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IPFC 3 Midterm 1 > Type 2 diabetes management > Flashcards

Type 2 diabetes management Flashcards

1
Q

If someones A1C is 1.5% above target what do you start

A

Metformin plus a second agent

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2
Q

What is first line therapy if healthy behaviour interventions don’t work?

A

Metformin

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3
Q

If someone presents with symptomatic hyperglycemia and/or metabolic decompensation, what do you start?
What symptoms do you look for?

A

Symptoms
- Polyuria (pee a lot)
- Polydipsia (thirst)
- Weight loss
- Volume depletion

Start insulin +/- metformin

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4
Q

What is the starting dose for metformin? Titrate? MDD?
Adjust in CKD?

A

250mg once daily titrated q3-7 days.
Max daily dose 2550mg/day

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5
Q

How do you adjust metformin dose based on kidney function?

A

eGFR 45+ = no dose adjustment
eGFR under 45 = decrease dose
eGFR under 30 = DO NOT USE

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6
Q

What are common or serious ADRs of metformin

A
  • GI N/V/D
  • Metallic taste
  • Lactic acidosis
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7
Q

How much does metformin lower A1C by?

A

1-1.5%

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8
Q

What is lactic acidosis?
Which type of patients is it most commonly seen in?

A

Metformin accumulation
- metformin shuts down enzyme that converts lactate to pyruvate
- impaired gluconeogenesis

Most common in
- renal insufficiency
- liver disease (excessive alcohol)
- cardiac failure

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9
Q

Which is the best agent in lowering A1C effect when added to merformin?

A
  1. SC semaglutide and other GLP1 receptor agonists
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10
Q

Which agent has the highest hypoglycemic risk in addition to metformin

A

Premixed insulin

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11
Q

Which SGLT2 inhibitor should be taken before the first meal of the day?

A

Canaglifozin

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12
Q

What is the expectation of eGFR when you start an SGLT2i

A

eGFR will drop a bit

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13
Q

What should you monitor for pre-treatment assessment when starting SGLT2i

A

Renal function
- Do not start if eGFR under 20
- Volume status including BP and electrolytes (correct first)
- Signs of decreased BP
- Assess for risk of amputation, fracture, DKA

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14
Q

What are ADRs of GLP-1 receptor agonists? Hypo risk? Contraindications? ongoing monitoring what value?

A
  • GI side effects N/V/D
  • Acute pancreatitis
  • Risk of thyroid c-cell tumours

Low hypo risk

CI: family history of medullary thyroid cancer and multiple neoplasia syndrome type 2

Monitor: SCr

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15
Q

Which DPP4 does not need renal dose adjustment

A

Linagliptin (trajenta)

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16
Q

Which DPP4 is CI in HF?

A

Saxagliptin

17
Q

What are ADRs of DPP4i? Weight gain?

A

Headache
Nasopharyngitis
Rash (rare)

Weight neutral
Low hypo risk

18
Q

Which lab value are DPP4i known for improving

A

Post-prandial control

19
Q

How much does DPP4i lower A1C by?

A

0.7%

20
Q

What are the ADRs of TZD

A
  • Edema
  • Heart failure
  • Weight gain
  • Bladder cancer
  • Fractures (women)
21
Q

How long does it take for full effect of TZD

A

6-12 weeks

22
Q

How much does sulfonylurea lower A1C by?

A

0.8% with metformin
1-2% in monotherapy

23
Q

Which drug class is better at lowering A1C, sulfonylurea or meglitinide

A

sunflonylurea

meglitinide = 0.7% w metformin
1% with monotherapy

24
Q

What lab value might increase a high doses when on acarbose, alpha-glucosidase inhibitor?

A

LFTs may increase

25
Q

How much does acarbose lower A1C by?

A

0.6%

26
Q

Acarbose,
risk of hypoglycemia?
Weight gain?

A

risk of hypoglycemia? No
Weight gain? Neutral

27
Q

What group is the evidence of benefit for acarbose? Which lab value is it good at controlling

A

Prediabetes

Post-prandial glucose

28
Q

If experiencing hypoglycemia on acarbose what should you take?

A

Only use glucose tabs
- other sugars may not be absorbed

29
Q

If you’re over 60 and have 2 CV risk factors and your A1C was 1.5% over target, and you had a major adverse cardio event, what drug you start?
What do the CV risk factors include?

A

GLP1-RA

Risk factors
- Tobacco
- Dyslipidemia
- hypertension
- central obesity

30
Q

Which drugs have PROVEN cardiorenal benefit in high risk populations

A

GLP1-RA
- dulaglutide
- liraglutide
- semaglutide

SGLT2i
- Canagliflozin
- Dapaglifozin
- Empagliflozin (eGFR >20)

31
Q

Which drugs have safe CV but NO proven benefit

A

GLP1-RA
- exenatide ER
- lixisenatide

DPP4i
- sitagliptin
- linagliptin
- alogliptin

Sulfonylurea
Meglitinides
Insulin

32
Q

Which drug have risk of HF

A

TZDs

33
Q

What insulin do you start of symptomatic hyperglycemia? What dose?

A

Basal insulin 10 units

34
Q

If basal insulin does not work and GLP1-RA and SGLT2i are CI, what is the next option

A

Add bolus insulin

35
Q

Which factors should be considered when recommending different anti-hyperglycemic drugs?

A
  1. Comorbidities
  2. Hypoglycemia risk
  3. Effects on body weight
  4. Adverse effects
  5. Cost
  6. Patient preference
36
Q

How do you assess the effectiveness of AHA?

A

A1C

37
Q

Which drugs can you give with eGFR <15 or on dialysis

A

GLP1-RA maybe

Linagliptin 5mg
Sitaglitpin 25mg

Insulins - dose reduction
Gliclazide - dose reduction

38
Q

What renal function do we not initiate SGLT2

A

eGFR <20 or dialysis

IPFC 3 Midterm 1 (8 decks)

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