Flashcards in 04 Thera VI T2DM Oral Therapies Diane Deck (103)
What is the pathophysiology of the pancreas in T2DM?
Impaired insulin secretion. Progressive loss of beta cell function
What is the pathophysiology of the liver in T2DM?
Impaired insulin sensitivity. Increased gluconeogenesis (glucose production)
What is the pathophysiology of the muscle and adipose tissue in T2DM?
Insulin resistance. Decreased glucose uptake
What is the pathophysiology of the GI tract in T2DM?
Site of glucose absorption. Decreased prandial response to glucose and incretin effect
What are the ADA adult glycemic goals?
A1c < 7%. FPG 70-130. 2hr PP < 180
What are the AACE adult glycemic goals?
A1c < 6.5%. FPG < 110. 2hr PP < 140
What drugs are Biguanides?
What is the MOA of Metformin?
Activates AMP-kinase: Decreases hepatic glucose production, decreases GI glucose absorption, improves peripheral glucose sensitivity
What is the A1c efficacy of Metformin?
Decreases it by 1-2%
What is the positive side of using Metformin?
NO weight gain or hypoglycemia associated. Can also improve the lipid panel (Decrease TG and LDL)
What is the Onset time of Metformin?
Days, max effect up to 2 weeks
How is Metformin metabolized/excreted?
No hepatic metabolism. 100% renally excreted
How is Metformin dosed?
Initial: 500mg BID or 850mg daily. Max: 2550mg/day (no added benefit > 2g/day)
How is Metformin ER dosed?
Initial: 500mg/day. Max 2000mg/day
What needs to be remembered about the administration of Metformin?
TAKE WITH FOOD. Titrate slowly
What are the common ADRs associated with Metformin?
GI effects: N/V/D, flatulence, abdominal discomfort (these are less with ER)
What are the counseling points with Metformin?
Recommend patients to take with food to decrease GI side effects. The side effects are transient, will improve over time
What is a rare side effect of Metformin (BBW)?
Lactic Acidosis. Risk increases with renal impairment and hypoxemia. Labs will show an increase in lactate (>5mmol), decreased blood pH, and electrolyte abnormalities (increase in anion gap)
What are the symptoms of Lactic Acidosis?
Very non-specific (need labs to prove it). N/V/D, hyperventilation, malaise, lethargy, myalgias
What are the contraindications associated with Metformin?
Hypersensitivity. Renal dysfunction (Scr > 1.5 for men and > 1.4 for women). Acute or chronic metabolic acidosis. Radiological studies with iodinated contrast (hold 48 hours prior to and after procedure)
What should you use caution with Metformin?
Chronic hepatic dysfunction (reduced lactate clearance). Hypoxic states (excessive alcohol, CHF, surgery)
What are the indications for Sulfonylureas?
Considered second-line to be added on to metformin and combination with insulin or other oral agents (except meglitinides). Can be used first-line in patients who cannot tolerate metformin
What are the main Sulfonylureas used?
Glimeperide (Amaryl). Glipizide (Glucotrol). Glyburide (DiaBeta, Micronase, Glynase)
What is the MOA of Sulfonylureas?
Binds ATP-dependent K channels --> depolarization of B-cells --> Ca influx --> increase insulin release. Partially reverses insulin secretory defect associated with T2DM
What is a drawback to Sulfonylurea use?
Effectiveness will decline over time
How much do Sulfonylureas decrease A1c?
1-2%. All agents equally effective
How are Sulfonylureas metabolized and eliminated?
Metabolism: Hepatic. Elimination: Renal (urine), feces
Which Sulfonylurea has the fastest onset?
Glyburide (1h). Glipizide (1-3h). Glimepiride (2-3h)
Which Sulfonylurea has the shortest duration of action?
Glipizide (10-14h). Glyburide (12-24). Glimepiride (24h)