z_medications (old) Flashcards
What is the mechanism of action of biguanides?
Increase insulin sensitivity
Decreases liver glucose production
Reduces GI glucose absorption
What are biguanides?
Metformin
Glucophage
ends in phage
What is the first line tx for T2DM?
Lifestyle Intervention + Metformin
What are the benefits of biguanides?
- Lower LDL & TG
- weight neutral
- potentially CA protective
- no HYPO
- Decrease CVD risk
- Affordable
What meds are approved for peds?
Metformin & liraglutide, have to be 10 years old
eGFR recs for metformin
Do not initiate <45
STOP <30
Side effects of metformin
- GI: bloating, diarrhea, abdominal pain
- B12 deficiency & worsening neuropathy with LT use
- Lactic acidosis of prescribed wrong
how to reduce diarrhea in metformin
- XR form
- Gradual dose titration
Sulfonylureas
end in ide
glyburide, glimepiride, glipizide
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
How do sulfonylureas work
- IDE- insulin down easy
- secretors
- stimulates sustained insulin release
- effective at lowering BG
Meglinitinides
“ide”
how do they work?
stimulate rapid insulin burst
aka secretors
Insulin Down Easier
Side effects of meglinides
-Cause HYPO
-better for inconsistent meals d/t shorter 1/ 2 life
-weight gain
SGLT-2 i
ends in __________
how does it work
flozin
increase urination
decreases renal glucose reabsorption
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
benefit of SGLT-2
Good luck for
- reducing CVD risk
- Preserves kidney function
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
Benefits of GLP-1
- weight loss
- reduce risk of CV events
- beta cell protective factor
disadvantages of GLP-1
- black box warning for thyroid tumor
- report s/s of pancreatitis
- nausea when starting
- $$$$$$$$
Dpp-4 inhibitors
ends in _________
liptin
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
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
benefit of dpp4-i
no weight gain
no hypo
TZD
ends in ________
mechanism of action
end in zone
increase insulin sensitivity
puts your cells in the zone
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?
- GLP-1 RA
- 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 ____%
50
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%
