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T2DM (Exam 2 Cut Off) Flashcards

1
Q

Criteria for Testing Asymptomatic Adults for DM

A
  • ALL adults who are overweight (BMI >= 25, or >=23 for Asian) who have additional risk factors
  • If no risk factors, start screening at 45 y.o. regardless
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2
Q

Additional Risk Factrs

A
  • Physical inactivity
  • First-degree relative with diabetes
  • High-risk race/ethnicity - Latino, Black, Native American, Asian, Pacific Islande
  • Gestational DM
  • Hypertension - OR on HTN meds
  • HDL < 35
  • TG > 250
  • Polycystic ovarian syndrome
  • A1C >= 5.7%
  • IGT
  • IFG
  • History of CVS
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3
Q

Pre-Diabetes Categories

A
  • IFG = 100-125 mg/dL
  • IGT = 140-199 mg/dL (2hr post load)
  • A1C = 5.7-6.4%
  • These indicate a risk factor for DM and CV disease
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4
Q

Diabetes Prevention

A

In patients with IGT, IFG, or AIC in prediabetic range:

  • Weight loss (7% of body weight)
  • Increase physical activity (150 min/week)
  • Metformin, especially if BMI >35 and less than 60 y.o., or history of gestational DM
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5
Q

Metformin

A
  • Biguanide
  • Decreases hepatic glucose production
  • Decreases intestinal glucose absorption
  • Increases insulin sensitivity
  • Efficacy: Decreases A1C ~1.5%
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6
Q

Metformin Dosing

A
  • Regular release: 500 mg BID, max: 2550 mg daily

- ER: 500 mg once daily, max: 2000 mg daily

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7
Q

Metformin AE

A
  • Primarily GI - take with food
  • Monitor B12 deficiency once a year
  • Lactic acidosis - rare
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8
Q

Metformin + Renal Dosing

A
  • D/C if eGFR =< 30
  • Reduce dose by 1/2 if already on Metformin and eGFR drops between 30-45
  • DO NOT INITIATE THERAPY WHEN eGFR BETWEEN 30-45
  • Calculate eGFR at least annually
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9
Q

Metformin Precautions

A
  • Radiocontrast studies - separate by 48 hours
  • > 80 y.o. unless eGFR is normal
  • Hypoxic states
  • Alcoholism
  • Unstable heart failure - frequent hospitalizations
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10
Q

Metformin Considerations

A
  • Weight: Neutral
  • Hypoglycemia: No
  • Cost: Inexpensive
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11
Q

Secretagogue

A
  • Sulfonylureas

- Glinides

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12
Q

Sulfonylurea

A
  • Increase insulin secretion from pancreatic B-cells
  • Efficacy: drops A1c ~1.5%
  • More rapid effect
  • Don’t use 1st generation sulfonylureas due to high risk of hypoglycemia
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13
Q

2nd Generation Sulfonylureas

A
  • Glipizide/Glyburide: give twice a day before meals
  • Glimepiride: give with first main meal of day
  • Glyburide NOT recommended at a first line sulfonylurea (greater hypoglycemic risk)
  • Don’t use Glyburide if CrCl < 50
  • Efficacy of all sulfonylureas decreases as T2DM progresses and B-cells are lost
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14
Q

Sulfonylurea Considerations

A
  • Hypoglycemia: Yes
  • Weight: Gain
  • Cost: Inexpensive ($4)
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15
Q

Glinides

A
  • Stimulate insulin release form pancreatic B-cells
  • Shorter half life and duration than sulfonylureas
  • Take with meals, targets postprandial glucose levels
  • Efficacy: decreases A1C ~1.5%
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16
Q

Glinide Dosing/AE

A

-Dose with each meal

AE

  • Hypoglycemia - less than sulfonylureas
  • Weight gain
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17
Q

TZDs

A
  • Thiazolidinedione
  • PPAR-gamma receptor activators
  • Insulin sensitizers, especially in peripheral tissues
  • Efficacy: decreases A1C ~0.5-1%
  • Effect may not be seen for up to a month
  • Dosed once a day (Pio max: 45 mg, Ros max: 8 mg)
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18
Q

TZD AE/CI

A

AE

  • Fluid retention
  • Peripheral edema
  • Weight gain - mainly due to fluid retention
  • Increased risk of new heart failure, fracture risk, hepatic impairment
CI
-NYHA class III or IV
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19
Q

TZD Use in CHF

A
  • Do NOT use in Class III or IV

- Can start class I or II with the lowest doses (ex: pio at 15 mg daily)

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20
Q

Pioglitazone + Bladder Cancer

A
  • Do not use in ACTIVE bladder patients
  • Use with caution if there is a history of bladder cancer
  • Exposure for >24 months had the greatest risk connected to bladder cancer
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21
Q

TZD Considerations

A
  • Hypoglycemia: No
  • Weight: Gain
  • Cost: Inexpensive
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22
Q

Alpha-Glucosidase Inhibitors

A
  • Delays intestinal carb absorption and decreases post-prandial blood glucose levels
  • Efficacy: Decreases A1C 0.5-0.8%
  • Dosing: 25 mg TID with meals, max doses: 100 mg TID
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23
Q

Alpha-Glucosidase AE/CI

A

AE

  • Diarrhea
  • Abdominal pain
  • Flatulence
  • NOT WELL TOLERATED

CI

  • Chronic intestinal disease
  • Cirrhosis
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24
Q

DPP4 Inhibitors

A
  • Prevent degradation of endogenous GLP-1
  • REsults in a rise of postprandial GLP-1 levels
  • Efficacy: Decreases A1C 0.5-0.7%
  • Once a day dosing
  • Tradjenta only one that doesn’t require renal dosing adjustment
  • Nesina only one available as a generic
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25
Q

DPP4 Inhibitor SE

A
  • Well tolerated
  • Few allergic reactions
  • Saxagliptin and Alogliptin associated with increased heart failure hospitalizations
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26
Q

DPP4 Inhibitor Considerations

A
  • Weight: Neutral
  • Hypoglycemia: No
  • Cost: Expensive
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27
Q

SGLT2 Inhibitors

A
  • Blocks sodium-glucose co-transporter

- Increases urinary glucose excretion

28
Q

SGLT2 Inhibitor SE

A
  • Genital mycotic infections - higher in females
  • UTI
  • Increased urination
  • Hypotension from volume depletion
  • Increased amputation risk with canagliflozin
29
Q

SGLT2 Inhibitor Considerations

A
  • Weight: Loss
  • Hypoglycemia: No
  • Reduction of blood pressure
30
Q

SGLT2 Inhibitors with CV/Renal Benefits

A
  • Empagliflozin

- Canagliflozin

31
Q

Welchol

A
  • Colesevelam
  • Approved for LDL reduction
  • Efficacy: decreases A1C 0.4-0.8%
  • Dose: 6 tablets daily or divided with meals BID
  • Not for monotherapy
  • Not used frequently
32
Q

Welchol AE/CI

A

AE

  • Constipation/nausea/indigestion
  • Increased TG

CI

  • Bowel obstruction
  • History of hypertriglyceridemia
  • TG > 500
33
Q

Cycloset

A
  • Bromocriptine
  • Dopamine Agonist
  • Increase insulin sensitivity
  • Efficacy: Decreases A1C 0.1-0.4%
  • Once daily dosing
  • Not used frequently
34
Q

GLP-1 Physiological Roles

A
  • Promotes satiety and reduces appetite
  • Reduces postprandial glucagon secretion from alpha cells
  • Reduces glucagon from liver and therefore its glucose output
  • Helps regulate gastric emptying
  • Enhances glucose-dependent insulin secretion
35
Q

GLP-1 RA

A
  • Incretin mimetic
  • Resistant to degradation by DPP4
  • Suppresses high glucagon levels
  • Delays gastric emptying
  • Efficacy: Decreases A1C ~1-1.6%
36
Q

Byetta

A
  • Dosing: 5 mg SQ BID within 60 minutes of starting a meal
  • Increase to 10 mg after 4 weeks
  • Not recommended if CrCl < 30
  • Store in fridge until first use
  • Store at room temperature while using
  • Priming for first step only
  • One pen should last 30 days (60 injections)
37
Q

Victoza

A
  • Dosing: 0.6 mg SQ daily x 1 week, then 1.2 SQ daily x 1 week, can increase to 1.8 if needed
  • Dosing is independent of meals
  • Store in fridge until first use
  • Priming for first step only
  • 3 mL pens with 18 mg of drug
38
Q

Bydureon

A
  • Dosing: 2 mg SQ weekly
  • Not recommended if CrCl < 30
  • Pen is single use (4 pens/month)
  • Autoinjector
  • Missed doses administered ASAP as long as there are 3 days until next dose, if <3 days then skip dose
39
Q

Trulicity

A

-Dosing: 0.75 mg DQ once weekly, can optionally increase to 1.5 mg
-Autoinjector
-Missed doses administered ASAP as long as there are 3 days until next dose, if <3 days then skip
-

40
Q

Ozempic

A
  • Dosing: 0.25 mg once a week, increase to 0.5 after 4 weeks, max: 1 mg
  • 0.25/0.5 mg: 1 pen + 6 needles per box
  • 1 mg: 2 pens + 4 needles/box
  • NEEDLES INCLUDED WITH PENS
  • Each pen requires priming step with first use
41
Q

Rybelsus

A
  • New oral GLP-1 RA
  • Once daily dosing
  • Take on empty stomach with no more than 4 oz of water
  • Wait 30 minutes before eating, drinking, or taking other meds
  • Tablets blister-packed
42
Q

GLP-1 RA Considerations

A
  • Hypoglycemia: No
  • Weight: Loss
  • Cost: Expensive

Shown to be as effective as pre-meal insulin when used with basal insulin

43
Q

GLP-1 RA Drugs Ordered by Weight Loss Benefits

A
  1. Semaglutide
  2. Liraglutide
  3. Dulaglutide
  4. Exenatide
  5. Lixisenatide

More best to worst

44
Q

GLP-1 RA with CV/Renal Benefits

A
  • Liraglutide
  • Semaglutide (injection)
  • Dulaglutide
45
Q

GLP-1 RA AE

A
  • N/V - most common, reduced with dose titration

- Acute pancreatitis

46
Q

GLP-1 RA CI

A
  • Gastroparesis
  • History of pancreatitis
  • History of medullary thyroid carcinoma
  • Multiple endocrine neoplasia syndrome 2
47
Q

Soliqua

A
  • GLP-1 RA + Basal Insulin
  • Glargine + Lixisenatide
  • 100/33 U pens
  • For uncontrolled patients on a basal insulin
  • Daily dosing
  • 1 box = 5 pens = 1500 units
48
Q

Soliqua Dosing

A
  • If < 30 U of basal insulin: 15 U of Soliqua
  • If > 30 U of basal insulin: 30 U of Soliqua
  • Titrate by 2-4 U per week if fasting glucose isn’t in range
  • Max dose: 60 U
  • If >60 U of basal insulin, use different/individual drugs
49
Q

Xultophy

A
  • GLP-1 RA + Basal Insulin
  • Degludec + Liraglutide
  • 100/3.6 U pens
  • 10-50 U daily
  • 1 box = 5 pens = 1500 units
50
Q

Glucose Monitoring

A
  • SMBG
  • 3 times/day if on insulin
  • PRN if on oral to help achieve goals, usually a max of 1x/day per insurance
51
Q

A1C Monitoring

A
  • At least twice a year for goal patients

- Every 3 months for those not at goal or if their therapy changed

52
Q

Diet Modifications

A
  • Weight loss will reduce insulin resistance
  • Saturated fats < 7% of total daily calories
  • Carbs from fruits, veggies, whole grains, legumes, low fat milk
  • Recommend sugar alcohols and nonnutritive sweeteners
  • Limit 1 drink a day for women and 2 a day for men
  • Drink alcohol with food to avoid hypoglycemia if on insulin or a secretagogue
  • Metabolic surgery consideration in adults with BMI >=35
53
Q

Exercise Modification

A
  • 150 min/week of moderate-intensity aerobic activity
  • Resistance exercise twice a week
  • Disrupt prolonged sitting every 30 minutes
  • Improves glycemia
54
Q

T2DM Initial Therapy

A
  • Metformin if not CI
  • Titrate to max dose over 1-2 months
  • Up dose after 5-7 days if GI effects haven’t occurred
  • If GI effects then occur, reduce dose and try to increase again at a later time
55
Q

T2DM Pharmacotherapy determined by….

A
  1. ASCVD
  2. CHF
  3. CKD
  4. Need to minimize hypoglycemia
  5. Need to promote weight loss/minimize weight gain
  6. Cost Issues
56
Q

If ASCVD Predominates…

A

-Use GLP-1 RA with CVD benefit: Liraglutide, Semaglutide, Dulaglutide

OR

-Use SGLT2-I with proven CVD benefit if eGFR is adequate: Empagliflozin, Canagliflozin

57
Q

If HF or CKD Predominates…

A

-Preferred: SGLT2-I with HF/CKD evidence: Empagliflozin, Canagliflozin, Dapagliflozin

OR

-GLP-1 RA if SGLT2-I not tolerated or CI

58
Q

Avoid in HF….

A
  • TZDs

- Saxagliptin

59
Q

Minimizing Hypoglycemia WITHOUT ASCVD/CKD

A
  1. Metformine
  2. DPP4-I, GLP-1RA SGLT2-I, or TZD
    * *Do NOT use GLP-1 RA and DPP4-I together
  3. If A1C is still above this goal, cotinue adding from these classes
  4. If above goal from ALL agents, add sulfonylurea or basal insulin with lower risk of hypoglycemia
60
Q

Weight Loss WITHOUT ACVD/CKD

A
  1. Metformin
  2. GLP-1 RA OR SGLT2-I
  3. If A1C is above goal, add med from the class not previously used
  4. If A1C still above goal on both agents, add DPP4-I if not on GLP-1 RA. Then add sulfonylurea, basal insulin, or TZD
61
Q

If Cost is a MAJOR Issue

A
  1. Metformin
  2. Sulfonylurea or TZD
  3. If A1C above goal
  4. If on both agents and A1C still above goal add basal insulin (NPH is least expensive)
62
Q

Intensifying Injectable Therapy

A
  • If A1C is above goal on multiple oral meds: start injections, GLP-1 RA preferred in most situation
  • Should consider injectable combo (GLP+Insulin) if A1C > 10%
  • Insulin is preferred if A1C >= 11% or symptomatic from hyperglycemia
63
Q

Starting Basal Insulin…

A
  • Start first
  • 10 units once a day or 0.1-0.2 units/kg daily
  • Increase 2 units every 3 days until fasting <130 mg/dL
64
Q

Start mealtime insulin if….

A
  • A1C still above goal despite adequate basal dose
  • Basal dose >0.7-1 units/kg/day
  • Fasting glucose at target, but high A1C
  • Initiate 4 units or 10% of basal dose at largest meal
  • Increase 1-2 units or 10% twice a week targeting post-prandial levels < 180 mg/dL
  • Stop sulfonylureas when starting mealtime insulin
65
Q

T2DM + Severe Insulin Resistance

A
  • Humulin R U-500
  • 5x more concentrated than 100U
  • Indicated if patient requries >200 U per day
  • High risk of medication errors
  • Unique PK/PD: mean onset: 15 minutes, duration: 21 hours
  • Will replace all other insulins
66
Q

U-500 Dosing/Frequency

A
  • If A1C > 8% (last month) and glucose >= 183 mg/dL (last week): 100% of TDD
  • If A1C =< 8% (last month) OR glucose < 183 mg/dL (last week): 80% of TDD
  • Can be BID: 60% of TDD at breakfast ad 40% at dinner
  • TID: 40% at breakfast, and 30% at lunch and dinner
67
Q

U-500 Administration

A
  • Do not use U-100 syringe,
  • Use syringes designated for U-500 insulin
  • Use pen for safest dosing

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