Unit X Endocrine, Chapters 48 & 49 Flashcards
How is T2D Diagnosed (labs)
Hbg A1C 6.5% or higher
Fasting Blood glucose > 126
Random Blood Glucose or OGTT > 200
Tx for T2D: Step 1
Metformin and lifestyle changes
Tx for T2D: Step 2
Maintain Step 1 (Metformin & Lifestyle)
Add second Drug
TZD (Actos)
DPP-4 Inhibitor (Januvia)
SGLT-2 Inhibitor (Conagliflozin)
GLP-1 Receptor Agonist (Exenatide)
*Can try Sulfonylurea or basal insulin if do not achieve blood glucose goal with these options.
Tx for T2D: Step 3
Maintain Step 2 (Metformin & Lifestyle + additional drug)
Add third Drug (Can consider possible basal insulin)
TZD (Pioglitazon, Actose, Avandia)
DPP-4 Inhibitor (Sitagliptin)
SGLT-2 Inhibitor (Conagliflozin)
GLP-1 Receptor Agonist (Exenatide)
Drug choice depends on step 2 choices and independent patient factors
*As with step 2, a drug listed above can be replaced with a sulfonylurea or basal insulin if goal is not been reached with current regimen.
Tx for T2D: Step 4
If 3 drug combo that includes basal insulin fail (after 3-6 months), proceeded to combo injectable including insulin and GLP-1 Receptor Agonist
What T2D treatment step is the starting point for an Hbg A1C >9%
Step 2
Metformin & Lifestlye + Additional Drug
TZD (Proglitazone, Actose, Avandia)
DPP-4 Inhibitor (Sitagliptin)
SGLT-2 Inhibitor (Conagliflozin)
GLP-1 Receptor Agonist (Exenatide)
What is the starting treatment for a pt diagnosed with T2D with a Hbg A1C of 10% or greater, a fasting blood glucose of 300 or more, or are markedly symptomatic?
Combination injectable therapy
Where is insulin synthesized and what does it do?
Synthesized by beta cells in the pancreas and is normally secreted in response to a rise in glucose levels
What duration of action is (Insulin):
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Adipra)
Short duration/RAPID-acting
How are short duration/rapid acting insulins administered in relation to meals?
GIVEN WITH MEALS (15-20 min before eating)
What duration of action is (Insulin):
Regular (Humulin/NovolinR)
Short Duration/SHORT acting
How are short-duration/short-acting insulins administered in relation to meals?
GIVEN WITH MEALS
Which insulins are considered short-duration/RAPID acting?
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
Which insulins are considered short-duration/SHORT acting?
Regular Insulin (Humulin/NovolinR)
What duration of action (Insulin) is Humulin/NovolinN?
Intermediate (NPH)
Which Insulin(s) are Intermediate Acting?
NPH (Humulin/NovolinN)
How is Humulin/NovolinN administered in relation to meals?
Not given with meals
Regularly dosed 2-3 times per day
What is the ONLY insulin that can be mixed with short-duration insulins?
Intermediate (Humulin/NovolinN)
Which insulins are considered Long Duration?
“Basal Insulin”
Glargine (Lantus)
Detemir (Levemir)
What duration of action (Insulin) are Glargine (Lantus) and Detemir (Levemir)
Long Duration
*also referred to as ‘basal insulin’
How are Long Duration Insulins dosed?
Once a day, taken at night
24 hour duration
Which insulins are considered Ultra-Long Duration?
Glargine (Toujeo)
Degludec (Tresiba)
What duration of action (Insulin) are Glargine (Toujeo) & Dejludec (Tresibia)
Ultra-long duration
When is the use of Ultra-Long Duration insulin indicated?
When diabetes is very difficult to control
What is the major concern/risk factor for patients taking insulin?
Hypoglycemia
How is hypoglycemia managed in patients taking insulin?
Educate pt on s/s of hypoglycemia
Pt. should always carry something with them to bring a quick rise in blood glucose if needed.
s/s of a RAPID drop in blood glucose?
tachycardia, palpitations, sweating, and nervousness
s/s of a GRADUAL drop in blood glucose?
HA, confusion, drowsiness, and fatigue
Insulin drug interactions?
Hypoglycemic agents : (sulfonylureas, glinides, ETOH)
Hyperglycemic agents: (thiazide diuretics, glucocorticoids sympathomimetics)
Beta Blockers: Mask s/s of hypoglycemia
Name a drug that is a Biguanide
Metformin
What drug class is Metformin?
Biguanide (noninsulin med for diabetes)
MOA of Biguanides?
1) Prevent a rise in glucose levels after eating (keeps existing levels from rising, doesn’t drop existing levels)
2) Decreases glucose production in liver
Benefit of Biguanide (Metformin) MOA?
Little to no risk of hypoglycemia
Indication for Biguanides?
Prevention of hyperglycemia with no risk of hypoglycemia in diabetic patients
Prevention/delay of T2D in high risk individuals
Common adverse reactions of biguanides?
Mostly GI (nausea, weight loss), can be controlled by titrating dose. lactic acidosis (s/s: hyperventilation. myalgia, malaise and somnolence)
Contraindications for use of biguanides (2)?
Heart Failure
Renal Failure (BLACK BOX): Metformin is excreted UNCHANGED by kidneys. Significant kidney impairment causes metformin toxicity and metabolic acidosis.
What patient population do biguanides work especially well for?
Those with odd eating schedules/meal skippers
Give examples of Sulfonylureas
Glipizide
Glyburide
What drug class are Glipizide & Glyburide?
Sulfonylureas
MAO of Sulfonylureas?
Increase insulin release by the beta cells within the pancreas (regardless of food)
Why are sulfonylureas ineffective to treat T1D?
Because of the mechanism of action–it increases insulin release by beta cells within the pancreas. In T1D, the beta cells have been destroyed
**Pancreas must be functioning for these drugs to work.
What is a significant risk for patients taking Sulfonylureas?
Hypoglycemia (because of MOA and release of insulin not being in relation to food intake)
Contraindications for Sulfonylureas?
Pregnancy
Breastfeeding
Cautions with Sulfonylureas adverse reaction, not hypoglycemia?
Hepatic and renal dysfunction
Adverse reactions with Sulfonylureas?
HYPOGLYCEMIA
Weight Gain
Examples of Glinides/Meglitinides
Starlix
Prandin
What drug class are Starlix & Prandin?
Glinides/Meglitinides
MOA of Glinides?
Act like Sulfonylureas–promote insulin release from the pancreas.
How are the MOA of Sulfonylureas and Glinides different?
Glinides have a much shorter duration of action than Sulfonylureas.
Glinides MUST BE TAKEN WITH MEALS (MUST eat within 30 min of dosing) to prevent severe hypoglycemia.
If patients are unresponsive to sulfonylureas, what other during class will be ineffective for these patients?
Glinides (r/t to same MOA)
How are Glinides taken in relation to meals?
MUST eat within 30 min of taking Glinides to prevent severe hypoglycemia.
Give examples of Thiazolidinediones (TZD)/Glitazones
Actos
Avandia
What drug class are Actos and Avandia?
Thiazolidinediones (TZD/Glitazones)
MAO of Thiazolidinediones (TZD)/Glitazones?
Decrease Insulin Resistance
What is a risk of Thiazolidinediones (TZD)/Glitazones?
Promote fluid retention that can cause heart failure in those predisposed due to underlying CVD (Black Box).
What is the black box warning for Thiazolidinediones (TZD)/Glitazones?
Risk for heart failure due to fluid retention
Adverse Reactions to Thiazolidinediones (TZD)/Glitazones (5)?
Hypoglycemia HF (Black Box) Increase fractures (women only) Ovulation resulting unintended pregnancy Bladder Cancer
Contraindications for Thiazolidinediones (TZD)/Glitazones?
Absolute: Bladder cancer or history of bladder cancer
Osteoporosis and high fall risk
Monitoring requirements for Thiazolidinediones (TZD)/Glitazones?
ALT at baseline and every 3-6 months
Give examples of Alpha-Glucosidase Inhibitors
Precose
Glyset
What drug class are Precose & Glyset?
Alpha-Glucosidase Inhibitors
MOA of Alpha-Glucosidase Inhibitors?
Delay absorption of carbohydrates
What is limiting for the frequent use of Alpha-Glucosidase Inhibitors?
Significant GI side effects (gas, bloating, ‘not feeling well’)
Adverse Effects of Alpha-Glucosidase Inhibitors?
Significant GI Effects (gas, bloating, and ‘not feeling well’)
Give examples of Dipeptidyl Peptidase-4 Inhibitors (DPP-4)/Gliptins
Tradjenta
Januvia
What drug class are Tradjenta & Januvia?
Dipeptidyl Peptidase-4 Inhibitors (DPP-4)/Gliptins
MOA of Dipeptidyl Peptidase-4 Inhibitors (DPP-4)/Gliptins?
Enhance the action of INCRETIN HORMONES
group of hormones that their sole function-through various functions) is to decrease blood glucose
What is the action of INCRETIN HORMONES?
Through various functions, decrease blood glucose
Are Dipeptidyl Peptidase-4 Inhibitors (DPP-4)/Gliptins approved for monotherapy or adjunct therapy
Adjunct ONLY
Adverse Reactions to Dipeptidyl Peptidase-4 Inhibitors (DPP-4)/Gliptins
Pancreatitis
Hypersensitivity (angioedema, SJS)
Use of Dipeptidyl Peptidase-4 Inhibitors (DPP-4)/Gliptins should be used with care in which patients?
Hx of Pancreatitis
Elevated triglyceride levels (Increased triglycerides are a common cause of pancreatitis).
Give examples of Sodium Glucose Co-Transporter 2 Inhibitors
Invokana
What drug class does Invokana belong to?
Sodium Glucose Co-Transporter 2 Inhibitors
MOA of Sodium Glucose Co-Transporter 2 Inhibitors
Decreased reabsorption of filtered glucose so, glucose is excreted through the urine
Adverse Effects of Sodium Co-Transporter 2 Inhibitors
Increase UTIs and genital yeast infections r/t increased glucose in urine.
Give examples of Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists
Byetta
What class of drug does Byetta belong to?
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist
MOA of Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists?
INCRETIN MIMETICS
Act like incretin hormones. So, these drugs stimulate incretin mechanisms to decrease glucose levels
Adverse Effects of Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists?
GI Upset (weight loss) Hypoglycemia (mild) Renal Impairment (monitor)
Monitoring requirements of Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists?
Renal function r/t risk of renal impairment
How do thyroid hormone needs change with
pregnancy?
Need to increase dosage by 30% once pregnancy confirmed (if had hypothyroidism prior to conception)
What are the effects of untreated hypothyroidism on a
baby born to a mom with hypothyroidism?
Developmental delays
Is hypothyroidism in infants transient or permanent?
Either
What is the importance of early hypothyroidism in infants?
Early detection and treatment (within the first few days of life) physical and mental development will be normal
Explain how hypothyroidism in babies is determined to be transient or permanent?
If baby has hypothyroidism, treat for three years.
Stop treatment for 4 weeks.
Retest.
If the retest is normal, hypothyroidism was transient, no further treatment needed. If restest still shows hypothyroidism, it is permanent and lifelong replacement therapy is necessary.
What is the clinical name for HYPERthyroidism?
Graves’ Disease
Treatment for Grave’s Disease?
Surgical removal of thyroid
Destruction of Thyroid with radioactive iodine
Suppression of thyroid hormone synthesis with antithyroid drug
Give examples of Thionamides?
Methimazole
Propylthiouracil (PTU)
Methimazole & PTU belong to what class of drugs?
Thionamides (anti-thyroid medications)
What drugs are adjunct therapy to drug therapy for HYPERthyroidism and what do they do?
Beta blockers (suppress tachycardia)
Non-radioactive Iodine (inhibit synthesis and release of thyroid hormone)
s/s of Thyrotoxic Crisis (Thyroid Storm)
Profound hyperthermia (105 or greater) severe tachycardia Restlessness Agitation Tremor
Causes of Thyrotoxic Crisis (Thyroid Storm)
Major Surgery
Severe Infection/Sepsis
Are synthetic or natural drugs for HYPOthyroidism preferred?
Synthetic (more stable/consistent dosing)
What drug is used to treat Hypothyroidism?
Levothyroxine (T4)/Synthroid
How is Levothyroxine (T4)/Syntrhroid administered in relation to
food
Should be taken on an empty stomach 30-60 min before breakfast. CONSISTENTLY.
Levothyroxine (T4)/Synthroid half-life long or short?
Long (approximately 7 days), contributes to sustained thyroid levels over time (but also takes a long time to reach therapeutic effect)
How long does it take to reach normal plasma thyroid levels/full effects after starting Levothyroxine (T4)/Synthroid?
Approximately one month (4 half-lives)
What is important to teach about thyroid supplement prescriptions (can it be easily substituted)?
Make sure that formulation/manufacturer/drug company doesn’t change—it can affect the concentration of the drug and impact the effect on thyroid levels.
**If a change is made, retest serum level in 6 weeks and make necessary adjusments
Monitoring parameters for Thyroid replacement
Upon initiation of drug therapy, check levels every 6 weeks
Once stable, retest every 6-12 months
Adverse Effects of Levothyroxine (T4)/Synthroid?
Acute OD (thyrotoxicosis) s/s include: Tachycardia Angina Tremor Nervousness Insomnia Hyperthermia Heat intolerance and sweating Hyperthyroidism
Levothyroxine (T4)/Synthroid Drug Reactions (7)?
All Heartburn Meds (take 4 hours after Levothyroxine if needed)
Seizure meds (Dilantin, Phenobarb, Tegretol)
Zoloft
Warfarin
Catecholamines
Insulin
Digoxin
Indications for use for Thionamides?
HYPERthyroidism-
Graves’ disease
Adjunct to radiation
Thyrotoxic Crisis (Thyroid Storm)
*Usually short term until a decision about long term treatment can be made (surgery or radioactive iodine)
Which Thionamide is first-line indication for HYPERthryroidism? What are exceptions?
Methimazole (Tapazole)
EXCEPT pregnant women and breastfeeding
EXCEPT THYROTOXIC CRISIS– PTU works faster
How long does it take to reach the therapeutic effects (euthyroid state) of Methimalzoe?
3-12 weeks
Adverse Effects of Methimazole?
1) Agranulocytosis
s/s include:
sore throat and fever
Typically within the first 2 months of initiating treatment
2) Hypothryroidism
What is typical dosing for Methimazole?
ONCE DAILY
When is PTU preferred over Methimazole?
Pregnancy
Breastfeeding
Thyrotoxic Crisis (works more quickly than Methimazole)
Radioactive Iodine Indications for use
ADULTS ONLY
Used as bridge/prep to having thyroid removed
Contraindications for Radioactive Iodine?
Children
Pregnancy
Lactation
What is a consistent adverse effect of radioactive iodine?
Hypothyroidism-almost always requires supplementation
What is dosing for PTU (initial and maintenance)?
3-4 times a day initially
2-3 times a day for maintenance
How long does it take to achieve the full effect of Radioactive Iodine?
2-3 months (may take multiple rounds of treatment)
What drugs REDUCE Levothyroxine absorption and need to have administration separated by at least 4 hours?
H2 Receptor Blockers (Tagament, etc) Proton Pump Inhibitors (Pepcid, etc) Aluminum Containing Antacids Calcium Containing Supplements Iron Supplements
What drugs ACCELERATE Levothyroxine absorption and may require an increase in levothyroxine dosing?
Antiepiletics (Dilantin, Carbamazepine, Phenobarbital)
Rifampin
Zoloft
What drugs have ACCELERATED DEGREDATION from levothyroxine (drug effects are enhanced by Levothyroxine) and may require reduced dosages of these drugs?
Warfarin
Catecholamines (Increases cardiac responsiveness and can cause cardiac dysrhythmias)
What drugs have INCREASED REQUIREMENTS when taken with Levothyroxine?
Insulin
Digoxin
