- weight loss - reduce risk of CV events - beta cell protective factor

z_medications (old) Flashcards by Katie Parker

What is the mechanism of action of biguanides?

Increase insulin sensitivity
Decreases liver glucose production
Reduces GI glucose absorption

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What are biguanides?

Metformin
Glucophage
ends in phage

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What is the first line tx for T2DM?

Lifestyle Intervention + Metformin

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What are the benefits of biguanides?

Lower LDL & TG
weight neutral
potentially CA protective
no HYPO
Decrease CVD risk
Affordable

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What meds are approved for peds?

Metformin & liraglutide, have to be 10 years old

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eGFR recs for metformin

Do not initiate <45
STOP <30

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Side effects of metformin

GI: bloating, diarrhea, abdominal pain
B12 deficiency & worsening neuropathy with LT use
Lactic acidosis of prescribed wrong

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how to reduce diarrhea in metformin

XR form
Gradual dose titration

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Sulfonylureas

end in ide
glyburide, glimepiride, glipizide

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Side effects of sulfonylureas

Hypo esp. in reduced kidney/liver function
- weight gain
- does not lower CVD risk
- doesn’t work as well after 5 years

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How do sulfonylureas work

IDE- insulin down easy
secretors
stimulates sustained insulin release
effective at lowering BG

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Meglinitinides
“ide”
how do they work?

stimulate rapid insulin burst
aka secretors
Insulin Down Easier

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Side effects of meglinides

-Cause HYPO
-better for inconsistent meals d/t shorter 1/ 2 life
-weight gain

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SGLT-2 i
ends in __________
how does it work

flozin
increase urination
decreases renal glucose reabsorption

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s/s of SGLTi-2

-Glycosuria- high glucose in urine
- Increase UTIs & candida/yeast infections
- Fournier’s gangrene (genital infection)
- osmotic diuresis –> increased urination, dehydration, hypotension
- Potential for DKA

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benefit of SGLT-2

Good luck for
- reducing CVD risk
- Preserves kidney function

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GLP-1
mechanism of action

tide
imitate GI incretin hormone, GLP-1
Suppress glucagon secretion
increase insulin secretion
delays gastric emptying
reduce appetite
changes tide in gut
INJECTIBLE

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Benefits of GLP-1

weight loss
reduce risk of CV events
beta cell protective factor

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disadvantages of GLP-1

black box warning for thyroid tumor
report s/s of pancreatitis
nausea when starting
$$$$$$$$

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Dpp-4 inhibitors
ends in _________

liptin

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DPP-4 inhibitor mechanism of action

inhibit DPP-4 enzyme that breaks down GI incretin hormone GLP-1
- extend duration of GLIP-1
- first hits your lips then your gut

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s/s of dpp-4 i

DISABLING joint pain- tell MD immediately
headache/flu like s/s
increase risk of HF
increase risk of pancreatitis

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benefit of dpp4-i

no weight gain
no hypo

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TZD
ends in ________
mechanism of action

end in zone
increase insulin sensitivity
puts your cells in the zone

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benefit of TZD

decrease FFA

s/s of TZD

-increase fracture risk esp in elderly -may worsen/cause CHF -monitor for edema/wt gain -does not lower CVD risk

Bolus insulin is ________

fast acting

Name the bolus insulins and their duration

Gary Loves Red Apples Glulisine <5 H Lispro <5 H Regular (human insulin) 5-8 H Aspart 3-5 H

Name the basal insulins and their duration

Nancy Does Good Deeds NPH (human) 12 H Detemir 24 H Glargine 24 H Degludec 42 H

What's recommended if HF or CKD predominates?

1st- SGLT2 i 2nd- GLP-1

IF pt has HF what should be avoided?

TZD NO saxagliptin

When does CKD predominate?

UACR >30 or esp >300 eGFR 30-60

When does HF predominate?

HFrEF (LVEF<45%)

When does ASCVD predominate?

age >55 w/ coronary, carotid, or lower extremity artery stenosis >50%

What's recommended if ASCVD predominates?

1. GLP-1 RA 2. SGLT2i

What insulins have demonstrated CVD safety

Degludec U100 glargine

Which SGLTi2 are most effective?

canagliflozin empagliflozin dapagliflozin

What meds are good if you need to minimize hypo risk?

- Metformin - Dpp-4 - GLP-1 -SGLT2i -TZD

What meds are good if you need to minimize risk of wt gain? or promote wt loss?

- Metformin - GLP-1 RA - SGLT2-I - then DPP-4i

If cost is a major barrier, recommend:

- Metformin - SU - TZD

Which GLP-1 is best?

Semaglutide --> Liraglutide --> dulaglutide --> exenatide --> lixisenatide

What should be considered before insulin in T2DM?

GLP-1 RA

What to do w/ insulin if hypoglycemia occurs?

- try to determine cause - lower dose by 10-20%

In T2DM, how to start basal insulin

10 U/day 0.1-0.2 IU/kg/d

When to start prandial insulin in T2DM

reached basal dose >0.5 IU/kg if A1c is above target but fasting goal is met

How to start prandial insulin in T2DM

- 4 IU/day or 10% of basal at largest meal - if A1c <8%, can lower basal by 4 IU or 10% - titrate by increase dose 1-2 IU or 10-15% twice weekly

If wanting to switch from bed time NPH to 2x/day NPH

- decrease total dose to 80% - 2/3 AM, 1/3 PM

When should insulin be considered in T2DM right away?

- s/s catabolism - A1c >10% - BG >/=300 -T1DM v. T2DM is being ?

T1DM insulin recommendations

- multiple prandial + basal or pump - rapid acting insulin analog to reduce hypo risk - match prandial insulin dose to CHO intake, pre-prandial BG and predicted PA

DCCT of 7% reduce microvascular complications by ____%

What are human insulins

Regular (short acting)- Humulin/novolin R's NPH (intermediate) Humlin N, Novolin N Premix 70/30 (Humulin 70/30 or Novolin 70/30)

Timing T1DM

Basal- longer duration, more consistent plasma concentration Rapid acting quicker onset and peak, shorter duration v. human insulin

proper storage of insulin

- no extreme heat/cold - never in freezer, direct sunlight, glovebox - never expired - open- can be stored at room temp; usually good for 28 days - unopened- in fridge

T1DM insulin recs

50% basal, 50% bolus based on wt in kg 0.4-1 u/kg/day higher during puberty, illness, pregnancy

what does basal insulin do

regulate overnight, fasting BG

what does bolus insulin do

regulate postprandial BG CHO counting can help with this

where to inject insulin

abdomen thigh butt upper arm

how to inject insulin

- rotate sites to avoid lipohypertrophy (accumulation of subq fat) -NOT in muscle - use short needle 4 mm

If someone w/ T1DM used SGLT2 i what could happen?

2-4x increase risk of DKA small improvement in A1c/weight when used with insulin

What is pramlinitide

-only FDA approved oral med for T1DM - reduce A1c by 0-0.3% - reduce wt 1-2 kg

When should pancreas islet transplantation be considered?

- total pancrectomy - renal transplant - recurrent DKA - severe HYPO, ongoing

Why is pancreas islet transplant seldom used?

- need to be on immunosuppressive tx for life - CGM's and closed loop pump-sensor systems are available

Why would pancreas islet transplant even be considered?

can normalize BG reduce microvascular complications

In T2DM, how long should Metformin be used for?

- as long as tolerated, not contraindicated - can be used along w/ insulin

when choosing oral meds for T2DM what should be considered?

- pt preference - risk of hypo - CVD comorbidities - impact on wt - cost - side effects

how often to re-evaluate meds regimen in T2DM

q 3-6 months

When should metformin be started?

At time of T2DM dx

how long is monotherapy effective in T2DM

usually only a few years before additional tx needed

Each new med added to Metformin lowers HgbA1c by?

0.7-1%

Which GLP-1 is available in oral medication form? What's the s/s?

Oral semaglutide robust WL lower risk of hypo increase GI side effects $$$$$$$$$$$$

goal of basal insulin in T2DM

- restrain hepatic GLU production - limit HYPER overnight & b/w meals

How to reduce risk of HYPO overnight w/ T2DM on insulin

Long-acting analog instead of NPH

A person w/ T2DM on insulin may benefit from NPH & regular human insulin when

- relax A1C goal - low rates of HYPO - significant insulin resistance - cost concerns

When to use concentrated insulin in T2DM

- high insulin resistance

U500 is x times more concentrated than U100

5x ]*has a special tiny syringe that MUST be used

a 3 mL pen of U500 has how many units of insulin? how long is it good for?

1,500 units 3 days

a 20 mL vial of U500 has how many units of insulin? good for how long?

10,000 units good for 40 days

What is benefit of GLP-1 over basal insulin in T2DM?

less hypo, less wt gain

combination injectable therapy what is it?

insulin glargine + lixisenatide insulin degludec + liraglutide

what is nasal glucagon who can use it how much does it raise BG

Basquimi age 4+ nasally absorbed 67-73 pt rise

glucagon who is it approved for how much does it raise BG how is it administered what are the types

age 2+ 20-30 pts and it's short lived; need CHO immediately after subq Gvoke pre-filled syrings or Gvoke hypo pen

how to dose glucagon injection

adults and kids 2-12 who are >/=45 kg take 1 mg kids 2-12 <45 kg take 0.5 mg

Glucagon emergency kit approved for what ages how to dose how to administer

all ages adults- 1 mg kids <6 or <25 kg- 0.5 mg kids >/= 6 or >25 kg- 1 mg subq or IM MUST mix the glucagon powder with filled syringe to reconstitute it

How much do Initial meds reduce A1c

O.5-2%

Each new added class of meds has what effect on A1C

0.7-1%