Pharmacotherapy of Oral Diabetes Medications Exam 2 Flashcards
1
Q
What is the role of self-monitoring blood glucose (SMBG)?
A
- Assessment of current glycemic status
- Confirms hypo- or hyperglycemia symptoms
- Assessment of current therapy
- Assessment of impact of intervention on glycemic control
- Evaluation for trends in control
- Quicker feedback than A1c
- Identification of asymptomatic hypoglycemia
- Identify A1c mismatch with perceived glycemic control
- Evaluation of food and other factors on glycemia
2
Q
What would be a reason to set an alternate A1c goal from normal?
A
- High risk for hypoglycemia
- High risk of complication if hypoglycemia occurs: Fall risk, hypo unawareness, etc.
- Barriers to drug therapy required for optimal control
- Lower risk for chronic complications (short life expectancy)
- Elderly
3
Q
Biguanide PK
A
- decreases hepatic glucose production
- insulin sensitization in muscle and fat
4
Q
Biguanide use
A
Should always be used in type 2 unless there is a C/I
5
Q
Metformin dosing
A
most people don’t get a clinical response over 2000mg per day
6
Q
Metformin renal dosing
A
- eGFR ≥45 – 59: Monitor renal function every 3-6 months
- eGFR ≥30-44: Use caution, consider 50% dose reduction, no new therapy
- eGFR <30: Use C/I
7
Q
Biguanide ADE
A
- Diarrhea
* Decreased B12
8
Q
What are risk factors for lactic acidosis? (not underlined; FYI)
A
- acute CHF
- dehydration
- excessive alcohol intake
- hepatic or renal impairment
- sepsis
- note: stop 48 hrs prior to imaging proc; contrast dye can put pt in acute kidney injury which would also increase risk of lactic acidosis
9
Q
Biguanide monitoring parameters
A
- Renal function
* B12
10
Q
Biguanide pearls
A
- Start low dose and titrate up
- CVD events UKPDS
- Can improve lipid profile
11
Q
Sulfonylurea PK
A
increases insulin secretion
12
Q
Glipizide dosing
A
- for the BID dosing, should tailor medication to what time the problem of the day happens to the pt
13
Q
Glyburide renal dosing
A
Not recommended if eGFR<60
14
Q
Sulfonylurea ADE
A
- Hypoglycemia
* Weight gain
15
Q
Sulfonylurea C/I
A
Sulfa allergy
16
Q
Sulfonylurea Place in Therapy
A
- 2nd or 3rd line
- A1c lowering 1-2% when started as monotherapy; not as good when added as adjunct therapy
17
Q
Sulfonylurea pearls
A
Glyburide is on the Beer’s List of Drugs to AVOID in elderly
18
Q
Metglitinides PK
A
increases insulin secretion (glucose dependent)
19
Q
Metglitinides dosing
A
- dosing with meals
- no renal considerations
20
Q
Metglitinide ADE
A
- Hypoglycemia
* Weight gain
21
Q
Metglitinide C/I
A
Don’t use with
gemfibrozil (decreases metabolism of metglitinide)
22
Q
Metglitinide Place in Therapy
A
2nd or 3rd line
23
Q
Metglitinide Pearls
A
Skip if patient skips meal
24
Q
Thiazolidinediones PK
A
- Max clinical effect not apparent for 6-12 wks
* Increased insulin sensitivity
25
TZDs Hepatic Considerations
- Pioglitazone: If liver function test (LFT) are >3 x ULN, discontinue therapy. Do not reinitiate therapy if due to drug
- Rosiglitazone: Do not initiate if active liver disease or LFTs >2.5 x ULN
- no renal dosing
26
TZD ADE
* Peripheral edema / fluid retention
| * Elevated LFTs
27
TZD C/I
* NYHA III or IV heart failure (for initiation of therapy)
| * DI: gemfibrozil (decreases TZD metabolism)
28
TZD Warnings
* Can exacerbate HF at any stage with fluid retention (BBW)
| * Hepatotoxicity
29
TZD Monitoring parameters
- LFT
- Alkaline phosphatase
- Total bilirubin at baseline
30
TZD Pearls
* Can take up to 12 weeks to see effect
| * Pioglitazone preferred over rosiglitazone
31
GLP-1 PK
- increase insulin secretion
- decrease glucagon secretion (glucose dependent)
- slows gastric emptying
- increases satiety
32
GLP-1 dosing
there are different dosing frequency anywhere from once daily to once weekly
33
Exenatide renal dosing
CrCl <30 stop
34
GLP-1 ADE
GI upset (nausea, vomiting, diarrhea)
35
GLP-1 C/I
Personal or family history of medullary thyroid carcinoma (BBW) (Except Lixisenatide)
36
GLP-1 warnings
* Acute pancreatitis
* Gallbladder disease
* Gastroparesis
37
GLP-1 Place in Therapy
* Patient must be okay with injections
| * CVD (Liraglutide) benefits
38
GLP-1 Pearls
* Promote weight loss
| * CV protection
39
LEADER
- specific to liraglutide
- reduced CV events and CV deaths
- reduced all cause mortality
- FDA added indication: risk reduction of MACE (major adverse CV events) in adults with DMII and established CVD
40
DDP4 Inhibitor PK
- indirectly increases insulin secretion
- decreases glucagon secretion
- glucose dependent
41
DDP4 Inhibitor renal dosing
All but Tradjenta
42
DDP4 Inhibitor ADE
Increased LFT’s
43
DDP4 Inhibitor Warnings
• Heart failure
(saxagliptin and alogliptin) added April 2016
• Hepatotoxicity
44
DDP4 Inhibitor Pearls
No weight gain
45
SGLT-2 Inhibitor PK
blocks glucose reabsorption by the kidney
46
SGLT-2 Inhibitor renal dosing
just know that they all have renal dosing
47
SGLT-2 Inhibitor ADE
Urinary tract infections
48
SGLT-2 Inhibitor C/I
eGFR <30
49
SGLT-2 Inhibitor Warnings
* Increased risk of bone fractures
* Ketoacidosis
* Bladder cancer (dapagliflozin)
* Lower limb amputations (BBW) (canagliflozin)
* Fournier’s Gangrene
* Pancreatitis
50
SGLT-2 Inhibitor Pearls (not underlined)
- CV protection (empagliflozin)
- No weight gain
- Pleiotropic effects (decreased BP, decreased uric acid)
51
EMPA-REG
- specific to empagliflozin
- reduction in: primary endpoint, CV death, all cause mortality, heart failure
- FDA added indication: risk reduction of CV mortality in adults with type 2 and CVD
52
Alpha Glucosidase Inhibitors PK
slows intestinal CHO digestion / absorption
53
Alpha Glucosidase Inhibitors dosing
- 25mg TID with meals
| - skip if meal is skipped
54
Alpha Glucosidase Inhibitors ADE
Significant GI upset (increase in gas (74%) due to fermentation of unabsorbed CHO, bloating, diarrhea)
55
Alpha Glucosidase Inhibitors C/I
- Inflammatory bowel disease
- colonic ulceration
- intestinal obstruction
- malabsorption disorders
56
Alpha Glucosidase Inhibitors Warnings
* Hepatoxicity
| * Renal impairment
57
Amylin Analogue PK
reduces postprandial elevations by prolonging gastric emptying, suppresses glucagon secretion and produces satiety
58
Amylin Analogue ADE
* Significant hypoglycemia (BBW)
* Headache
* Nausea
* Anorexia
59
Amylin Analogue C/I
Gastroparesis
60
Amylin Analogue Warnings
Hypoglycemia
61
Amylin Analogue Place in Therapy
Must be okay with injections
62
Place in Pearls
* Weight loss
| * BBW Severe hypoglycemia when co-administered with insulin (decrease mealtime insulin by 50%)
63
Dopamine-2 Agonist PK
increases insulin sensitivity
64
Dopamine-2 Agonist dosing
- once daily in the morning
| - no renal dosing
65
Dopamine-2 Agonists ADE
Hypoglycemia
66
Dopamine-2 Agonists Warnings
CV effects (not expected with Cycloset)
67
Bile Acid Sequestrant (BAS) PK
* 4-6 weeks onset
| * decrease hepatic glucose production and increase incretin levels
68
Bile Acid Sequestrant (BAS) Warnings
Gastroparesis
69
Which medications should be used if patient is having trouble with their fasting blood glucose?
- biguanide
- TZD’s
- SU’s
- SGLT-2
- Dopamine agonists
- Bromocriptine
- DPP4 inhibitors
70
Which medications should be used if patient is having trouble with their post-prandial blood glucose?
- metglitinide
- DPP-4 inhibitors
- GLP-1
- AGi
71
When should you measure a post-prandial blood glucose?
2 hrs after same meal or before the next meal
72
initiation of oral therapy
- Lifestyle therapy (diet and exercise) stressed for all patients
- Start metformin and other adjunct therapy if needed
- The rest of the order of adding medication use the step-wise thought process and think about patientcentered factors
- Titrate medications where there is room to titrate
73
Which drugs has a contraindication for Heart failure?
- TZD
| - DPP4 inhibitors
74
Which drugs has a contraindication for Renal impairment?
metformin
75
Which drugs has a contraindication for GI Disorders?
- Agi
| - GLP1
76
Which drugs has a contraindication for Bone Fractures?
- SLGT2
| - TZD
77
Which drugs has a contraindication for Hepatotoxicity?
- TZD
- DPP4
- AGi
78
Which drugs has a contraindication for Thyroid carcinoma?
GLP1
79
ADA Recommendations in Prediabetes
- Target A1c goal of 5.7-6.4%
- Encourage lifestyle changes: 7% weight loss, increase physical activity (150min/wk)
- Consider metformin if: BMI >35, Age <60, Women with prior GDM
80
Common Barriers to Monitoring and Control
- Concurrent health conditions
- Life stressors with higher priority
- Inadequate knowledge of why and how
- Inadequate access or cost to meds / supplies / food
- Poor adherence to monitoring, follow up, or meds
- Fear of hypoglycemia, injections, monitoring or discomfort
- World view / life view undervaluing health or future health
- Health professional inertia
81
Which medications have possible β-cell preservation?
- TZD
- GLP-1
- DPP-4 inhibitors
82
What are the meds that decrease A1c by < 1%?
- GLP-1
- Dopamine-2 Agonists
- DDP4 Inhibitor
- BAS
- AGi
- Amylin Analogue
- Metglitinide
- SGLT-2 Inhibitor
83
What are the meds that decrease A1c by > 1%?
- GLP-1
- Dopamine-2 Agonists
- TZD
- Biguanide
- Sulfonylurea
