 receptor agonists considered hormone-based therapy?
basically same as mechanism of action; hint: 4
1) stimulate pancreas → increases insulin & decreases glucagon
2) slows gastric emptying → delays glucose spikes
3) reduces appetite → leads to weight loss
4) crosses BBB → increases satiety
How are GLP-1 receptor agonists given?
Once a day or once a week injectable
If GLP-1 receptor agonists are used in combination it can cause ____
hypoglycemia
List 5 side effects of GLP-1 receptor agonists
1) Nausea
2) Abdominal pain
3) Constipation
4) Pancreatitis risk
5) Injection site reactions
List 4 examples of GLP-1 receptor agonists
1) Semaglutide (Rybelsus/ Ozempic)
2) Exenatide (Byetta)
3) Dulaglutide (Trulicity)
4) Liraglutide (Victoza)
Semaglutide (Rybelsus/ Ozempic)
Rybelus → oral agent
Ozempic → SQ injection
Also used for weight loss (Wegovy; diff name)
Exenatide (Byetta)
SQ injection
Use cautiously in → pts w/ pancreatitis, gallstones, kidney dysfunctions & high triglycerides
AVOID alcohol!
How is Dulaglutide (Trulicity) administered?
SubQ injection
How do DDP-4 (Gliptin) inhibitors work? Hint: 4
1) inhibits dipeptidyl peptidase 4 (DDP-4) enzyme, which destroys the GI incretin hormones GLP-1 & GIP
2) increase insulin secretion
3) decrease glucagon secretion to decrease glucose production
4) allows incretin hormones to remain in circulation longer
Do DDP-4 inhibitors speed up or slow down gastric emptying?
Slow gastric emptying
Can cause weight loss
DDP-4 inhibitors can only cause hypoglycemia if combined with ____ or ____
insulin or sulfonylureas
List 4 examples of DDP-4 (gliptin) inhibitors
1) Sitagliptin (Januvia)
2) Saxagliptin (Onglyza)
3) Linagliptin (Tradjenta)
4) Alogliptin (Nesina)
What is the biggest DDP-4 inhibitor?
Januvia!!
List 8 side effects of DDP-4 inhibitors
1) Headache
2) Constipation/ Diarrhea
3) N/V
4) Pancreatitis
5) Joint pain
6) Renal impairment
7) Upper resp infections
8) Hypoglycemia
How do sodium glucose co-transporter 2 inhibitors (SGLT2) work?
Inhibit reabsorption of glucose in the proximal renal tubules; promote glucose excretion in urine
What line Tx are SGLT2 inhibitors considered?
Second line Tx
List 3 benefits to using SGLT2 inhibitors
1) Can cause weight loss
2) Decreases CV complications
3) decreases risk of hyperkalemia
SGLT2 inhibitors are contraindicated for patients with?
Renal impairment
SGLT2 inhibitors imcrease risk of what 3 things?
1) yeast infections
2) UTIs
3) amputations
List 2 key points to note when giving SGLT2 inhibitors
1) Take without regard to food
2) Increase PO fluid intake
List 3 examples of SGLT2 inhibitor meds
1) Canagliflozin (invokana)
2) Apagliflozin (Farxiga)
3) Empagliflozin (Jardiance)
What do all SGLTs inhibitors provide?
Renal protection by decreasing the protein loss & reducing the damage caused by hyper filtration
List 3 mechanisms of action of Amylin analogues (amylinomimetics)
1) slows gastric emptying, which helps regulate the postprandial rise in blood glucose
2) suppresses postprandial glucagon secretion
3) increases sense of satiety, possibly reducing food intake & promoting weight loss
When should Amylin analogues be given?
Immediately before meals
List one example of an Amylin analogues
1) pramlintide: Symlin injectable
3 key points to note when giving Amylin analogues
1) They are SQ injections
2) Do NOT give if not eating
3) Will cause Hypoglycemia
List an example of a hyperglycemia agent?
Glucagon
Define process of glycogenolysis
Triggers the liver to convert stored glucose (glycogen) into usable form & then releases into bloodstream
Who are hyperglycemic agents used for?
Severe hypoglycemia → when patient is unable to take oral glucose
What is administered to a patient if glucose levels fall below 70 mg/dL?
D50 (Ampid-50) or glucagon to raise blood sugar levels
List 3 routes of administration for Glucose (D50)
1) SubQ
2) IM
3) IV
Why should we provide a small snack when patient is awake or able to swallow after hypoglycemic episode?
To prevent rebound hypoglycemia after receiving Glucagon
