Pharm2 1 T2DM Agents pt1

Question 1

What is LADA? & its pathophysiology?

Answer 1

Type 1.5: latent autoimmune diabetes of adulthood
Beta cell function and insulin resistance(LADA)
prototypical patient is 25-30 year old and is thin.

Question 2

What’s the prototypical patient/frequent mistake made? with LADA?

Answer 2

It’s often dx as T2DM based on their age and not on their symptoms.

Question 3

Which type of DM?: autoimmune, presents at a young age. 6 months-11 year old. They present with weight loss, polyuria, polydipsia, they get an altered mental status

Answer 3

Type 1

Question 4

DKA is the severe result of uncontrolled

Answer 4

Type 1 DM

Question 5

Which type of DM?: obese (central adiposity), polyuria, polydipsia, vision changes, multiple fungal infections, hypertension, dyslipidemia especially hypertrygliceridemia.

Answer 5

Type 2 DM

Question 6

With Gestational Diabetes: women gain lots of weight during pregnancy, develop diabetes, and have ___ birth weight babies.

Answer 6

large birth weight babies

mom had gest dm, but always controlled it

Question 7

How does insulin work?

Answer 7

Insulin is a co-mediator of the Na-K pump to drag glucose across the membrane so it can be utilized. Otherwise glucose sits in serum where it can’t do anything of use.

Question 8

How long does a typical Diabetic patient actually have diabetes before they manifest symptoms?

Answer 8

~10 years

Question 9

Diff btwn DM and Prediabetes

Answer 9

Fasting glucose >126 = Diabetes. 2 separate reading on 2 separate days

Fasting glucose btwn 106-126: Prediabetes.

Question 10

Why is the Oral glucose tolerance test done less often than Fasting glucose or HbA1C?

What’s an upside of doing this test though?

Answer 10

bc it’s time consuming, despite being more sensitive.

Question 11

HbA1C is a ____ hemoglobin.

What does it really measure?

Answer 11

glycosylated hemoglobin
Glucose in bloodstream over 3 months. The higher your blood sugar levels, the more hemoglobin you’ll have with sugar attached (mayoclinic).

Question 12

HbA1C > __: Diabetes

HbA1C > __: Prediabetes

Answer 12

DM: >6.5
PreDM: 5.7-6.4

Question 13

How to dx DM with Random Glucose test

Answer 13

> 200 + DM symptoms

Question 14

PreDM, from a physiologic standpoint:

Answer 14

they lose some of the ability to drag the sugar across membranes after they eat – higher postprandial glucose levels.

Question 15

T2DM Oral Medications

Seven classes of oral agents, one SQ class, all FDA-approved for T2DM:

Answer 15

Biguanides PO
Thiazolidinediones (TZDs) PO
Sulfonylureas PO (SUs)
DPP-4 inhibitors PO
Meglitinides PO (rarely, if ever, used)
Incretin-mimetics SQ
SGLT-2s: (brand new class of drugs)

Question 16

2 classes of Insulin sensitizers & their Route of Admin.

How do they work? (don’t over-think this)

Answer 16

Biguanides PO
Thiazolidinediones (TZDs) PO
make individual cells more sensitive to insulin…

Question 17

4 classes of Insulin secreatogues & their route of admin

How do they work?

Answer 17

Sulfonylureas PO (SUs)
DPP-4 inhibitors PO
Meglitinides PO (rarely, if ever, used)
Incretin-mimetics SQ

squeezes insulin out of your pancreas

Question 18

__: the oldest class of diabetic medication, since the 1950’s.

Answer 18

Sulfonylureas

Question 19

Both guidelines discussed in class say start with ___ unless it is CI

Answer 19

Metformin

Question 20

Metformin’s dual mechanism of action

Answer 20

sensitizes the body to insulin. Reduces Glucagon from causing gluconeogenesis in the liver.

Question 21

the most commonly prescribed and first-line therapy for type 2 diabetes

Answer 21

Biguanides (Metformin)

Question 22

Metformin takes how long to have its full effect?

Answer 22

Work slowly (~ 4 weeks) – full effect

Question 23

Can Biguanides may cause hypoglycemia. Why?

Answer 23

No (almost), Can aide in weight loss, lower cholesterol
B/c it does not promote insulin secretion. Hypoglycemia may only occur if caloric intake is not adequate or exercise is not compensated for calorically.

Question 24

____ is the only currently available biguanide:

Answer 24

Metformin

Question 25

Treat aggressively or nonagressively for each of these types of patients?

1. Diabetics with few comordibities, and no documented coronary artery disease.
2. Longstanding diabetic with a longstanding sugar burden and has proven CVD

Answer 25

1. be aggressive with pushing glucose down.

2. be more careful about pushing sugars down

Question 26

When do Diabetics test their sugar levels throughout the day (finger-sticks)?

Answer 26

(fasting plasma glucose) - when they first get up in the morning
(postprandial glucose) - 2 hours after largest meal of day, usually dinner

Question 27

Why must you be careful about pushing sugars down with a self-testing DM patient with longstanding sugar burnden and proven CVD?

Answer 27

self testing does not tell the whole story.
High fat content meals will be absorbed more slowly, and the sugar will take more than 2 hours for these glucose levels to peak. Low fat meals can be absorbed sooner than 2 hours.

Question 28

Hypoglycemia: glucose level __

Answer 28

< 70

Question 29

More accurate way to monitor glucose levels than a finger-stick? About how much do they cost?

Answer 29

Continuous glucose monitors (CGM) – using plastic catheter inserted into interstitium. Measures interstitial glucose. These pumps cost $8000.

Question 30

Formulations Biguanides exist as (3)

Answer 30

BID (2/day) formulation - Glucophage®
Long-acting QD (1/day ) - Glucophage XR®
It also come in combination with tons of other PO drugs.

Question 31

Metformin – Glucophage®
FDA-approved ≥__YOA as adjunct to D&E as monotherapy or combination therapy in T2DM (and other conditions such as PCOS)
Timing: Swallow whole; take with meal
Dosing: titrate up - Initially 500 mg BID -max 2,000 mg QD (1 week intervals)

Answer 31

10 years old

Question 32

Why must you titrate up Metformin?

Answer 32

B/c of its GI side effects & nausea. Titration hopefully avoids this.

Question 33

Cautions for Metformin (3)

Answer 33

renal disease or dysfunction, metabolic acidosis, concomitant IV contrast agents - dye (hold metformin during and for 48 hours after contrast use) – hydrate before, during and afterwards – CT scans

Question 34

Metformin - what level is monitored?

When do you cutoff for each gender?

Answer 34

Creatinine cutoff for men:1.5; women: 1.4

Question 35

If a woman becomes pregnant on Metformin, or any other T2DM drug. What do you do?

Answer 35

Switch to insulin.

Question 36

2 side fx or Metformin

Answer 36

GI disturbances (diarrhea, dyspepsia)
Lactic acidosis (half of all cases are fatal)

Question 37

Metformin’s Efficacy in lowering HbA1C

Answer 37

Lowers HbA1C ~2.0.

actual range: 1.1 – 3.0