Pharmacologic Management T2DM Flashcards
Pharmacologic Management T2DM
What are two common sulfonylureas?
Glyburide
Gliciazide
Pharmacologic Management T2DM
How do insulin secretagogues or sulfonylureas work? What is the most efficient dose?
Increase beta-cell secretion of insulin
Most efficient dose is 50% max
Pharmacologic Management T2DM
Renal impairment is a contraindication to sulfonylureas. True/False
True
Pharmacologic Management T2DM
What are the Sick Day Medications?
S sulfonylureas
A ACE-i
D diuretics, direct renin inhibitors
M Metformin
A ARBs
N NSAID
S SGLT2-i
Pharmacologic Management T2DM
Drug of choice in pregnancy
- Insulin
- Metformin is also considered acceptable (2nd line)
Contraindications to sulfonylureas
- severe renal or hepatic impairment
- Hypersensitivity to sulfonylureas or sulfas
- Uncontrolled infection/burn/trauma
- Type 1 DM
- Adrenal/pituitary insufficiency
- pregnancy
Pharmacologic Management T2DM
Most common/serious adverse rxn to sulfonylureas
- Hypoglycemia (higher risk w/ glyburide)
- Weight gain
Pharmacologic Management T2DM
Patient counselling re: sulfonylureas
- Hypoglycemia
- Numerous interactions
- SMBG
- Photosensitivity
- Avoid alcohol
- Take with food at the same time each day
Pharmacologic Management T2DM
What are some basal insulins, their duration of action and dosing frequency?
NPH
- 24 hours
- daily/BID
glargine (Basaglar, Lantus)
- 24 hours
- daily/BID
glargine hc 300 u/ml (Toujeo)
- 36 hours
- daily
detemir (Levemir)
- 6 to 24 hours
- daily or BID
degludec (100u/ml or 200u/ml)
- up to 42 hours
- daily
Pharmacologic Management T2DM
What are some bolus insulins?
- regular
- aspart
- lispro
Pharmacologic Management T2DM
Interactions for sulfonylureas (Risk x)
- metiglinide
- mecamylamine
- aminolevulinic acid (oral)
Pharmacologic Management T2DM
What are some thiazolinediones?
- glitazones
- pioglitazone
- rosiglitazone
- troglitazone
Pharmacologic Management T2DM
How do thiazolinediones work?
- improves insulin action in the cell (ie. decrease insulin resistance)
Pharmacologic Management T2DM
What are some contraindications to thiazolindediones?
- hypersensitivity
- heart failure
- acute coronary events
- pregnancy
Pharmacologic Management T2DM
Thiazolinediones drug interactions
- OCP’s (reduces by 30%)
- pioglitazone CYP 450 drug: +++ interactions including quinolones, azoles, etc
Pharmacologic Management T2DM
What is the action of alpha glucosidase inhibitors (Acarbose, Miglitol)? How do you take it? What are some contraindications? Major drug interactions? What do you do if you have hypoglycaemia?
Inhibits CHO absorption
- TID before meals, take with the first bite!
- Contraindications: IBD, colonic ulceration, digestive disorders, GFR<25
- Major interactions: warfarin (risk bleeding), digoxin
- Reversal of hypoglycemia should be with dextrose, or if severe then IV glucose or glucagon. Sucrose, fructose, or starches will not be absorbed.
Pharmacologic Management T2DM
What are meglitinides (repaglinide, nateglinide)? what is the indication for use?
insulin secretagogues, to be used if sulfonylureas not effective/successful
Pharmacologic Management T2DM
What are the SGLT2-i drugs?
Canagliflozin
dapagliflozin
empagliflozin
ertugliflozin
Pharmacologic Management T2DM
What are SGLT2-i adverse reactions?
Major
DKA (euglycemic)
UTIs/urosepsis/pyelo
nephrotoxicity can occur
Common
hypotension/intravascular volume depletion
increased LDL
VVC
drop in GFR up to 15% expected when initiated
Pharmacologic Management T2DM
Amylin agonists (pramlintide) how do you take it and how do they work?
Modulates gastric emptying (amylinomimetic) –> improves satiety & prevents post prandial glucagon and glucose –> reduced calorie intake & weight loss
Subcut injection - avoid the arm!
Do not use in gastroparesis
Pharmacologic Management T2DM
What are DPP4i (trade names, MOA)
- gliptins (sitagliptin, saxagliptin, linagliptin, Alogliptin)
- GLP-1 is an incretin hormone that stim glucose-dependent insulin secretion, increases insulin biosynthesis, and reduces appetite and food-intake. DPP-4 prevents the breakdown. It is weight neutral. Reverses microalbuminuria.
*hint incretin=secretion (insulin, also synthesis)
Pharmacologic Management T2DM
GLP-1 agonists (Trade names, MOA, administration)
- Liraglutide, Exenatide, Semaglutide
- incretin hormone (increases insulin production, decreases appetite)
- subcut injection - BID dosing or weekly (extended)
Pharmacologic Management T2DM
What are some contraindications to GLP-1?
IBD
pancreatitis
gastroparesis
Thyroid conditions (hyperplasia or thyroid C Cell tumour has been associated)
Pharmacologic Management T2DM
Biguanides
MOA
Indication
Contraindications
- Metformin
- increases peripheral insulin uptake and utilization (improved insulin sensitivity), decreases hepatic glucose production, decreases intestinal absorption of glucose
- 1st line T2DM
CI
- GFR< 30
- HOLD 48 hours before/after radiographic dye
Precautions
- check renal fntn post imaging before restarting
- nursing infants can have hypoglycaemia
