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Endocrine 1 > Tx of T2DM - Oral Agents > Flashcards

Tx of T2DM - Oral Agents Flashcards

1
Q

What are the outcomes of large diabetes prevention studies based on lifestyle changes and meds?

A
  • studies have shown that the biggest impact on preventing DM is lifestyle changes: increase exercise, decrease calories and fat, and losing weight
  • Da Qing Study
  • Finnish DM Prevention Study: 58% RRR incidence of DM
  • DM Prevention Program: 58% RRR
  • Toranomon Study
  • Indian DPP
  • studies show that meds can also prevent DM but not as effectively as lifestyle changes: TRIPOD, STOP-NIDDM, DPP, DREAM
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2
Q

given a pt at risk for DM, apply the lifestyle change outcomes to reduce or prevent profession to DM

A
  • counsel of weight loss (5-10%)

- increase physical activity (at least 150 min/week)

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3
Q

Given a pt at risk for DM, select the medication to reduce or prevent progression to DM based on the outcomes of the prevention studies

A

metformin

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4
Q

ADA criteria for the use of metformin for prevention of DM in a pt at high risk for DM/preDM

A
  • ADA recommends considering metformin for those at the highest risk:
  • IFG + IGT plus other risk factors:
  • A1c > 6%
  • HTN
  • positive family hx
  • obese
  • <60
  • low HDL
  • high TG
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5
Q

State the outcomes of the DCCT on the development or progression of microvascular diabetes complications

A

this study proved normalizing blood glucose could prevent or delay progression of diabetic complications

  • in the primary prevention group:
  • 76% RRR in the development of retinopathy
  • 34% reduction in nephropathy
  • 60% reduction in neuropathy
  • secondary prevention group:
  • 54% RRR in retinopathy
  • 43% reduction in nephropathy
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6
Q

state the outcome of the UKPDS concerning the reduction of microvascular complications

A
  • drug therapy group vs. diet group to control blood glucose

- outcome: 25% reduction in microvascular complications

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7
Q

glycemic goals of therapy for a nonpregnant adult with T2DM

  • a1c
  • preprandial blood glucose
A
  • A1c: <7%

- BG: 80-130

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8
Q

identify pts who may safely achieve an A1c of < or equal to 6.5%

A
  • those with a short duration of DM
  • long life expectancy
  • no significant cardiovascular dz
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9
Q

identify the pts who need less stringent A1c goals

A
  • people who are at risk for severe hypoglycemia
  • have a limited life expectancy
  • have advanced complications and/or severe co-morbid diseases
  • have had DM for many years and have trouble achieving <7% despite use of multiple glucose lowering meds
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10
Q

What are patient risk factors for the development of prediabetes/diabetes

A
  • impaired fasting glucose
  • impaired glucose tolerance test
  • A1c > 5.7-6.4%
  • BMI > 30
  • < 60 yo
  • women w/ hx of gestational DM
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11
Q

given a pt w/ prediabetes, choose a tx plan to reduce their risk for developing DM

A
  • lifestyle changes are tx of choice
  • if meds needed: metformin
  • tx other cardiovascular risk factors: BP, lipids, smoking
  • monitor for development of DM annually
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12
Q

Place in therapy for metformin in the tx of T2D

A

if lifestyle changes fail to achieve glycemic goals and have not achieved an A1c <7.5% then metformin is the drug of choice

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13
Q

expected clinical effect of metformin on the patient’s blood glucose control

A
  • lowers fasting plasma glucose concentrations by about 55 mg/dl
  • reduces A1c by 1-2%
  • no hypoglycemia
  • no weight gain
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14
Q

contraindications to metformin

A
  • renal function
  • unstable CHF
  • liver dz
  • alcohol abuse
  • pregnancy/lactation
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15
Q

renal function guidelines for metformin use

A
  • DO NOT use in CKD stages 4 and 5
  • do not initiate therapy at stage 3B but may continue use at 1000mg max dose
  • avoid initiating therapy at stage 3A if expected to become unstable but may continue use at 2000mg max
  • CKD stages 1 and 2: max dose 2550 mg
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16
Q

initial dose of metformin

A

500 mg once or twice daily (Letassy said she starts w/ once daily)

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17
Q

titration dose of metformin

A
  • start at 500 mg daily
  • dose should be increased at the rate of 1 tab weekly
  • up to a max dose of 2500 mg per day

*her example:
500mg daily x 1 week; increase to 500 mg BID x 1 month; then add 500 mg where needed

18
Q

MoA of metformin

A
  • decreases hepatic glucose production from gluconeogenesis and glycogenolysis
  • increases glucose uptake in the muscle by increasing movement of glucose transporters to the cell membrane and by increasing their sensitivity to insulin and glucose
19
Q

ADRs of metformin

A

GI are MC

  • early satiety and anorexia
  • nausea w/ or w/o vomiting, anorexia, diarrhea, bloating, and abdominal discomfort
20
Q

what needs to be monitored when taking metformin?

A
  • B12 concentrations

- some pts may need replacement

21
Q

what is the expected clinical effect of the sulfonylureas (SU) and meglitinides on the pts BG control?

A
  • fasting BG to drop 60-70 mg/dl

- A1c reduction of 1-2%

22
Q

contraindications to SUs and meglitinides

A
  • T1D
  • DM d/t pancreatic resection
  • hx of adverse rxns to SUs or sulfa drugs
  • stress: emotional, severe infection, trauma, major surgery
  • significant renal or hepatic dz
  • those predisposed to significant hypoglycemia
23
Q

MoA of SUs and meglitinides

A

-stimulate beta cells to release more insulin

24
Q

ADRs associated w/ SUs and meglitinides

A
  • GI: nausea, heartburn
  • Derm: rash and puritis; sulfa structure and hypersensitivity
  • hypoglycemia
25
Q

what is the expected clinical effect of pioglitozone on the pts BG control?

A
  • average decrease in A1c is 1.5% (in pts w/ a baseline of 9%) and is seen after 12-14 weeks
  • average decrease in A1c when added to another agent: 0.8-1.3%

(the numbers don’t agree with this but the packet says it’s more effected when used in combo)

26
Q

contraindications to the use of pioglitazone

A
  • Class III and IV CHF (it precipitates heart failure)
  • anemia
  • impaired liver function
  • T1D
  • pregnancy
27
Q

MoA of pioglitazone

A
  • interact w/ a nuclear receptor (peroxisome proliferator activated receptor gamma)
  • when activated, it binds w/ response elements on DNA, altering transcription of many genes that regulate carb and lipid metabolism
  • results: increase in gene expression of glucose transporters
  • decreases insulin resistance in peripheral tissue
  • decreases hepatic glucose production
28
Q

ADRs associated w/ pioglitazone

A
  • weight gain**
  • edema
  • anemia (dilutional effect)
  • heart failure and exacerbation of CHF
  • skeletal effects: decrease in bone density and increased risk of fx
  • increased risk of heart dz
  • macular edema (rare)
  • increase in serum transaminases
29
Q

what is the expected clinical effect of the DPP-4 inhibitors (januvia) on the pts BG control?

A

0.6-0.8% drop in A1c

30
Q

contraindications to the use of DPP-4 inhibitors

A
  • T1D
  • DKA
  • caution in: risk of heart failure, hx of pancreatitis, and CrCl < 45
31
Q

given a pts renal function and Januvia use, select the max daily dose

A
  • max daily dose: 100 mg daily
  • moderate renal insufficiency (CrCl 30-<50): 50mg daily
  • severe renal insufficiency (CrCl < 30) or w/ ESRD requiring dialysis: 25mg daily
32
Q

MoA of DPP-4 inhibitors

A
  • they inactivate DPP-4
  • DPP-4 is an enzyme that deactivates GLP-1
  • GLP-1 functions to slow gastric emptying and stimulates the pancreas to produce insulin in response to a meal
33
Q

ADRs of DPP-4 inhibitors

A
  • stuffy/runny nose
  • sore throat
  • URI
  • HA
  • serious hypersensitivity rxns
34
Q

what is the expected clinical effect of the SGLT2 inhibitors (invokana, farxiga, jardiance) on the pts BG control?

A
  • A1c decrease of about 1%

- some weight loss d/t increased excretion of glucose

35
Q

contraindications of SGLT2 inhibitors

A
  • do not use in pts w/ severe renal imapirment (eGFR < 45) ESRD, or on dialysis
  • T1D
36
Q

MoA of SGLT2 inhibitors

A
  • inhibit sodium glucose transporters in the proximal tubules of the nephron
  • this inhibition prevents the reabsorption of flitered glucose in the kidney
  • glucose passes through the nephron and out into the urine
37
Q

ADRs associated w/ SGLT2 inhibitors

A
  • increased risk of yeast infections and UTIs
  • risk of hyperkalemia
  • increase in LDL
  • hypotension
  • increased risk of acute renal failure
  • decline in hgb and hct
  • euglycemic DKA ***
38
Q

risk factors for euglycemia DKA d/t SGLT2 inhibitors

A
  • major illness
  • reduced fluid and food intake
  • reduced insulin dose
  • type 2 DM

**the packet doesn’t specifically state the risk factors, this is just what I interpreted them as

39
Q

symptoms of euglycemia DKA d/t SGLT2 inhibitors

A
  • mild elevation of glucose (<200)
  • high anion gap metabolic acidosis
  • elevated blood or urine ketones
  • most pts have T2D
40
Q

given a child w/ T2D, select the most appropriate therapy

A
  1. Insulin therapy indications:
    - ketosis or DKA
    - unclear if T1 or T2
    - unusual cases like a random BG >250 or A1c >9%
  • all other cases:
    1. lifestyle changes: nutrition interventions and physical activity
    2. metformin
  • confirm T2
  • start low (500mg) d/t GI side effects
  • monitor for glycemic deterioration
  • add insulin if needed
    3. test A1c every 3 months
  • target = <7%
  • intensify tx if needed

Endocrine 1 (18 decks)

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