Pales diabetic meds

Question 1

Sulfonylurea-I

Answer 1

Second generation: Glyburide (Micronase, Diabeta), Glipizide (Glucotrol) regular and XL, Glimepride (Amaryl)
Main mechanism: increase an insulin secretion by blocking K channels of b-cells of pancreas
The effect decreases with prolong use, 50% failure in 5 years

Contraindications: pregnancy/lactation, significant liver or renal insufficiency, sulfa allergy (?)

Question 2

Sulfonylurea side effects

Answer 2

GI upset
Urticaria
Jaundice (due to biliary stasis)
SIADH  (decreased Na, increased  BP)
* Weight gain

* Hypoglycemia
Over age of 60
Impaired renal function
Poor nutrition
Multidrug therapy

Question 3

Sulfonylurea comparison

Answer 3

Glipizide/Glimepride have dual (renal/liver) elimination routes, Glyburide is solely renally eliminated. So with CRF use Glipizide/Glimepride.
Avoid using sulfonyluria with unstable renal failure/irregular meals pattern/older patients with frequent hypoglycemic episodes.
Use regular rather XL forms in these patients if you absolutely need to.

Question 4

Meglitinides

Answer 4

Repaglinide (Prandin)
Nateglinide (Starlix)
Act by closing ATP-dependent K channels of b-cells.
Short acting (about 2-4 hours)
monotherapy or with other diabetic drugs excluding sulfonyluria
Should be taken with meals and if patient skips a meal, he should skip a dose as well
Greater effect on postprandial rises
Good drug to switch to in patients on sulfonyluria at risk for hypoglycemia
Adverse effects:
hypoglycemia, weight gain

Question 5

Incretins

Answer 5

Injectable/GLP 1
Exenatide (Byetta, Bydureon)
Liraglutide (Victoza)

Oral (DPP-IV inhibitors)
Sitagliptine (Januvia)
Saxagliptine (Oglyza)
Vildagliptin (Galvus)
Linagliptin (Trajenta)
Alogliptin (Nesina)

Question 6

DPP-IV inhibitors

Answer 6

the -gliptins

Modest HbA1c reduction (about 0.7)
May be used with renal failure, but dose is to be adjusted
Doesn’t cause hypoglycemia
No weight change
May cause pancreatitis (???)

Question 7

GLP-1 analogs

Answer 7

Exenatide, liraglutide, albiglutide, dulaglutide

SQ injections
Average of 7-12 lbs weight loss
Great in obese diabetics
Major side-effects: nausea(common), pancreatitis (rare)
No hypoglycemia when used alone or with Metformin

Question 8

Biguanides

Answer 8

Metformin(Glucophage)
Mechanism:, decreases glucose production by liver(primary), increases sensitivity of insulin receptors
decreases LDL, TC, and TG
* Promotes weight loss
* Doesn’t cause hypoglycemia
Side effects:GI upset, * lactic acidosis, decreases B12 and Folate intestinal absorption

Question 9

biguanide contraindications

Answer 9

Renal and liver insufficiency (Cr.>1.5)
Chronic hypoxia
past Hx of lactic acidosis
alcoholism
Withhold if Pt. getting iodinated contrast

Question 10

Thiazolidinediones

Answer 10

Rosiglitazone (Avandia ) and Pioglitazone (Actos)
Mechanism: increases sensitivity to insulin (primary), decreases hepatic gluconeogenesis
May be combined with SU, or MF
Caution when combining it with insulin
May cause significant weight gain

May take few weeks to work
May cause water retention. Should not be used with significant history of CHF or poor E.F.
May cause liver damage. Not to be used for patients with liver problems(ALT >2.5N)
Rosiglitazone may increase risk of MI, almost was pulled out of market

Question 11

a-Glycosidase Inhibitors

Answer 11

Acarbose (Precose) and Miglitol (Glyset)
Mechanism: decreases absorption of CH by decreasing brash-border alpha-Glycosidase blunting postprandial. hyperglycemia
No hypoglycemia, lactic acidosis, weight gain
monotherapy or with other
most useful for severe postprandial gluc. rise

From UKPDS
0.5% decrease in HbA1c
Only 39% remained on the drug after 3 years
Terrible Flatulence-30%
Diarrhea: 16%
Contraindications:
Major GI disorders

Question 12

GlucosuricsSGLT-2 Inhibitors

Answer 12

Canagliflozin
Dapagliflozin

Block the re-uptake of glucose in the renal tubules --> promote loss of glucose in the urine.
Mild weight loss and NO hypoglycemia.
Side effects
Urinary tract infections
Dehydration 
Yeast infections

Question 13

Pramlintide

Answer 13

Analogue of Island Amyloid Polypeptide (secreted by B-cells in equal amounts with insulin).
Suppresses glucagon secretion, delays gastric emptying, and decreases appetite.
Rarely used

Question 14

mechanism unknown diabetes drugs

Answer 14

Bile Acid Sequestrants
Colesevelam (Welchol)
Primarily used for LDL reduction
No effect on CV events

Bromocriptine
dopamine 2 receptor agonist,
Causes nausea, vomiting, dizziness, and headache.

Question 15

Insulin preparations

Answer 15

Regular insulin at high dose acts like intermediate-acting. It’s rarely used now.
All insulin preparations tend to last longer with renal insufficiency
Intermediate-acting insulins and long acting insulins can be given once or a twice a day in different patients depending on circumstances.
Intermediate-acting insulins should be combined with short-acting insulins in Type I and in more severe Type II patients

Question 16

When and how to start insulin in Type II DM

Answer 16

Earlier rather than later
Individualize to patient (based on BS log)
Usually long acting is first one to be started
Fixed combinations should not be the first choice
- Too much hypoglycemia
- Cannot change the dose of one insulin without changing the dose of the other
Don’t stop the oral meds unless contraindications

Question 17

Dawn phenomenon

Answer 17

hyperglycemia in the morning
diurnal increase of anti-insulin hormones secretion in am
normal or high blood sugar at 3 am
no night sweats
insulin/ diabetic med dose not high enough
treatment: increase medications

Question 18

samojyi effect

Answer 18

morning hyperglycemia
rebound after night time lows
3 am blood sugar ery low
night sweats
doses of insulin/ diabetic medication too high

treatment: decrease medications