Pharm2 1 T2DM Agents pt1 Flashcards
What is LADA? & its pathophysiology?
Type 1.5: latent autoimmune diabetes of adulthood
Beta cell function and insulin resistance(LADA)
prototypical patient is 25-30 year old and is thin.
What’s the prototypical patient/frequent mistake made? with LADA?
It’s often dx as T2DM based on their age and not on their symptoms.
Which type of DM?: autoimmune, presents at a young age. 6 months-11 year old. They present with weight loss, polyuria, polydipsia, they get an altered mental status
Type 1
DKA is the severe result of uncontrolled
Type 1 DM
Which type of DM?: obese (central adiposity), polyuria, polydipsia, vision changes, multiple fungal infections, hypertension, dyslipidemia especially hypertrygliceridemia.
Type 2 DM
With Gestational Diabetes: women gain lots of weight during pregnancy, develop diabetes, and have ___ birth weight babies.
large birth weight babies
mom had gest dm, but always controlled it
How does insulin work?
Insulin is a co-mediator of the Na-K pump to drag glucose across the membrane so it can be utilized. Otherwise glucose sits in serum where it can’t do anything of use.
How long does a typical Diabetic patient actually have diabetes before they manifest symptoms?
~10 years
Diff btwn DM and Prediabetes
Fasting glucose >126 = Diabetes. 2 separate reading on 2 separate days
Fasting glucose btwn 106-126: Prediabetes.
Why is the Oral glucose tolerance test done less often than Fasting glucose or HbA1C?
What’s an upside of doing this test though?
bc it’s time consuming, despite being more sensitive.
HbA1C is a ____ hemoglobin.
What does it really measure?
glycosylated hemoglobin
Glucose in bloodstream over 3 months. The higher your blood sugar levels, the more hemoglobin you’ll have with sugar attached (mayoclinic).
HbA1C > __: Diabetes
HbA1C > __: Prediabetes
DM: >6.5
PreDM: 5.7-6.4
How to dx DM with Random Glucose test
> 200 + DM symptoms
PreDM, from a physiologic standpoint:
they lose some of the ability to drag the sugar across membranes after they eat – higher postprandial glucose levels.
T2DM Oral Medications
Seven classes of oral agents, one SQ class, all FDA-approved for T2DM:
Biguanides PO Thiazolidinediones (TZDs) PO Sulfonylureas PO (SUs) DPP-4 inhibitors PO Meglitinides PO (rarely, if ever, used) Incretin-mimetics SQ SGLT-2s: (brand new class of drugs)
2 classes of Insulin sensitizers & their Route of Admin.
How do they work? (don’t over-think this)
Biguanides PO
Thiazolidinediones (TZDs) PO
make individual cells more sensitive to insulin…
4 classes of Insulin secreatogues & their route of admin
How do they work?
Sulfonylureas PO (SUs)
DPP-4 inhibitors PO
Meglitinides PO (rarely, if ever, used)
Incretin-mimetics SQ
squeezes insulin out of your pancreas
__: the oldest class of diabetic medication, since the 1950’s.
Sulfonylureas
Both guidelines discussed in class say start with ___ unless it is CI
Metformin
Metformin’s dual mechanism of action
sensitizes the body to insulin. Reduces Glucagon from causing gluconeogenesis in the liver.
the most commonly prescribed and first-line therapy for type 2 diabetes
Biguanides (Metformin)
Metformin takes how long to have its full effect?
Work slowly (~ 4 weeks) – full effect
Can Biguanides may cause hypoglycemia. Why?
No (almost), Can aide in weight loss, lower cholesterol
B/c it does not promote insulin secretion. Hypoglycemia may only occur if caloric intake is not adequate or exercise is not compensated for calorically.
____ is the only currently available biguanide:
Metformin
Treat aggressively or nonagressively for each of these types of patients?
- Diabetics with few comordibities, and no documented coronary artery disease.
- Longstanding diabetic with a longstanding sugar burden and has proven CVD
- be aggressive with pushing glucose down.
2. be more careful about pushing sugars down
When do Diabetics test their sugar levels throughout the day (finger-sticks)?
(fasting plasma glucose) - when they first get up in the morning
(postprandial glucose) - 2 hours after largest meal of day, usually dinner
Why must you be careful about pushing sugars down with a self-testing DM patient with longstanding sugar burnden and proven CVD?
self testing does not tell the whole story.
High fat content meals will be absorbed more slowly, and the sugar will take more than 2 hours for these glucose levels to peak. Low fat meals can be absorbed sooner than 2 hours.
Hypoglycemia: glucose level __
< 70
More accurate way to monitor glucose levels than a finger-stick? About how much do they cost?
Continuous glucose monitors (CGM) – using plastic catheter inserted into interstitium. Measures interstitial glucose. These pumps cost $8000.
Formulations Biguanides exist as (3)
BID (2/day) formulation - Glucophage®
Long-acting QD (1/day ) - Glucophage XR®
It also come in combination with tons of other PO drugs.
Metformin – Glucophage®
FDA-approved ≥__YOA as adjunct to D&E as monotherapy or combination therapy in T2DM (and other conditions such as PCOS)
Timing: Swallow whole; take with meal
Dosing: titrate up - Initially 500 mg BID -max 2,000 mg QD (1 week intervals)
10 years old
Why must you titrate up Metformin?
B/c of its GI side effects & nausea. Titration hopefully avoids this.
Cautions for Metformin (3)
renal disease or dysfunction, metabolic acidosis, concomitant IV contrast agents - dye (hold metformin during and for 48 hours after contrast use) – hydrate before, during and afterwards – CT scans
Metformin - what level is monitored?
When do you cutoff for each gender?
Creatinine cutoff for men:1.5; women: 1.4
If a woman becomes pregnant on Metformin, or any other T2DM drug. What do you do?
Switch to insulin.
2 side fx or Metformin
GI disturbances (diarrhea, dyspepsia) Lactic acidosis (half of all cases are fatal)
Metformin’s Efficacy in lowering HbA1C
Lowers HbA1C ~2.0.
actual range: 1.1 – 3.0
