Pharm diabetes Flashcards
type 1 diabetes
autoimmune beta-cell destruction
type 2 diabetes
progressive insulin secretory defect
what are the other types of diabetes?
gestational, genetic defects in beta-cell function and insulin action, diseases of the exocrine pancreas, drug or chemical induced
what is A1C?
average glucose levels. greater than 6.5 = diabetes
what is the A1C goals in a younger, healthier person with T2D? older person with comorbidities/longer duration of T2D? T1D? regular T2D?
younger/healthier: 6-6.5%
older, comorbidities: 7.5-8.5%
T1D: 7-7.5%
T2D: less than 7%
what are the general concepts of treatment of diabetes mellitus?
- diet, weight, and physical activity optimization
- self-monitoring of blood glucose and ketones
- patient self-management education and training
- reduction of cardiovascular risk (smoking cessation, BP, lipid control)
- pharmacologic therapy
progression of type 2 diabetes
fasting glucose greater than 120
in prediabetes: beta cells are able to make more glucose to make up for insulin resistance, then the cells stop responding/die off
how do the islets of langerhans appear in T2D?
alpha cell dysfunction: secrete high levels of glucagon
fewer Beta cells: secrete insufficient levels of insulin/mass declines over time
amyloid plaques
incretin hormone: where produced and why? example
synthesized in L cells in ileum and colon in response to incoming nutrients
- stimulate insulin secretion
- example: glucagon-like peptide 1
glucagon-like hormone 1 (GLP-1) actions
- incretin hormone that enhances glucose-dependent insulin secretion
- slows gastric emptying
- suppresses glucagon secretion
- promotes satiety
- receptors are in islet cells, CNS, elsewhere
what happens to GLP-1 release in T2D?
release is reduced (causing decreased insulin and increased blood sugar)
what are the main pathophysiological defects in T2DM?
- decreased pancreatic insulin secretion and increased glucagon secretion
- decreased peripheral glucose uptake
- increased hepatic glucose production (esp at night)
- decreased incretin effect causing gut carbohydrate delivery and absorption
- combined effect of hyperglycemia
recommendations for therapy for type 2 diabetes
- initiate metformin therapy along with lifestyle interventions (unless contraindicated)
- if they are markedly symptomatic - consider insulin right away
- if metformin/noninsulin monotherapy does not achieve or maintain the A1C target - add second oral agent such as GLP-1 receptor agonist
metformin: class, mechanism, action
- class: biguanides
- mechanism: activates AMP-kinase and inhibits mitochondrial sioform of glycerophosphate dehydrogenase
- action: decreases hepatic glucose production
metform: advantages/disadvantages
- advantages: no weight gain, no hypoglycemia, reduction in cardiovascular events
- disadvantages: GI SE (start at low dose and build up), lactic acidosis, vit B12 deficiency
what is a contraindication of metformin?
reduced kidney function
glibenclamide/glyburide, glipizide, gliclazide, glimepiride: class, mechanism, action
- class: sulfonylureas
- mechanism: closes K ATP channels on beta-cell plasma membranes (works directly in pancreas)
- action: increase insulin secretion
glibenclamide/glyburide, glipizide, gliclazide, glimepiride: advantages/disadvantages
-advantages: generally well tolerated
-disadvantages: relatively glucose-independent stimulation of insulin secretion: hypoglycemia
weight gain, blunt myocardial ischemia preconditioning
repaglinide/nateglinide: class, mechanism, action
- class: meglitinides
- mechanism: closes K ATP channels on beta-cell plasma membranes
- action: increases insulin secretion
repaglinide/nateglinide: advantages/disadvantages
- advantage: accentuated effects around meal ingestion (short acting)
- disadvantage: hypoglycemia, weight gain, blunt myocardial ischemic preconditioning, dosing frequency (compliance)
pioglitazone: class, mechanism, action
- class: thiazolidinediones
- mechanism: activates the nuclear transcription factor PPAR-gamma
- action: peripheral insulin sensitivity increased
pioglitazone: advantages/disadvantages
- advantages: no hypoglycemia, HDL cholesterol increased, triglycerides decreased, possible reduction in myocardial infarcts
- disadvantages: weight gain, edema, heart failure, bone fractures, increased bladder cancer
rosglitazone: class, mechanism, action
- class: thiazolidinediones
- mechanism: activates the nuclear transcription factor PPAR-gamma
- action: peripheral insulin sensitivity increased
rosglitazone: advantages/disadvantages
- advantages: no hypoglycemia
- disadvantages: LDL cholesterol increased, weight gain, edema, heart failure, bone fractures, increased cardiovascular events
why pioglitazone over rosglitazone?
pioglitazone is cheaper (generics)
when is rosglitazone contraindicated?
heart disease
acarbose/miglitol: class, mechanism, action
- class: alpha-glucosidase inhibitor
- mechanism: inhibits intestinal alpha-glucosidase
- action: intestinal carbohydrate digestion (and consequentyl glucose absorption) slowed
acarbose/miglitol: advantages/disadvantages
- advantages: nonsystemic medication, post prandial glucose decreased, weight neutral, no hypoglycemia
- disadvantages: GI side effects, dosing frequency, modest reduction in A1C
exenatide, liraglutide, albiglutide, dulaglutide: class, mechanism, action
- class: GLP-1 receptor agonists
- mechanism: activates GLP-1 receptors
- action: insulin secretion increased, glucagon secretion decreased (both glucose-dependent), slows gastic emptying, increases satiety
exenatide, liraglutide, albiglutide, dulaglutide: advantages/disadvantages
advantages: weight reduction and potential for improved beta-cell mass/function
disadvantages: GI SE, cases of acute pancreatitis, hypoglycemia, caution with renal insufficiency, C-cell hyperplasia/medullary thyroid tumors in animals, injectable
difference between exenatide/liraglutide/albidlutide/dluaglutide
exenatide: twice daily or weekly
liraglutide: daily
albiglutide: weekly
dulaglutide: weekly
sitagliptin/alogliptin/saxagliptin/linagliptin: class, mechanism, action
- class: DPP-4 inhibitors (incretin enhancers)
- mechanism: inhibit DPP-4 activity
- action: active GLP-1 concetration and GIP concentration, increased insulin secretion and decreased glucagon secretion
sitagliptin/alogliptin/saxagliptin/linagliptin: advantages/disadvantages
-advantages: no hypoglycemia, weight neutral
-disadvantages: occasional reports of urticaria/angioedema, URIs, headache, arthralgias
pancreatitis
canagliflozin/dapagliflozin/empagliflozin: class, mechanism, action
- class: SGLT2 (sodium glucose cotransporter 2) inhibitor
- mechanism: reduces glucose resorption in the kidney: alpha cell agonist
- action: urinary glucose excretion increases and increased glucagon secretion