Pharm: Block 3 Flashcards
1
Q
Fasting Plasma Glucose reflects the hepatic glucose output level, what are the ranges?
A
Norm= <100mg
Impaired fasting= 100-125mg
Diabetes= >126mg
2
Q
Oral Glucose Tolerance Test is a 2hr post-load test reflecting glucose uptake by peripheral tissues (insulin sensitivity), what are the ranges?
A
Normal= <140mg impaired= 140-199mg Diabetes= >200mg
3
Q
What are the reference ranges for HbA1C?
A
Normal= <5%
Inc risk= 5.7-6.4%
Diabetes= >6.5%
4
Q
When HbA1C is lower, _____ is the major contributor to overall hyperglycemia
A
Post-prandial glucose-
- HbA1C <7.3, post-prandial contributes 69.7%
- HbA1c >10.2, post-prandial contributes 30.5%
5
Q
When HbA1C is higher, _____ is the major contributor to overall hyperglycemia
A
Fasting plasma glucose-
- HbA1C <7.3, fasting glucose contributes 30.3%
- HbA1C >10.2, fasting glucose contributes 69.5%
6
Q
Diabetes is #_ leading cause of death from it’s complications which can include ?
A
Macrovascular- heart attack, stroke, PVD
Micro- retin/neuro/nephropathy
Acute- Hypoglycemia, DKA, HHS
7
Q
Diabetic BP control reduces CV risk by _% and microvascular complications by __%
What is the general reduction assumption?
A
CVD- 33-50%
Micro- 33%
For ever 10mm SBP decrease, diabetic risks decreases by 12%
Reducing DBP from 90 to 80mm dec CVD risk by 50%
8
Q
Glucose control in diabetes is generalized by every _% dec of A1C = ?
A
1% dec = 40% reduced risk in microvascular complications
9
Q
When is gestational diabetes tested for?
What are the S/Sx?
A
24-28th week
Glucosuria, Polydispia, Polyuria, UTI infections, blurred vision
10
Q
What happens in untreated gestational diabetes?
A
Large birth weight
Premature delivery
C-section
Inc risk of infant death
11
Q
What are the gestational blood sugar goals?
A
Preprandial= <95mg
1hr postprandial= <140mg
2hr postprandial= <120mg
12
Q
What is the therapy for pregnant women with risk factors using standard diagnostic criteria?
A
Screen for undiagnosed T2DM at first prenatal visit
13
Q
What is the therapy for pregnant women without known prior diabetes?
A
24-28wks, 75g 2h OGTT
Diagnostic cut points
14
Q
What is the therapy for women with gestational diabetes?
A
6-12wks, OGTT and non-pregnancy criteria
15
Q
What is the therapy for women w/ Hx of GDM and pre-diabetes?
A
Lifestyle interventions
Metformin for diabetes prevention
16
Q
What medication is preferred for gestational diabetes?
A
Insulin- reqs frequent titration and referral to specialists
17
Q
All insulins are pregnancy Category __ with the exception of ____
A
Category B
Except Glargine and Glulisine- Category C
18
Q
What types of insulin are most commonly used?
A
Regular
Rapid acting
NPH insulin
19
Q
Characteristics of non-insulin medicaiton use in GDM?
A
Lack long term safety data and cross placenta
Glyburide
Metformin
Both Category B
20
Q
Define Hypoglycemia
A
Blood glucose below 70mg and 10x more common in T1DM
21
Q
What are the Sympathetic Sx of Hypoglycemia
A
Tachy, tremor, sweating, anxiety, hunger
22
Q
What are the Neuroglycopenic Sx of hypoglycemia
A
Confusion, weak, drowsy, dizzy, blurred vision, difficulty speaking and concentration
23
Q
Level 1 Hypoglycemic stage and treatment
A
Glucose 60-70
Adrenergic Sx
15-15-15- 15g CHO, wait 15m, treat if Sx persist
24
Q
Level 2 Hypoglycemia stage and treatment
A
Glucose 41-59
Adrenergic and neuroglycopenic Sx
30-15-30: 30gm CHO, wait 15m, treat again
25
Level 3 Hypoglycemia stage and treatment
Glucose <40
Adrenergic and neuroglycopenic Sx with possible seizure/coma
Glucagon 1mg subQ or 50mls D50W IV (only give to unconscious/responsive/confused PT)
26
Characteristics of HHS
Hyperosmolar Hyperglycemic State- inc glucose in urine impairing concentration ability/process causing more H2O loss than Na (HyperOsmo) despite insulin presence (doesn't red blood sugar levels)
27
When/who does HHS usually occur in?
Older T2DM PTs
| Younger PTs with prolonged hyperglycemia and dehydration or renal insufficiency
28
What are the hallmark lab results for DKA?
```
Hyperglycemia
Acidosis
Anion gap
Large ketonemia/ketonuria
Rapid onset in PTs that can be alert, stupor or comatose
```
29
What are the hallmark lab results of HHS?
```
Similar to DKA except:
Higher plasma glucose >600
Elevated serum osmolality
pH > 7.30
Little/no ketonuria/nemia
Onset- days to weeks
```
30
MOA of Insulin
T1DM replacement/T2DM supplementation to facilitate glucose uptake in peripheral tissue while dec glucose/glucagon secretions to overall dec circulating glucose
31
What are the 3 adverse effects of Insulin?
Hypglycemia
Weight gain
Lipodystrophy- hypertrophy/atrophy at injection site
32
What factors affect insulin pharmacokinetics?
Route: IV>IM>SC
Absorption: Abd fat>Post arm>Lat thigh>Sup buttocks; exercise/massage, lower dose/concentrations absorb faster
33
How is insulin clearance altered?
RF- 60% exogenous cleared
| LF- 30-40% exogenous cleared
34
Bolus insulin are broken into what two subcategories?
Rapid- Lispro, Aspart, Glulisine
Short acting- Regular: Humilin, Novolin
35
Basal insulin are broken into what two subcategories?
Intermediate- NPH (Neutral Protamine Hagedorn)
Long acting- Glargine
Detemir
36
What two insulin subcategories include meds that are insulin analogs?
Rapid acting
| Long acting
37
What is the inhaled version of insulin?
Afrezza- in T1DM, must be used w/ long lasting insulin
38
Afrezza is NOT recommended for ?
DKA treatment
| PTs w/ respiratory complications- smoke/quit in last 6mon, COPD, asthma or cancer
39
What type of diabetic PT uses U-500 Insulin?
PTs w/ severe insulin resistance used BID 30m prior to meals in U-500 or tuberculin U-100 syringes
40
What is the NPH/Regular insulin combo made up of?
Humulin 70/30
| Novolin 70/30
41
What is the NPH/Rapid acting insulin combo?
Humalog Mix 75/25 (neutral protamine lispro/lispro)
Humalog Mix 50/50 (neutral protamine lispro/lispro)
Novolog Mix 70/30 (aspartate protamine suspension/aspart)
42
Characteristics of Rapid-Acting Insulins
```
Aspart, Lispro, Glulisine, Afrezza
Onset <0.5hrs
Peak .5-2hrs
Duration 3-6hrs
Admin 15m prior to meal, less risk of post-prandial hypoglycemia than regular insulin
Approved for CSII
```
43
Characteristics of Short Acting Insulin 100
Onset .5h
Peak 2-5hrs
Duration 4-12hrs
DOC for IV, approved for CSII, must inject 30m prior to meal
44
Characteristics of Short Acting Insulin 500
Onset less than .5h
Peak 4-8h
Duration 13-24hrs
Inject 30m prior to meal in highly insulin resistant PT, caution w/ accidental OD
45
Characteristics of the Intermediate Acting Insulin?
```
Onset 1-4hr
Peak 3-12hr
Duration 16-24hr
Greater risk of nocturnal hypoglycemia
Cloudy appearance combined with protamine
```
46
Characteristics of the Long Acting Insulin
```
Onset 1-2hr
Peak None
Duration 7.6 > 24
Less nocturnal hypoglycemia
Daily for T2DM
BID for T1DM
```
47
How are syringes selected for insulin administration?
30u/0.3ml
50u/0.5ml
100u/1ml
U500 or Tuberculin syringe for U-500
48
Insulin syringes measures _
| Tuberculin syringes measures _
Units
| mls
49
T1DM is AKA ?
Insulin dependent DM
| Juvenile onset DM
50
T1DM insulin physiologic regimens use insulin __
Analogs
51
What are the two insulin regimens for T1DM?
1-2 basal injections per day
w/ prandial injections
CSII therapy
52
How are T1DM insulin regiments measured out?
Based on weight, 0.5u/kg
| Inc dose for obese, illness, sedentery or puberty
53
How much basal/bolus insulin for T1DM?
Basal- 40-50% of body's daily insulin requirement
| Bolus- 50-60%; 10-20% of daily requirement before/at each meal from carb intake determination
54
What is the insulin : carb ratio?
```
Regular insulin: 450/TDD=CHO coverage dose
Rapid-Acting: 500/TDD=CHO coverage dose
1u/15gm of CHO
Obese= 1:5
Lean/insulin sensitive= 1:20
```
55
What is the purpose of corrective/supplemental doses?
Given when blood sugar is unexpectedly high and to bring pre-meal/bed glucose levels into range
56
What insulin management method provides estimate of PTs sensitivity to insulin?
Corrective/Supplemental Dose
57
Define the Rule of 1500 and 1800
Correction bolus set up after basal dose has been tested for accuracy
Regular: 1500/TDD
Rapid-Acting: 1800/TDD
58
What is the Correction Dose equation
CD= current BG - desired BG / correction factor
59
If pre-breakfast/lunch/supper/bedtime glucose is high/low, adjust ?
B- evening basal
L- next morning bolus
S- next day morning basal and/or pre-lunch bolus
Bed- adjust supper rapid/reg insulin dose next day
60
If 2hr post prandial glucose is high/low, adjust ?
Pre-meal rapid/reg insulin dose next day
61
If 0300 blood glucose is high/low, adjust ?
Evening basal insulin dose next day
62
Define Dawn Phenomenon
| How is it fixed?
Insufficient evening basal insulin leads to AM hyperglycemia secondary normal waking process
0200-0300 SMBG shows normal/elevated blood sugar
Inc evening basal insulin
63
Define Somogyi Effect
| How is it fixed?
Too much evening basal insulin leads to hypoglycemia in middle of night
0200-0300 blood sugar shows dec levels
Body adjusts w/ inc glycogenolysis and gluconeogenesis
Dec evening basal insulin
64
T2DM is AKA ?
Non-Insulin Dependent DM
Adult Onset DM
Decline B-Cell function and secretion
Characterized by insulin resistance and lack of secretion w/ lower secretion over time
65
What are the risk factors for T2DM?
```
Inactivity
FamHx w/ 1* relative
Ethnicity
Women delivered +9lb baby
GDM Dx
PCOS
HTN
CVD Hx
Dyslipidemia
```
66
What are the objective glucose tests for T2DM risk factors?
HbA1C > 5.7%
Impaired tolerance
Impaired fasting
67
Insulin resistance is related to ___ and is proportional to _____
Weight
| Amount of visceral adipose tissue
68
Define VAT
Visceral Adipose Tissue- fat cells located within abdominal cavity
69
How does VAT affect insulin resistance?
```
Higher rate of lypolysis, inc FAs that are released into portal circulation, drain to liver and stimulate VLDL and dec insulin sensitivity in peripheral tissues
Produce cytokines (TNF-a, IL-6) which contribute to resistance
```
70
What is adiponectin's role in insulin resistance?
Improves sensitivity but decreases with inc obesity
71
PTs w/ ____ _have 5-6x inc risk of T2DM
```
Metabolic Syndromes- have 3 of 5 components-
abd obesity: m40", w35"
HDL: m<40mg, w<50mg
Triglycerides: >150mg
BP: SBP>130 DBP >85
Fasting glucose: >100mg
Any above "or on Rx"
```
72
What are the 4 criteria for Dx T2DM?
A1C > 6.5%
FPG > 126mg
2hr PG >200mg during 75g OGTT
Random PG >200mg
73
What confirmatory/validation tests are done on T2DM samples prior to final Dx?
Unless Dx is clear, same test is repeated using new blood sample for confirmation
2 discordant results= result above cut off needs to be repeated
74
Glycemic targets for Non-pregnant adults w/ diabetes?
A1C <7%
Pre-prandial PG 80-130
Post-prandial PG <180
75
T2DM targets are based off of what factors?
```
Age/life expectancy
Comorbid conditions
Diabetes duration
Hypoglycemia status
Individual PT considerations
Known CVD
Adv microvascular issues
```
76
Most stringent T2DM target is ?
| Less stringent T2DM target is ?
<6.5%
| <8%
77
What are the goals of Medical Nutrition Therapy?
Eating pattern to improve overall health
Glycemic BP and lipid goals
Body weight goals
Delay/prevent DM complications
78
How much exercise should T2DM get?
+150min of aerobics across 3 days/wk with no more than 2 consecutive days w/out exercise
Resistance training x 2days/wk
79
What part of the VS needs to be assessed at every T2DM Dr visit?
BP
+130/80= anti-HTN treatment w/ goal of <130/80
PTs w/ BP >120/80= lifestyle mods
80
What is the lipid management criteria for T2DM?
All ages w/ ASCVD/10yr risk >20%= high intensity statin
+40y/o and no ASCVD= moderate statin
ASCVD and LDL is >70 on max statin= additional LDL lowering therapy
81
Can T2DM get influenza, PPSV23, HepB vaccines?
Influenza- >6mon old
PPSV- >2yrs old
HepB- unvaccinated adults with diabetes aged 19-59 and consider in unvaccinated adults >60yrs
Do not coadminister, minimum interval between doses- 8wks
82
MOA of Biguanides
Dec glucose production and enhances glucose uptake while slowing intestinal absorption of sugars
83
```
What med is the first line drug of choice for T2DM?
What are two additional benefits this drug class offeres?
```
Biguanides
| Impoved CV outcome
84
Two clinical uses of Biguanides?
T2DM
| PCOS
85
How are Biguanides dosed?
| What type of PT should these meds be used with caution?
Only labeled oral agent for use in children 10-16y/o
Geriatrics (renal dysf), don't titrate to max dose
86
What are the adverse effects of Biguanides
GI upset/diarrhea
Metallic taste and dec B12 absorption
Hypoglycemia (low)
Lactic acidosis (rare)
87
What is a contraindication of using Biguanides?
ScR >1.4 female / 1.5 in males
| Risk of lactic acidosis
88
What is are the drug interactions of Biguanides?
Stop Metformin if radiology iodinated contrasts are given
Resume after 2-3 days and normal renal function is proven
Cimetidine- competes for renal secretion w/ metformin and can inc metformin levels
89
What needs to be monitored for in PTs taking Biguanides?
Situations that increase lactic acid and decrease tissue perfusion
Liver Dz
Chronic alcohol
90
MOA of Sulfonylureas
Binds to sulfonylurea receptor on B-cells to stimulate insulin secretion in T2DM
91
What are the cautions for Sulfonylureas?
Why does this class need monitoring?
Hepatic/Renal Dysfunction
Reduced efficacy over time, 5-7% fail/year
92
Adverse effects of Sulfonylureas
```
Hypoglycemia- esp if used with Glyburide or Chlorpropamide
Weight gain
Skin rash
GI upset/cholestasis
HypoNa
Allergic reaction w/ sulfonylurea
```
93
What are the drug interactions of Sulfonylureas?
Protein binding displacement- esp 1st gen
Hepatic metabolism 2C9 and 2C19
Avoid Chlopropamide in PTs w renal dysfunction or elderly
GLP-1 agonist/DPP-4 inhibitor- dec dose by 50% to reduce hypoglycemia risk
94
What are the drug names of the first generation Sulfonylureas?
Chlopropramide- highest hypoglycemic risk
Tolazamide
Tolbutamide- shortest acting
95
What are the names of the 2nd generations Sufonylurea drugs?
Glipizide/XL
Glyburide/micronized
Glimepiride
96
Which 2nd Gen Sulfonyurea is safe for pregnancy?
Which one is safer for PTs with renal dysfunction?
Glyburide
Glimepiride
97
What is the MOA of Meglitinides
Stimulate insulin secretion from B-cells of pancreas like Sulfonyureas but from different sites (reqs presence of glucose to stimulate insulin secretion)
98
What are the adverse effects of Meglitinides?
```
Dizzy
URI/Flu-like Sx
Slight risk of inc serum uric acid
Hypglycemia, less than Sulfos
Weight neutral
```
99
Which Meglitinides have better efficacy at lowering A1C?
Repaglinide > Nateglinide
100
When is the use of Meglitinides preferred/inidcated?
2 or 3 in line w/ Metformin in place of Sulfos in PTs with irregular eating schedules or who develop late hypoglycemia while on Sulfos
101
Meglitinides can be used in conjunction with what other meds?
Metformin, TZD, DPP-4 inhibs, or GLP-1 Agonists but,
| Use w/ Sulfonylureas won't improve glycemic parameters
102
When are Meglitinides considered for use as a monotherapy?
One of the last monotherapy considerations in PTs w/ A1C less than 7.5%
Use w/ Caution
103
What are the names of the Meglitinides?
Nateglinide- 2CP substrate
| Repaglinide- 2C8 and 3A4 substrate
104
What medication can double effects of Repaglinide?
| How?
Gemfibrozil, inhibition of glucoronidation
105
MOA of Thiazolidinediones
Enhance T2DM insulin sensitivity in muscle/fat by increasing glucose transporter expression through PPAR-y binding
106
What are the adverse effects of Thiazolidinediones?
```
Weight gain
Dilution anemia
MI
Inc Fx rate
Hep failure- d/c if LFTs > 3x
```
107
When is caution exercised when using TZDs?
NYHA Class 1/2 HF, contraindicated in 3 and 4
| Bladder cancer
108
What drug interactions does TZDs have?
MI risk if Rosiglitazone is used w/ nitrates
| CHF risk 2.5x if used in combo w/ insulin
109
What needs to be monitored when using TZDs?
HbA1C- not seen for 4mon
Livier- draw baseline LFT and secondary if Dz suspicion
CV- Rosigli inc LDL but Pioglit dec TG and improves lipid profile
HF- inc risk w/ Rosiglitazone
110
Characteristics of GLP-1
Glucagon-Like Peptide Agonist
Secreted from L cells and action is glucose dependent= low risk of hypoglycemia
Dec glucagon secretion, slows gastric emptying and inc satiety
Stimulates B cells
111
Characteristics of GIP
Glucose Dependent Insulinotropic Polypeptide
Augments insulin secretion and is secreted by K Cells w/ little effect if glucose is >140
No effect on gastric motility of satiety
112
What is the MOA of DPP-4 inhibitors
Inhibs DPP4 enzyme to prevent GLP-1 and GLP degradation to inc insulin secretion and dec glucagon secretion, no effect on satiety/gastric motility
113
What are the adverse effects of DPP4-Inhibs
```
Weight neutral
Pancreatitis risk
Sita/Saxa- inc risk of URI/UTI
Saxa- worsen HF, dec lymphocyte counts
Modifications needed if renal impairment is present and taking Sita/Saxa and Alog.
```
114
What are the drug interactions of DPP-4 Inhibitors?
What are the names of the DPP-4 Inhibitors
Dec Sulfonylurea by 50% if used in combo
Linagliptin
Alogliptin
Sitagliptin
Saxagliptin
115
Which DPP-4 use does not require dose adjustment if PT has renal impairment?
Linagliptin
116
What are the adverse effects of GLP-1 agonists
What are the GLP-1 agonists names?
```
HA, N/Diarrhea
Lira/Dula/Exen- pancreatitis
Thyroid cancer
Renal insufficiency
Dulaglutide, Liraglutide, Exenatide
```
117
What are the contraindications of GLP-1 agonists?
T1DM
| PTs with Hx of medullary thyroid cancer/nodules or elevated calcitonin
118
What are the interactions of GLP-1s?
Delay drug absorptions
| Sulfonylurea- dec dose by 50% to dec risk of hypoglycemia
119
What needs to be monitored in TPs on GLP-1s?
Dec BP
Improved lipid profile
Baseline amylase/lipase for suspected pancreatitis
Dysphagia, hoarse and neck mass if suspected Thyroid cancer
120
MOA of Synthetic Anylin Analogue
Suppress inappropriate high postprandial glucagon secretion and increases satiety/slows gastric emptying
121
When is Synthetic Anylin Analogue used?
Adjunct to meal time insulin therapy in T1/2DM
122
How is Synthetic Amylin Analogue dosing determined
SQ prior to major meals +250kcal or +30gm of carbs in abdomen or thigh and at different site than insulin
123
What are the Synthetic Amylin Analogue adverse effects?
Severe Hypoglycemia
| N/V/Anorexia
124
What are the Synthetic Amylin Analogue contraindications?
Don't use w/ gastroparesis or PTs taking motility agents
Peds
Hypoglycemia
125
What are the Synthetic Amylin Analogue interactions?
2x inc hypoglycemia T1DM- dec prandial insulin dose by 50%
| May delay drug absorptions
126
MOA of a-glucosidase inhibitors
Inhibit enzymes in small intestine to delay breakdown of sucrose/complex carbs to cause and overall dec in post-prandial blood glucose w/out effecting glucose, lactose and fructose in T2DM
127
When is a-glucosidase inhibitor use considered good?
PTs near target HbA1C levels with near normal FPG levels BUT have high postprandial
128
How is a-glucosidase inhibitor dosage used?
Taken w/ first bite of meal and titrated based on tolerability
129
What are the adverse effects of a-glucosidase inhibitor use?
Weight neutral
| GI- gas, abd pain, diarrhea
130
What are the contraindications of a-glucosidase inhibitor use?
PTs w/ short bowel sydrome
IBDz
Cirrhosis
131
What is a unique characteristic of using Beano with a-glucosidase inhibitors?
Dec GI side effects but will decrease efficacy
132
What are the a-glucosidase inhibitor drug names?
Acarbose
Miglitol
Dont use either if SrCr is below 2mg
133
MOA of Selective Sodium Dependent Glucose CoTransporter 2 Inhibitors
Inhibits transporter which reduces reabsorption of filtered glucose and lowers renal threshold of glucose to increase urinary excretion of glucose in T2DM PTs
134
What are extra benefits of using Selective Sodium Dependent Glucose CoTransporter 2 Inhibitors Empagliflozing and Canagliflozin
FDA approval for reducing CV risk
135
What are the names of Selective Sodium Dependent Glucose CoTransporter 2 Inhibitors drugs?
Canagliflozin
Dapagliflozin
Empagliflozin
136
What are the adverse effects of Selective Sodium Dependent Glucose CoTransporter 2 Inhibitors use?
```
Genital Fungal infection
UTIs
Inc LDL
Weight loss
Low hypoglycemic risk if monotherapy
Dec BP
```
137
What are the precautions of Selective Sodium Dependent Glucose CoTransporter 2 Inhibitors use?
Cana- inc stroke risk
Dapag- inc bladder cancer risk
Do NOT use if renal dysfunction is present
138
What drug classes can cause an increase of blood glucose?
BBs
Diuretics- thiazides, Loop
Niacin
139
What are the 3 phases of thrombus formation?
Adhesion
Activation
Aggregation
140
What are the 5 steps of a platelet aggregation pathway and plaque rupture
1: homeostasis, NO and PGI2 released
2: homeostasis; NO and PGI2 induce cAMP synthesis, cAMP dec Ca and inhibs GP2b/3a activation
3: rupture; collagen, ADP, TXA2 and thrombogenics exposed, platelets recruited and activated
4: change; thrombogenics inhibit cAMP synthesis, activates the platelet
5: aggregation; platelets crosslink w/ fibrin creating thrombus
141
What mediates platelet adhesion to damaged endothelial sites?
Von Willebrand Factor- protein secreted by endothelial cells that circulate in plasma, mediates platelet adhesion at injury site
142
Function of prostaglandin
Modulate immune function via lymphocyte and are mediators in vascular phase of inflammation
143
What is the role of PGI2 that's released from undamaged endothelial cells?
Binds to platelets causing cAMP synthesis which inhibits release of granules containing aggregating agents
144
Adhered platelets release what chemical mediators?
ADP
TXA2
5HT
Platelet activating factor
145
What are the receptors on the surface of platelets that are activated by mediators?
Serotonin- 5HT, cause vessel spasm, inc cytosolic Ca release causing dec blood loss
Thromboxane Synthesis- liberates arachidonic acid from membrane, acid converted to PGG2 by COX to be matabolized into TXA2`
146
Steps of COX pathway
Mem phospholipids
Arachidonic acid
Prostaglandin
Sythases- TXA2 and PGI2
TXA2- constriction, platelet aggregation, bronchonstriction
PGI2- vasodilation, platelet anti-aggregation
147
Steps of platelet aggregation
TXA2- stims activation and aggregation of platelets and is a potent vasoconstrictor
G2b/3a- receptors for fibrin and aid in platelet activation to regulate platelet-platelet interaction and thrombus formation
148
Define Extrinsic Pathway
Tissue Factor pathway
Vit K depedent
Inhib by Warfarin which inhibits hepatic synthesis of clotting factors
149
Define Intrinsic pathway
Contact Activation Pathway
| Inhibited by heparin
150
What are the Natural Anticoagulants
Protein C- destroys 5a and 8a
Protein S- cofactor for Protein C
Anti-Thrombin 3- inactivates 2a, 7a, proteases, especially thrombin)
151
Define Prothrombin Time
Screening assay for Extrinsic Pathway
152
Define International Normalized Ratio
Prothrombin Time to account for differences in thromboplastin
153
Define Activated Partial Thromboplastin Time
APTT- screening test for Intrinsic System and it's factors
154
Define Hypocoagulability
Dysfunction in natural anticoagulants: protein C and S
155
What are the two categories of injectable anti-coagulants
Indirect Thrombin Inhib- UFH, LMWH (Enox/Dalt), Fonda
| Direct Thrombin Inhib- Biva, Arga
156
What are the categories of oral anti-coagulants
Indirect Thrombin Inhibs- Warfarin
Direct Xa inhib- Apix, Riva, Edox
Direct Thrombin Inhib- Diabigatran
157
MOA of Warfarin
Inhibs Vit K cofactors to reduce available Vit K needed for clotting factors
158
Clinical use of Warfarin
DVT/PE prophylaxis
A-fib heart valves
Secondary prevention after stroke/MI
Protein C/S deficiency
159
If rapid anticoagulation is needed with Warfarin, what can it be combined with?
Heparin/LMWH until INR goal is achieved
160
What are the T1/2 of Warfarin components?
10: 48-72hrs
2: 60hrs
9: 24hrs
S: 10
7/C: 6hrs
161
What is a normal INR goal?
What is DVT prophylaxis goal?
What is artificial heart valve goal?
0.8 - 1.2
2-3
2.5 - 3.5
162
How often is INR monitored when starting Warfarin?
Bi-weekly until goal is reached
| 4-6wks after
163
Adverse reactions of Warfarin
Bleed/bruise
Necrosis- related to C or S
Purple Toe Syndrome
Category X
164
How is Warfarin metabolized and what does it interact with?
2C9
| Displaced by other protein binding drugs w/ higher affinity since it's 99% protein bound
165
What PT education needs to happen when giving Warfarin
Avoid NSAIDs
| Consistent diet
166
What are 3 foods with high Vit K levels and what is one with low levels?
Kale +500
Spinach +400
Collards +400
Asparagus 48
167
How to manage high INRs with Warfarin PTs
Above range but below 4/5: reduce/skip dose
4.5-10: skip 1-2 doses, Vit K not routinely recommended
+10: stop Warfarin and give 2.5-5mg of Vit K regardless of bleeding
168
How much Vit K is given to Warfarin PT neededing emergent surgery?
<5mg w/ additional 1-2mg in 24hrs
| High bleed risk= 1-2/5mg
169
What to do with Warfarin associated major bleeding?
PCC instead of FFP
| Vit K 5-10mg by slow IV
170
What are the two types of PCC for use during associated major bleeding
Kcentra: prothrombin, Factor 7, 9 and 10, Protein C and S
Profilinine: Vit K dependent clotting factors 2 7 9 10
Use to reverse Fondaparinux
171
What is the Warfarin reversal agent?
Phytonadion
Mephyton- PO
Aquamephyton- injection
172
How is Phytonadione administration preferred?
PO- more predictable response
If IV- slowly over 30m to watch for adverse reaction
Avoid SubQ and IM
173
What does Heparin/LMWH do to the coagulation cascade?
Boosts Antithrombin 3
| Inhibits 10a and 2a
174
Characteristics of UFH
Macromolecule complex in histamine
| Extracted from pig intestine
175
What is the MOA of UFH
Binds to Anti-Thrombin 3 and speeds ability to inhibit thrombin
176
What is the clinical use for UFH
Prevent expansion and prevent thrombus formation
177
What are the pharmacokinetics of UFH?
SubQ or IV only
Not absorbed SubQ
NOT protein bound/secreted in milk/placenta crossing
Acts in minutes
178
What are the adverse reactions of UFH?
Bleeding- reverse w/ P.Sulfate
Thrombocytopenia- -150K
(HIT): systemic hypercoag in PTs on UFH x 7 days and 50% dec of platelet count from baseline from heparin Abs
Treat w/ d/c and direct thrombin inhib if anticoag is needed
Osteoporosis
Hyper Ka
179
Contrainidications for using UFH
```
HIT/Hx of HIT
Allergy
Active bleeds
Purpura
HTN
Surgery- brain, eye, back or LP
```
180
How much Heparin is in treatment doses?
| How much is in prophylaxis?
50-70u/kg w/ 12-18u/kg/hr maintenance
SubQ 5Ku Q8-12hrs
181
What needs to be monitored for UFH use?
```
aPTT
Hgb
Hct
Platelet
Bleeding sings
Pregnancy Class C
```
182
MOA of LMWH
Depolymerized UFH to bind to anti-thrombin 3 and inactivates 10a w/out affecting aPTT time
183
When is LMWH used?
Reduce thrombi expansion/formation and can be used w/ aspirin and Warfarin
184
Clinical use of Enoxaparin
Prophylaxis DVT and PE
Ischemic issue of unstable angina and Non Q-wave MI
Treat DVT/PE
Treat acute STEMI
185
Clinical use of Dalteparin
Prophylaxis for DVT and PE
| Treat Sx VTE/reduce recurrence in cancer PTs
186
What LMWH is Class B and preferred use in Pregnancy?
Enoxaparin
| Dalteparin
187
Pharmacobenefit of using LMWH
No PT or aPTT monitoring
| Long t1/2, 3-12hrs
188
Adverse effects of LMWH
Bleeding
HIT
Not completely reversed by Protamine
189
How is LMWH dosed?
Prevention: standard dose
Treatment: weight adjusted in mg or anti-Xa units
Only SubQ on BID schedule
190
What are the advantages of using LMWH over Heparin
Less HIT risk
Minimal monitoring
Longer t1/2
191
What is the preferred anticoagulant drug for pregnant women?
LMWH
192
MOA of Fondaparinux
SubQ administration that binds to antithrombin 3 and selectively inhibits 10a
193
When is Fondaparinux used in clinic?
Prophylaxis of DVT for PTs having knee/hip replacement and abd surgery
DVT/PE treatment when used w/ Warfarin Sodium
194
Adverse effects of Fondaparinux
Bleeding, don't use if platelets are below 100K
| Less likely to cause HIT, not FA approved for HIT
195
MOA of Protamine Sulfate
Protein from fish sperm that forms stable salt complex to rapidly reverse heparin/some LMWH
196
How is Protamine Sulfate administered?
Very slowly in IV over 10m and not to exceed 50mg
197
How much Protamine Sulfate reverses how much Heparin?
1mg reverses 100 units of heparin
198
What types of reactions can occur when doing a protamine sulfate infusion?
Transitory flushing, warmth, dyspnea, vomit and lassitude
| HOTN/Brady
199
Protamine Sulfate interacts w/ what drugs?
Cephalosporins
| Penicillins
200
What is the MOA of Direct Oral Factor Xa Inhibitors
Selectively block Xa w/out requiring co-factor
201
D/c _____ anti-coagulant in PTs without adequate continuous anticoagulation increases risk of stroke
Direct Oral Xa inhibitors
202
What are the clinical advantages of DOF Xa Inhibitors vs Warfarin?
```
Non inferior
Apixaban is superior
Fewer drug interactions
Antidote- Recombinant Factor Xa Andexx w/ activated charcoal w/in 2hrs
Not monitoring needed
```
203
What are the clinical disadvantages of DOF Xa Inhibitors vs Warfarin?
$$
| Can't use if PT has prostetic valves
204
What are the names of the 3 direct oral factor Xa inhibitor drugs?
Rivaroxaban
Apixaban
Edoxaban
205
What is the clinical indications for using DOF Xa INhibitors
Riva/Apix: stroke prevention and systemic embolism in PTs with non-valve A-fib
Prophylaxis of DVT for knee/hip surgery
DVT/PE treatment
Edox: stroke prevention and systemic embolism in PTs with non-valve A-fib; DVT/PE treatment after 5-10 days of parenteral anti-coag therapy
206
What PTs is the use of DOFXaI avoided in?
Riva- mod/severe liver dz
Apix- don't use in liver dz
Adeox- mod/severe liver dz or if CrCl <15ml
207
Avoid using DOFXaIs with what other drugs?
Drugs that are both p-glycoprotein and strong 3A4 inducers and inhibitors
208
Pregnancy categories for DOFXaI
Riva/Edox- C
| Apix- B
209
What are the limits for stopping Warfarin and starting DOFXaIs?
Riva when INR is less than 3
Apix- INR below 2
Edox- INR below 2.5
210
MOA of Direct Thrombin Inhibitors
Bind to active site of thrombin and inhibits down stream effects of converting fibrinogen to fibrin without need of cofactor
211
Clinical indication to use Bivalirudin
Percutaneous coronary intervention
Percutaneous transluminal corornary angioplasty
PTs w/ at risk of HIT/HITTS undergoing PCI/PTCA
212
Clinical indication to use Argatroban
Prophylaxis/treatment of PTs w/ HIT
| PT w/ HIT undergoing PCI
213
How does Bivalirudin and Argatroban get metabolized?
Biva- renal, adjust if CrCl is below 30
| Argatro- liver, dose adjust if impaired
214
What needs to be monitored when using Bivalirudin or Argatroban
Biva- aPTT 1.5-2.5 and ACT >2.5x baseline
Argato- aPTT 1/5-3 and ACT >2.5x baseline
215
How is the Warfarin bridge established w/ PTs on Bivalurdin or Argatroban
Over lap administration for 5 days min until INR is in target
Recheck INR after non-heparin anticoag effect is gone
216
MOA of Dabigatran
Direct thrombin inhibitor prodrug
217
When is Dabigatran used
Preventing stroke or systemic embolism in PTs w/ non-valvular A-fib
DVT/PE treatment/prevention
218
What therapeutic considerations need to be noted when using Dabigatran?
If +75y/o
Poor renal function
Under weight
Req'd BID dosing
219
What is the risk of discontinuing using Dabigatran?
PTs w/out adequate continuous anti-coag increases their risk of stroke
220
What drugs does Dabigatran interact with?
Aspirin/Clopidogrel doubles bleeding risk
100mg or less considered
Avoid Ticagrelor
221
What 4 P-Glycoprotein inhibitors may increase Dabigatran levels?
```
Ketconazole
Verapamil
Amiodarone
Clarthromycin
P-glycoprotein inducers DEC dabigatran efficacy
```
222
How do PTs modulate taking Dabigatran if they also take antiacids?
Take Dabigatran 2hrs prior to antacids
223
Adverse effect of Dabigatran is bleeding, so what's the antidote?
Idarucizumab and acitvated charcaol in 2hrs of admin and hemodialysis
224
What are the contraindications of using Dabigatran?
Mechanical heart valves
| Ketoconazole/strong p-glycoprotein inhibitors
225
When can PTs convert from Warfarin to Dabigatran?
What is it's Pregnancy Category?
Stop Warfarin and start Dabigatran at INR less than 2.0
Cat C
226
Dabigatran has to be dispensed and stored in the same package and used with in ?
4mon
227
How is Dabigatran dose adjusted for A-fib
75mg BID if CrCl is 15-30
Don't use if below 15
DVT/PE- don't use if below 30 or if on dialysis
228
Advantages of Dabigatran over Warfarin?
More effective stroke/ embolism prevention
Lower intracranial bleed risk
Fewer interactions
No monitoring
229
Disadvantages of Dabigatran over Warfarin?
```
Renal elimination= renal dosing
Not for use w/ fake valves
Dyspepsia
BID dosing
$$
```
230
MOA of Idarucizumab
Humanized monoclonal Ab that binds to Dabigatran and neutralized it
231
When is Idarucizumab used
Reverse Dabigatran for emergency surgery in next 8hrs
Life threatening bleeds
BUT doesn't work for Xa inhibitors
232
MOA of fibrinolytics/thrombolytics
Dissolve clots by activating conversion of plasminogen to plasmin w/ greatest benefit in use in first 3hrs and some benefits after 12hrs
233
What are the clinical uses of Fibrinolytics/Thrombolytics?
```
STEMI
Acute Ischemic stroke
Acute PE w/ instability
Restoration CV catheter flow
Severe massive DVT
Ascending thrombophlebitis of ilofemoral vein
```
234
MOA of thrombolytic enzymes
Human enzyme synthesized by kidney that directly converts uncomplexed plasminogen to active plasmin and Factors 5 and 7
235
MOA of tPA
Activates plasminogen that is bound to fibrin in thrombus and initiating fibrinolysis
236
What is the use of Alteplase
tPA for STEMI, PE and acute ischemic stroke within 3hrs
237
Reteplase and Tenecteplase are only approved for use in ?
Acute STEMIs
Rete- off label DVT and PE
Tene- mutant tPA w/ longer half life
238
What are the physiological steps of tPA use
1: tPA binds to fibrin in thromubs
2: plasminogen to plasmin
3: initiates fibrinolysis
239
What platelet aggregation inhibitor drug inhibits prostaglandin synthesis
Aspirin
240
What platelet aggregation inhibitor drug inhibits other anti-platelets
Dipyridamole
Aspirin
Cilostazol
241
What platelet aggregation inhibitor drug inhibits ADP P2Y12 receptor inhibitors
Clopidogrel
Ticagrelor
Prasugreal
Cangrelor
242
What platelet aggregation inhibitor drug inhibits G2b/3a receptors
Abciximab
Apitifibatide
Tirofiban
243
What are the drug names of the Glycoprotein 2b/3a Inhibitors
Abciximab
Eptifibatide
Tirofiban
244
MOA of Eptifibatide and Tirofiban
Reversibly inhibit binding of fibrin to GP receptor w/out Abs but have shorter duration of action than Abc
245
Therapeutic use of Eptifibatide and Tirofiban
| What caution is taken?
Used with heparin and aspirin for ACS and PCI to reduce thrombotic cardiac events
Special dose req'd for red renal function
246
What is a benefit of using Abciximab over the other two?
No renal adjustment needed
247
When is Abciximab used?
Adjunct to PCI for prevention of cardiac ischemic issues in PTs undergoing PCI or have unstable angina and PCI is planned for next 24hrs
248
What antiplatelet regime is recommended for all PTs with a NSTEMI?
ASA
P2Y12 inhib
G2a/3b inhibitor
249
All PTs with NSTEMI ACS are req'd to have anticoagulant therapy ASAP which includes ?
UFH/LMWH/Fondaparinux or Bivalirudin to prevent formation of fibrin and thrombus
250
MOA of P2Y12 inhibitors Clopidogreal and Prasugrel
Irreversibly inhibits ADP binding to receptor causing inhibition of GP2b/3a for platelet aggregation
251
MOA of Ticagrelor
Reversibly inhibits ADP binding to receptor causing inhibtion of GP2b/3a receptors
252
What is the clinical use of Clopidogrel?
Prevent atherosclerotic event in PTs with peripheral artery dz, recent stroke/MI
Unstable angina prophylaxis
Combo w/ aspirin to reduce CV issues
253
What is the clinical use of Prasugrel
W/ aspirin to prevent CV event in post-PCI in ACS PTs
254
Clinical use of Ticagrelor is ?
Reduce rate of thombotic CV events in PTs with ACS: unstable angina, N/STEMI or MI
255
Drug interaction of P2Y12 Inhibitor Clopidogrel
Prodrug
| 2C19 inhibitors reduce antiplatelet effect
256
Drug interaction of P2Y12 Inhibitor Prasugrel
Prodrug w/ least drug inteactions
257
Drug interaction of P2Y12 Inhibitor Ticagrelor
3A4 substrate
| BBWarning- dec efficacy w/ aspirin +100mg
258
Using P2Y12 inhibitors with ? or ? may increase bleeding risks
Anticoagulants Warfarin
| Antiplatelets NSAIDs
259
What are the adverse events and wash out period for Clopidogrel
Less than other 2
| 5-7days
260
What are the adverse events and wash out period for Prasugrel
Don't use +75y/o
| 7 days
261
What are the adverse events and wash out period for Ticagrelor
Dyspnea
| Careful in asthma/bradycardia PTs
262
Clinical use of Cangrelor
Idjunct to PCI in PTs not treated w/ P2Y12 inhibitor or G2b/3a to reduce risk of MI, repeat coronary revascularization or stent thrombosis
263
What are the adverse effects of Cangrelor
Bleeding but short half life leaves no antiplatelet effect after an hour of d/c
264
MOA of aspirin
Irreversibly inhibits COX1 and 2 to dec TXA2 production from arachidonic acid that lasts 7-10 days
265
What aspirin dose has shown to be effective prevention of CV events?
Complete COX1 inhibition is compelted w/ __mg of aspirin
50-160mg
75-150
266
Top 3 uses of aspirin are ?
Primary prevention of CV, stroke and A-fib stroke
50-59 w/ >10%= 81mg/day
60-69 w/ >10%= smaller benefit
<50 or >70= think twice before Rx
267
Avoid aspirin in what 4 previous Hx
High bleed risk
Previous GI bleed
On anticoagulant
Uncontrolled HTN
268
Adverse events of aspirin?
GI
Reyes Syndrome in kids if given aspirin when they had chickenpox or flu
Stop 7-10 day prior to surgery
Pregnancy C/D
269
Why are pregnant women to avoid aspirin
Closes ductus arteriosus
270
What med is the preferred analgesic or antipyretic during pregnancy
Acetaminophen
271
MOA of Dipyridamole
Stims prostacyclin synthesis and inhibits adenosine uptake to inhibit platelet aggregation
272
When is Dipyridamole used?
W/ aspirin to prevent CV ischemia
| Monotherapy has little benefit
273
Adverse effects of Dipyridamole
HA dizzy
| Coronary Steal Phenomenon in unstable angina PTs, so avoid use and allow 2-3 day wash out
274
Use Dipyridamole with caution and what other drugs?
Anticoagulants
| Could aggrevate myasthenia gravis
275
MOA of Aspirin/Dipyridamole
Irreversibly inhibit COX 1 and 2 to dec TXA2 and stim prostacyclin synthesis and inhibit adenosine uptake to platelets
276
When is used?
Secondary prevention to stroke post-ischemic stroke or TIA
277
Therapeutic considerations for Aspirin/Dipyridamole
Must be taken as combo, not together but separate
Protect from moisture
BID dose
278
Don't use Aspirin/Dipyridamole with ?
Anticoagulatns
| Children/teens w/ viral syndrome
279
MOA of Cilostazol
PDE3 inhibitor
Vasodilator
Inhibit platelet aggregation
280
Use of Cilostazol
Reduce Sx of Intermittent Claudication
| Use w/ aspirin enhances platelet inhibition
281
Contraindication for using Cilostazol
HF of any level
hemostatic disorder
Bleeding
282
Drug interactions of Cilostazol
Major 3A4 and 2C19 substrate
| 2-3 day washout
283
What is the Gold Standard for Dx PE?
```
*Pulmonary angiography*
D-Dimer
Inc Troponin
Inc NP
Electrocardiography
```
284
Define Massive PE
Acute PE with sustained HOTN SBP less 90mm
| Loss of pulse
285
Define Acute PE with persistant brady
HR <40
| S/Sx of shock
286
Define Submassive PE
PE w/out Systemic HOTN
RV dysfunction
Myocardial necrosis
287
Define Low Risk PE
PE and absence of markers of adverse prognosis
288
When ar fibrinolysis considered for PE PTs?
Massive acute
Submassive acute
NOT for low risk or submassive w/ minor Sx
NOT for undifferentiated cardiac arrest
289
Flow to determine if Submassive PE gets anticoagulant or not
RV dysfunction or heart necrosis
SBP <90, shock index >1, SPO2 <95%
RV dysfunction, elevated cardiac markers
If yes, alteplase 100mg over 2hrs
290
What agents are used to treat bleeding
Transfusion
Cryoprecipitate- plasma protein from whole blood
PCC- last line for reversing Apixaban, Dabigatran, Rivaroxaban or Edoxaban
Tranexamic Acid
291
Adverse effects of treating bleeding agents
Stroke PE DVT
| HTN reaction
292
MOA of Tranexamic Acid
Reversible comples to displace plasminogen from fibrin to inhibit fibrolysis and proteolytic plasmin
293
When is Tranexamic Acid used?
Label: heavy menstruation, tooth extraction in PTs w/ hemophilia
Off label: trauma hemorrhage, perioperative bleeds
294
What are the adverse effects of Tranexamic Acid?
How is it eliminated?
HA, Abd Pain, Back pain
95% renal and unchanged
295
What are the precautions for using Tranexamic Acid?
Hx of thrombotic events
| Renal dysfunction
296
What 3 nutrients are essential for hematopoiesis
Fe
B12
B9
297
What are the types of anemia?
Fe Def- most common
B12= megaloblastic anemia, GI Sx and neuro abnormals
B9= defective DNA synthesis and megaloblastic anemia
298
Define Transferrin
| Define Ferritin
Plasma protein that binds Fe and delivers it to tissue
Protein that binds to Fe, found in liver, spleen sk muscle and marrow
299
What agents are used as oral Fe supplements
Ferrous Gluconate
Ferrous Sulfate- most efficiently absorbed
Ferrous Fumurate
300
How long is oral Fe used
Continue 3-6mon after correction of iron loss
301
What precautions are taken with oral Fe supplements
Take w/ meals
Constipation
Black stool
302
When is IV iron used
Pts who cant tolerate/absorb PO Fe
Extensive anemia- IBD, SmBl Ressection, gastroectomy, CKD
Severe cases that need rapid correction
303
What are the IV Fe supplements
```
Iron Dextran (High- Dexferrum, Low- INfeD)
Sodium Ferric Gluconate Complex
Iron Sucrose
Ferumoxytol
Ferric Carboxymaltose
```
304
Adverse effects of IV Fe
GI
Hypersensitive
Fatal at 1-10g
Antidote; Deferoxamine
305
Function of Cyanocobalamin
Ring w/ cobalt atom that is cofactor for biochemical reactions
AKA extrinsic factor
306
B12 is essential for what processes?
Normal DNA synthesis
| Metabolize homocysteine and cysteine w/ B6
307
What is required for B12 to be absorbed?
| How is it transported
Intrinsic factor in stomach
| Transported on Transcobalamin 2 and stored in liver
308
When are B12 deficiency seen?
```
Vegetarians
Dysfunctional distal ileum
Defective/absent intrinsic factor
Gastroectomy
Pernicious anemia
```
309
What are the injectable forms of B12?
Hydroxocobalamin- preferred, more protein binding and remains in circulation longer
Cyanocobalamin
310
If pernicious anemia refuses/can't tolerate injections what can they take?
Oral B12 intrinsic factor
311
Adverse effects of B12
Death w/ parenteral admin
CV- congestion, HF, PV thrombosis
Derm: ithcing, exantherma
Swelling of whole body
312
Why is B9 required
Provide precursors for synthesis of aa, purines and DNA
313
Where is B9 absorbed?
Prox SmInt
Transported on plasma binding protein
Reqs reduction by dihydrofolate reductase to it's active metabolite methyltetrahydrofolate
314
What is the clinical use for Folate
```
Pregnancy
PTs w/ alcohol dependence
Hemolytic anemia
Liver dz
Renal dialysis
```
315
How much folic acid is used in dose?
1mg/day reverses megaloblastic anemia
316
What is the reduce folic acid version used for?
Leucovorin
Doesn't req dihydrofolate reductase for metabolism
Antagonist OD
Folate deficient megaloblastic anemia
317
What are the Hematopoietic Growth factors
Erythropoitin- glycoprotein that regulates RBC production/protection in renal peritubular cells
318
What is the MOA of Epoetin Alfa and Darbapoetin Alfa
Inc rate of proliferation and differentiation in marrow to inc reticulocyte release from marrow
Reqs Fe stores
319
When are Epoetin Alfa and Darbapoetin Alfa used?
RBC production anemia of chronic RF
Chemo
PT prep for surgery
320
What are the adverse reactions of Epoetin Alfa and Darbapoetin Alfa
Risk REMS program
Inc risk of death and CV events
Don't start if Hgb >10g/dL
321
What form of poetin is better?
Darbapoetin has less frequent dosing and longer half life
322
MOA of Filgrastim
| When is it used
Stims benefits of neutrophils
Chemo Pts
Neupogen- radiation injury syndrome
323
MOA of Sargramostim
| When is it used
Stims neutrophils
Acute myeloid leukemia
Marrow/stem cell transplant
324
Warning of using Filgrastim
| When is it's use d/c?
Alveolar hemorrhage
Nephrotoxic
ARDS
D/c at neutrophil count of +10K
325
Warning of using Sargramostim
| When is it d/c?
1st dose effect
Fluid retention
Pulmonary Sx
Inc blood counts, dec dose x 50%
326
Biguanides and Thiazolidinediones are AKA ?
| Sulfonylureas are AKA ?
Insulin Sensitizers
| Insulin Secretagogues
327
Characteristics of GLP-1 Agonists
Greater efficacy
+ weight loss
SubQ
More ADR- N/V/D
328
Characteristics of DPP-4 inhibitors?
Less efficacy
Weigh neutral
PO
Less ADR
329
Define Incretin Based Therapy
GLP-1 Agonists
DPP-4 Inhibitors
Greater insulin response to oral glucose than IV load
330
What are the two incretin hormones?
GIP
GLP-1
Both degraded by DPP-4s
