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DM Therapeutics Exam 1 > Week 2: Oral therapies, injectables, insulin and dosing > Flashcards

Week 2: Oral therapies, injectables, insulin and dosing Flashcards

1
Q

Strict targets

A 
AACE
<65 w no CVD
A1C<6.5%
FBG <110
PPG<140
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2
Q

Loose targets

A

ADA
A1C<7.5%
FBG 80-130
PPG<180

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3
Q

Sulfonylurea drugs

A

Glyburide
Glipizide
Glimepiride

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4
Q

which sulfonylureas are BEERs criteria

A

glyburide and glimepiride

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5
Q

SU dosing

A

qd

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6
Q

When is glyburide CI?

A

CrCl <50

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7
Q

SU side effects

A 
HYPOGLYCEMIA
WEIGHT GAIN
N/V
rash
cholestatic jaundice
hemolytic anemia
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8
Q

SU drug interactions

A 
alcohol
salicylates
clofibrate
other sulfonamides
allopurinol and probenecid
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9
Q

SU contraindications

A 
hypersens
DKA
CrCl <50 with glyburide
preggo near term
T1DM
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10
Q

SU cautions

A

impaired renal or liver fxn
elderly
sulfonamide allergy

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11
Q

SU counseling

A

take first thing in the morning
take glipizide 30 min pre brekky
avoid alcohol
ask ab hypoglycemia sx and weight gain

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12
Q

which DM medications may blunt myocardial ischemia preconditioning

A

SU

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13
Q

SU monitoring

A

hypoglycemia!

FBG, A1C,weight gain, allergic rxn, sun sensitivity

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14
Q

Do SU or Meglitinides cause more hypoglycemia?

GI upset?

A

SU cause more hypoglycemia

Meglitinides cause more N/V/GI Disturbances

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15
Q

Meglitinides drugs and brand names

A

Nateglinide (Starlix) and Repaglinide(Prandin)

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16
Q

Nateglinide (Starlix)dosing

A

60-120mg po TID with meals

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17
Q

Repaglinide (Prandin)dosing

A

0.5-2 mg TID dep on A1C

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18
Q

Meglitinides (Nateglinide and Repaglinide) SE

A

GI DISTURBANCES (~4%)
hypoglycemia
weight gain
HA

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19
Q

Nateglinide DDI

A

Mifepristone

Pazopanib

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20
Q

Repaglinide DDI

A

Mifepristone
Gemfibrozil
NPH (NEVER COMBO)
SU

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21
Q

Nono combos in DM

A

Repaglinide and NPH

DPP4i and GLP1-RA

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22
Q

Meglitinides CI

A 
hypersens
T1DM
DKA
NPH
caution in severe renal disease
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23
Q

Meglitinides counseling

A

admin ~30 min before meals
skip a meal, skip the dose
avoid alcohol
ask ab hypog and weight gain

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24
Q

Meglitinides monitoring

A

PPG
hypog
A1C
weight gain

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25
Q

Biguanides (Metformin [glucophage]) renal dosing

A

GFR

> 45 none
30-45 1/2 dose
<30 D/C
ARF D/C until reversed

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26
Q

Metformin titration

A

500 dinner
500 breakfast 500 dinner
500 breakfast 1000 dinner
1000 breakfast 1000 dinner

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27
Q

Metformin SE

A 
GI UPSET
WEIGHT LOSS
N/V/D
discomfort
anorexia
Vit B12 deficiency
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28
Q

Metformin DDI

A 
Dofetilide
Dalfampridine
radioplaque contrast dyes
cimetidine
trimpethoprim
tropsium
corticosteroids
danazol
LH
Lamictal
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29
Q

Metformin CI

A 
hypersens
renal disease/dysfxn
metabolic acidosis
DKA
Lactic acidosis
caution in elderly, excessive alcohol, CHF requiring tx
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30
Q

Metformin counseling

A

take with food!
avoid alcohol
GI upset
ask ab: GI SE, weight loss

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31
Q

Metformin monitoring

A 
renal fxn
GI tolerance
FBG/PPG
A1C
B12 levels
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32
Q

TZD drugs and brand names

primary MOA

A

Rosiglitazone (Avandra) and Pioglitazone (Actos)

increase glc sensitivity in periph muscle

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33
Q

TZD dosing (Rosiglitazone and Pioglitazone)

A

Rosi 4-8mg qd

Pio 15-30 mg qd

34
Q

TZD SE

A

edema (worsens HF)
weight gain
**bladder cancer
fractures

no hypoglycemia:)

35
Q

TZD BBW

A

CHF (exacerbates)
sx: rapid weight gain, dyspnea, edema

MI - Rosiglitazone only

36
Q

TZD CI

A 
hypersens
T1DM
DKA
CHF
ACS
active bladder cancer
MI
37
Q

TZDs monitoring

A 
LFTs
edema
weight gain
cholesterol panel
FBG/PPG
A1C
fractures
38
Q

a-glucosidase inhibitors (AGis) drugs and MOA

A

Acarbose (Precose) and Miglitol

dec sucrose and complex carb breakdown in sm int brush border

39
Q

AGIs dosing

A

(Both)

25mg po TID

40
Q

AGi SE

A

abdominal pain
diarrhea
flatulance
bloating

41
Q

AGi CI

A 
hypersens
DKA
cirrhosis
IBS
Crohn's
colonic ulceration
intestinal obstruction
SCr >2.0
caution in impaired rfx
42
Q

AGi counseling

A

take w 1st bite of each meal

ask about GI upset and timing

43
Q

AGi monitoring

A

PPG
A1C
Gi sx
needs to be taken with meals @ 1st bite!

44
Q

Gliptins/DPP4i drugs (brand and generic) and MOA

A

Sitagliptin (Januvia) Saxagliptin (Onglyza)
Linagliptin (Tradjenta) Alogliptin (Nesina)
suppress glucagon secretion
slow gastric emptying
dec food intake
promotes B cell prolif

45
Q

Which DPP4i does not require renal dosing

A

Linagliptin

46
Q

Linagliptin (DPP4i) DDI

A

phenytoin
rifampin
carbamazepine
st johns wort

47
Q

Which DPP4is have increased risk of HF

A

Saxagliptin and Alogliptin

48
Q

DPP4i/GLiptins SE

A 
nasopharyngitis
URI
abdominal pain
HA
N/V/D
hepatotoxicity
pancreatitis
HF (saxa and alo)
hypog
49
Q

Saxagliptin (DPP4i) DDI

A

Conivaptan

50
Q

DPP4i monitoring

A

FBG/PPG, A1C, URI, GI SE

51
Q

SGLT2i drugs

A

Canagliflozin (Invokana) Empagliflozin (Jardiance)

Dapagliflozin (Farxiga) Ertugliflozin

52
Q

SGLT2i SE

A 
genital mycotic infections
inc urination
UTIs
weight loss
ketoacidosis
gangrene
lower limb amputation
bladder cancer (dapa)
hyperkalemia (cana)
53
Q

SGLT2i DDI

A 
UGT enzyme inducers
rifampin
ritonavir
phenytoin, phenbarbitol
hypotension w ACEi or ARB or diuretic
digoxin
54
Q

SGLT2i CI

A

dialysis
renal failure
GFR <30
ESRD

55
Q

SGLT2i FDA approvals

A

cana: ESRD and T2DM,dec ASCVD events in T2DM, adjunct to diet and exercise
dapa: ESRD and T2DM, GFR, CV death, dec HF risk, adjunct to “
empa: dec CV death in T2DM, adjunct to “, no renal or HF bennies
ertu: adjunct to “

56
Q

SGLT2i counseling

A 
at the same time qd
take in morning
hydrate
bladder cancer hx
rfxn status
57
Q

SGLT2i monitoring

A 
FBG/PPG
A1C
eGFR
hydration
UTI sx
yeast infxns
BP
weight
LDL-C
58
Q

GLP1-RA drugs (brand and generic)

and MOA

A

SQ: Exenaltide IR (Byetta), Liraglutide (Victoza), Lixisenatide (Adyixin), Exenatide ER (Bydureon, Bcise), Dulaglutide (Trulicity), Semaglutide (Ozempic SQ)
PO: semaglutide po (Rybelsus)

dec glucagon secretion, increase insulin prod, dec gastric emptying, inc # B cells

59
Q

GLP1-RA SE

A 
hypoglycemia
N/V/D/GERD
jittery
HA
URI/cough
inj site rxn
pancreatitis
cholelithiasis
60
Q

GLP1-RA w CVD and T2DM bennies

A

Dulaglutide (Trulicity)
Liraglutide (Victoza)
Semaglutide (Ozempic)

61
Q

GLP1-RA DDI (hypo and hyer g)

A

hypog: androgens, ins/SU, pegvisomat
hyperg: corticosteroids, danazol, LH RH, somatropin, thiazides

62
Q

GLP1-RA BBW

A

thyroid T cell
multiple endocrine neoplasia syndrome type 2 (MEN2)
medullary thyroid carcinoma

63
Q

GLP1-RA that needs renal dosing

64
Q

GLP1-RAs that need to be taken within 60 min of first meal

A

exenatide (B
lixenatide
semaglutide po

65
Q

GLP1-RA counseling

A 
upset GI is SE but will dec w time
eat small frequent meals
store if fridge until using
Rybelsus (Semaglutide po) NEEDS to be taken exacty 30 min before first meal
ask ab: GI upset and timing
66
Q

GLP1-RA dosing

A

BID: exenatide IR

qd: lixisenatide, liraglutide, semaglutide po
qweek: exenatide ER, semaglutide, dulaglutide

67
Q

Ultra rapid acting insulins
SQ or IV?
mix w NPH?
onset

A

Ins Aspart: SQ pumps, no IV
Ins Lispro-aabc: can mix w NPH, SQ pumps, no IV
onset ~15 min

68
Q

Rapid acting insulins (BOLUS)
SQ or IV?
mix w NPH?
onset

A 
Humalog and Novolog
eat within 15 min of using
can mix w NPH
SQ pumps
no IV
onset 15-30 min
69
Q

Short-acting insulins aka?
SQ or IV?
mix w NPH?
onset

A 
regular insulins
Humilin-R and Novolin-R
clear colorless
SQ pumps
IV in DKA tx, TPN
onset 30-150 min
70
Q 
Intermediate acting insulins
add ons?
mix w?
frosting?
shake?
onset
A 
Humulin-NPH
Novolin-NPH
zinc and protamine
can mix w regular, aspart, lispro, glulisine
frosting = potency is lost
do not shake!
onset 2-4h
71
Q

Long-acting aka?
3 types, 6 drugs
onset

A 
BASAL
insulin glargine, detemir, degludec
glargine = Basaglar Lantus
detemir = Levemir
degludec = Tresiba, Toujeo
(Semglee?)

onset 1-9h

72
Q

what is unique about tresiba

A

ins degludec
3-5d until s-s so can only titrate q5 days
dont have to worry about stacking ins and can take at any time/be inconsistent

73
Q

insulin DDI

A 
TZDs
ACEi 
MAOi
thiazides
hormones
BBs
AGi
74
Q

insulin monitoring

A 
FBG/PPG
hypog
weight gain
inj site rxns
cough
75
Q

factors that affect insulin absorption rate

A

insulin type

site: abdomen

76
Q

Which DM meds cause weight gain?

A

SU
Meglitinides
TZD
insulin

77
Q

Which DM meds cause weight loss

A

Metformin
SGLT2i
GLP1-RA
DPP4i

78
Q

71 yo female with PMH heart failure, T2DM, HTN and dyslipidemia

which guideline?
what is the target range and therapeutic goal?
Drug options?

A 
loose target--> ADA
A1C <7.5%
FBG 80-130
PPG <180
goal is to minimize hypoglycemia

Metformin
then SGLT2 with HF benefits (Empa or Dapa)

79
Q 
60 yo male with PMH gout, T2DM x 2 years
A1c = 8.0%
which guideline?
what is the target range and therapeutic goal?
Drug options?

what if 3 months goes by and not at goal a1c?

A 
strict target --> AACE
A1C <6.5%
FBG <110
PPG <140
goal is to minimize macro and micro vascular complications

dual or triple therapy (1 of the therapies is metformin)
GLP1RA, SGLT2i, DPP4i, TZD, SU/GLN

@ 3 mo with a1c above goal, add basal insulin

a1c: <8% >8%
0. 1-0.2U/kg 0.2-0.3U/kg

80
Q

55 yo patient (81kg) PMH HTN, T2DM x 3 yrs
Medications: Empagliflozin 10 mg po qd, Tresiba 30U qd, Lisinopril 20 mg po qd, Metformin 1000mg po BID, Ozempic
A prandial insulin dose is to be added to the patients regimen since the a1c is still above goal even after basal insulin. What guideline and basal dose should be given? what are drug options?
What side effects should be monitored?

A

use AACE guidelines since the patient is under 65–> strict targets

10% of basal = 30(0.10) = 3U
Humalog or Novolog

eat within 15 min of using, monitor FBG,PPG
lipohypertrophy (rotate injections)

81
Q

How do we start basal and bolus at the same time according to AACE (strict) guidelines?

A

0.3-0.5U/kg/d
50% as basal
50% as bolus /3 = per meal

82
Q

How do we add a basal insulin according to ADA (loose) guidelines? Bolus?

A

basal is 0.1-0.2U/kg/day

bolus is 4U/day or 10% of basal at one meal

DM Therapeutics Exam 1 (2 decks)

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