Diabetes Flashcards
(211 cards)
1
Q
Alpha cells make_____
A
glucagon
2
Q
Beta cells make _____
A
insulin
3
Q
Delta cells make ______
A
somatostatin
4
Q
Epsilon cells make _______
A
ghrelin
5
Q
Diabetes mellitus is____
A
lack of insulin
6
Q
Type I DM
A
-insulin dependent
Cause by: autoimmune mediated that can be triggered by virus or other toxic process in the environment
-In Type I DM—because there is no beta cell function—there is no basal insulin secreted nor is there a prandial [food related] response
TREATMENT: exogenous insulin
7
Q
Type II DM
A
-Lack of sensitivity of target organs to insulin
-Pancreas has some beta cell function intact [at least—early on in the
disease process], but the secretion and action is not sufficient to keep
blood sugar normal
-Obese states contribute to the insulin resistance
8
Q
Pathogenesis of type II diabetes
A
- Decreased insulin secretion
- Ineffective glucose uptake [skeletal muscle]
- Increased hepatic glucose production
- Decreased incretin effect
- Increased free fatty acid production
- Neurotransmitter dysfunction
- Increased glucose reabsorption
- Diminished beta cell response (insulin deficiency)
- Increased stimulus needed for beta cell function (insulin resistance)
- Decreased muscle uptake of glucose
- Impaired insulin secretion
- Increased hepatic glucose production
all of the above lead to hyperglycemia
9
Q
Pancreas produces which peptide hormones
A
insulin
glucagon
somatostatin
10
Q
4 categories of diabetes
A
- type 1
- type 2
- gestational
- diabetes d/t other causes
11
Q
What can can type 2 cause
A
- Postprandial hyperglycemia
- Hyperinsulinemia from slow release
of insulin - Impaired insulin secretion—glucose
toxicity can occur - Increased hepatic glucose
production - Insensitivity to insulin in tissues
[hallmark of this disease]
12
Q
Insulin resistance-causes and associated conditions
A
- aging
- obesity
- medications
- rare d/o
- genetics
- type 2 dm
- htn
- dyslipidemia
- atherosclerosis
- PCOS
13
Q
Other Defects Do Occur—β
Cells vs. Tissue Receptors
A
- β cells in pancreas sense glucose levels→ leads to the production and release of insulin
- Receptors in tissue are part of auto-regulationsystem located in all organs
- Insulin on the receptors allow glucose transport into cells for utilization
- Defects in the receptors or defects in receptor response to insulin can lead to tissue insensitivity to insulin and increased glucose levels
14
Q
Type I DM
A
- usually during childhood and puberty
- commonly undernourished
- moderate genetic predisposition
- beta cells are destroyed, eliminating the production of insulin
15
Q
TYPE II DM
A
- commonly over age 35
- obesity usually present
- strong genetic predisposition
- inability of beta cells to produce appropriate quantities of insulin; insulin resistance; other defects
16
Q
What medications are not 1st line for gestational DM bc they cross the placenta?
A
metformin and glyburide
17
Q
Other less common type of diabetes
A
Diabetes related to disease of the exocrine pancreas—cystic fibrosis Diabetes from other endocrine dysfunction—Cushing syndrome, acromegaly, chromocytoma Drug induced diabetes—high dose corticosteroids
18
Q
Causes of type II DM
A
-Lack of sensitivity of target organs to insulin
-Pancreas has some beta cell function intact [at least—early on in the disease process], but the secretion and action is not sufficient to keep
blood sugar normal
-Obese states contribute to the insulin resistance
19
Q
Glucogenesis
A
is a metabolic pathway that results in the generation of glucose from certain non-carbohydrate carbon substrates.
20
Q
Glycolyisis
A
breaks down glucose into two three-carbon compounds and generates energy
21
Q
What happens in insulin resistance?
A
- not enough insulin
- loss of insulin receptors
- loss of insulin receptor function
22
Q
Downstream effects of insulin resistance?
A
- increased fatty acids in blood
- lipolysis for glucose
- decreased protein storage
23
Q
What is lipolysis
A
metabolic process through which triacylglycerols (TAGs) break down via hydrolysis into their constituent molecules: glycerol and free fatty acids (FFAs)
24
Q
DM + HTN + dyslipidemia are risk factors for?
A
ASCVD-atherosclerotic cardiovascular disease
25
What meds work best for DM with heart failure?
SGLTs inhibitors-have a diuretic effect and lower the risk of HF in diabetics who are at risk
26
SGLT inhibitors are?
inhibitors are a class of prescription medicines that are FDA-approved for use with diet and exercise to lower blood sugar in adults with type 2 diabetes.
27
Examples of SGLT2 inihibitors
canagliflozin, dapagliflozin, and empagliflozin
28
Consequences of diabetes and insulin restistance
lower HDL and icnreases LDL and triglycerides
29
LDL levels
50-100
30
HDL levels
>40
31
Triglycerides
<150
32
If a diabetic with ASCVD is on a maximally tolerated statin and LD Is >70 what should you add to their meds
PCSK-9 inhibitor or Ezetimibe to help reduce LDL more
33
Moderate intensity statins
```
Simvastatin 20/40 mg
Pravastatin 40/80 mg
Atorvastatin 10/20 mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Rosuvastatin 5.10 mg
Pitavastatin 1/2/4 mg
```
34
High Intensity Statins
Atorvastatin 40/80 mg
| Rosuvastatin 20/40 mg
35
Risk for ASCVD
- obestiy
- htn
- dyslipidemia
- smoking
- FH of CAD
- CKD
- albuminuria
36
Aspirin in DM with risk of ASCVD
-ADA now recommends that ASA 72-162
mg/day be used for secondary
prevention in diabetics with ASCVD
-ASA can be considered for primary
prevention in diabetics who are at
increased risk of ASCVD
-ASA is not recommended for diabetics
with low ASCVD risk—diabetics less than
age 50 and have no other ASCVD risk
factors are considered low risk
37
When should we screen for DM?
All adults >45 should be screened every 3 years—or every 2 years if they have risk factors
All comers—regardless of age who are at risk or are suspected of having DM should be screened
38
Diagnostic Criteria for DM
DIAGNOSIS REQUIRES 2 ABNORMAL TEST RESULTS:
-FPG ≥126 mg/dL ; Fasting is defined as no caloric intake for at least 8 h.*
OR
-2-h PG ≥200 mg/dL during OGTT. The test should be performed as
described by WHO, using a glucose load containing the equivalent of 75 g
anhydrous glucose dissolved in water.*
OR
-A1C ≥6.5% ; The test should be performed in a laboratory using a method
that is certified and standardized to the DCCT assay.*
OR
-In a patient with classic symptoms of hyperglycemia or hyperglycemic
crisis, a random plasma glucose ≥200 mg/dL.
39
What is insulin
polypeptide hormone made of 2 peptide chains connected by disulfide bonds. Synthesized as a prodrug that
undergoes cleavage to form insulin and c-peptide—both of which are secreted by the Beta cells of the pancreas
40
What triggers insulin secretion
increased blood sugar
41
MOA of insulin
- Exogenous insulin is given to replace
absent insulin in Type I Diabetes Mellitus
- Exogenous insulin is given to supplement
insulin secretion in Type II Diabetes Mellitus
42
ADE of insulin
Low blood sugar
Weight gain
Local injection site reactions, lipodystrophy
Bronchospasm can occur with inhaled insulin—those with COPD and smokers should not use this form of insulin
43
Meal insulin bolus
is determined by the amount of CHO to be
ingested; this amount is divided by the insulin-to-CHO ratio [the number of grams of CHO that 1 unit of insulin covers]—this ratio is individualized and will vary from
patient to patient
44
Correction insulin bolus
is used to quickly reduce BS back to
| normal; the dose is determined by the sensitivity factor [the amount the BS will decrease with 1 unit of insulin]
45
Goal of cholesterol in DM
lower LDL by 50%
46
Basal Insulin
- This is the steady background insulin that controls BS in the fasting state [overnight and in between meals]
- Basal insulin enables stored fat and glucose to be released in appropriate amounts to sustain metabolism during time when fuel is not being consumed and metabolized
47
What does insulin promote
fat storage and amino acid conversion to
proteins; promotes transport and storage of
glucose as triglyceride into fat cells
48
What does insulin lower?
Lowers serum blood sugar by enhancing transport of glucose into tissues; inhibits release of fatty acids
into blood
49
Normal action of insulin
Increases nitric oxide [NO] production in blood vessels
Acts as a vasodilator; inhibits platelet aggregation
A person with normal insulin sensitivity—insulin can be considered
antiatherogenic
50
What can decrease GLUT 1-5 transporter affinity for insulin
Corticosteroids, obesity, chronic high blood glucose
51
Insulin Lispro
RAPID ACTING
| Ex: Ademlog, Humalog, Lyumjev
52
Insulin Aspart
RAPID ACTING
| Ex: NovaLog, Fiasp
53
Insulin Glulisine
RAPID ACTING
| Ex: Apidra
54
Regular Insulin
SHORT ACTING
| Ex: Humulin R u-100, Humulin R u-500, Novolin R
55
Inhaled Insulin
SHORT ACTING
| EX: Afrezza
56
Insulin Aspart
- Given within 15 minutes before or 15 minutes after the person starts eating
- Onset is quick—5-15 minutes; peaks at 60 minutes; effective duration is about 2 hours
- Comes in 10 cc vials and prefilled and cartridge pens [cartridge pens are being phased out]
- Once opened, drug is good for 28 days
57
Insulin Lispro
- Given within 15 minutes before or 15 minutes after the person starts eating
- Onset is quick—15-30 minutes; peaks at 60-90 minutes; effective duration is about 3 hours
- Comes in 10 cc vials and prefilled and cartridge pens [cartridge pens are being phased out]
- Once opened, drug is good for 28 days
58
Insulin Glulisine
- Given within 15 minutes before or 15 minutes after the person starts eating
- Onset is quick—5-30 minutes; peaks at 90-120 minutes; effective duration
is about 3 hours
- Comes in 10 cc vials and prefilled SoloStar pen
- Can be refrigerated or stored at room temperature
- Once opened, drug is good for 28 days
59
Inhaled Insulin—Afrezza
Short-acting human insulin powder for inhalation
Can be used in both types of DM [in those >18 years]—use with basal in the Type I diabetic
Insulin is delivered in microparticles; absorbed & eliminated more rapidly
Provides higher insulin levels with peak effects in about 2 hours
4-, 8- and 12-unit single use cartridges
Dosed beginning with largest meal
Interactions and side effects—same as regular insulin
Can affect lung function—contraindicated in COPD [risk acute bronchospasm]
Patient must have baseline PFTs, then repeated every 6- 12 months
Should not be used in smokers or in those with severe asthma
60
Regular Insulin
- Short acting soluble crystalline zinc
insulin
- Both forms will begin to work in 30
minutes, but peak in 2-3 hours, and
duration of action is 6-12 hours—it
hangs around a long time...
- Humulin R is made from nonpathogenic
E. coli and is zinc-insulin crystals
dissolved in a clear fluid—it is available
in U100 and U500 concentrations
- expires 31 days after opened
61
Intermediate Acting Insulin
Only one formulation available in US
Formed by adding zinc and protamine to regular insulin
Used for basal in Type I or Type II diabetes—is usually given with rapid or short acting insulin to cover mealtime—it can only be given SQ—and it should never be used when rapid BS lowering in needed
62
Neutral Protamine Hagedorn [NPH]
- Manufactured as Novolin N or Humulin N
- Both are zinc suspension that includes
protamine
- Both come in U100 concentrations and are
cloudy suspensions
- NPH is made from noninfectious E. coli
- Comes in 10 cc vials and prefilled pens
- Onset of action—2 hours; peaks in 5-6 hours and duration of action is 12 hours
- should be room temp before injecting
- can be mixed with aspart, lispro, and glulisine
63
Long Acting insulin
Long-acting insulins are used for basal control and should only be given SQ—and they should not be mixed with any other insulin
Lantus is the prototype in the class
64
Insulin Glargine
LONG ACTING
| EX: Basaglar, Lantus, ZSemglee, Toujeo
65
Insulin Detemir
LONG ACTING
| EX: Levemir
66
Insulin Degludec
ULTRA LONG ACTING
| EX: Triseba
67
Insulin Glargine
- The isoelectric point of insulin glargine is lower than that of human insulin leading to a formation of a precipitate at the injection stie that releases the insulin over an extended time—it has a slower onset than NPH, and a flat prolonged blood sugar lowering effect with no peak
- Available in 10 cc U100 vials and Solostar pen
- Onset of action in 2-3 hours; duration of near 24 hours
- No difference in absorption regardless of site used
68
How to initiate Insulin Glargine-Lantus
```
Adding to oral agents—start 10 units
evening dose—14 hours before first
meal of the day
Converting from once daily NPH—
Insulin glargine dose remains the same
Converting from BID NPH to glargine—
take total NPH dose & decrease by
20% for starting dose
*****↑Glargine until fasting glucose target
of 100 mg/dL reached; then stop—that
is the maximum dose
```
69
Insulin GLargine U300 (Toujeo)
- Brand name Toujeo—duration is >24 hours
- Once a day at the same time—may take up to 5 days before maximum effect is seen
- When switching from Lantus—it is a 1:1 unit conversion
Comes in 1.5 and 3 cc SoloStar pens-
70
Insulin Detemir
- This insulin has a fatty acid chain that enhances association to albumin—slow dissociation from albumin results in long-
acting properties, much like that of insulin glargine
- Used as basal insulin in both Type I and Type II diabetics
- Onset of action is 3-8 hours, no peak, and duration of 6-23 hours [depends on the dose]—usually given as a BID insulin
71
Insulin Degludec
Ultra long-acting insulin
Brand name is Tresiba
Duration of action is 42 hours; given SQ once per day any time of the day
Comes in U100 vial and FlexTouch pen; also comes in U200 FlexTouch pen
When converting from glargine or detemir—it is a 1:1 unit conversion—however, Triseba is about 70% as potent—so expect
to have to increase the dose over the first few weeks by 30%
72
Side effects of long acting insulin
```
The greatest risk is low BS—s/sx include
headache, anxiety, tachycardia,
confusion, vertigo, sweating,
shakiness, increased appetite, blurred
vision, weakness/fatigue
```
73
RAPID ACTING: LISPRO (HUMOLOG)
ONSET: 5-15 MIN
PEAK:30-90 MIN
DURATION:2-4 HR
74
RAPID ACTING: ASPART (NOVOLOG)
ONSET: 5-15 MI
PEAK: 1-3 HRS
DURATION: 3-4 HRS
75
RAPID ACTING: GLUILISINE (APIDRA)
ONSET: 5-15 MIN
PEAK: 30-90 MIN
DURATION: 3-4 HRS
76
SHORT: REGULAR
ONSET: 30-60 MIM
PEAK: 2-4 HRS
DURATION:6-12 HRS
77
INTERMEDIATE INSULIN: NPH
ONSET: 2-4 HRS
PEAK: 6-10 HRS
DURATION:10-16 HRS
78
LONG ACTING: GLARGINE (LANTUS)
ONSET: 2 HR
PEAK: NO PEAK
DURATION: 20-24 HR
79
LONG ACTING: DETEMIR (LEVEMIR)
ONSET: 1 HR
PEAK: NO PEAK
DURATION:6-24 HR
80
INSULIN MIXES:
70/30 (NPH + REGULAR)
HUMULIN + NOVILIN
ONSET: 30-60 MIN
PEAK: 3-8 HR
DURATION: 10-18 HR
81
INSULIN MIXES:
| HUMILIN 50/50 (NPH + REGULAR)
ONSET: 30 MIN
PEAK: 3-5 HR
DURATION: 10-18 HR
82
INSULIN MIXES:
| HUMALOG 50/50 (NPH-LIKE +LISPRO)
ONSET: 15 MI
PEAK: 2-4 HR
DURATION:10-16 HR
83
INSULIN MIXES:
HUMALOG 75/25
(NPH-LIKE + LISPRO)
ONSET: 15 MIN
PEAK: 2-4 HR
DURATION: 10-16
84
INSULIN MIXES:
| NOVOLOG 70/30
ONSET: 15 MIN
PEAK: 2-4 HR
DURATION: 10-16 HR
85
standard insulin treatment
injections twice a day
86
intensive insulin treatment
3 or more injections per day
- But those on intensive therapy have less
retinopathy, nephropathy and neuropathy
- But intensive therapy is not for everyone—
those with long-standing disease, those with
significant microvascular complications,
those with advanced age and those with
hypoglycemic unawareness should not be
on intensive treatment regimens
87
Starting dose of insulin for adults
0.6U/kg/day for adults
88
Starting dose of insulin for children
0.25-0.5 U/kg/day
89
2 units of insulin covers how many grams of CHO
40
90
Guide to Type I DM dosing
Determine total insulin needed for the day
Long-acting Lantus®™or Levemir®™
Use 50% of total insulin dose at bedtime
Taken regardless of meals
Regular, Aspart , Lispro or Glulisine
-50% of total insulin dose is divided by 3 for pre-meal bolus
- Omit bolus if meal not taken
91
Guide to Type II DM dosing
Basal insulin with oral agents
- When starting Lantus or Levemir START with 10 units or 0.2 unit/kg at supper or bedtime; increase by 2-4 units every 3-5 days to achieve fasting glucose of 100-120
[DO NOT dose the long-acting insulin to have a fasting morning glucose <100 mg/dL]
- Start NPH 10 units at supper or bedtime; increase by 1- 2 units every 3-5 days to achieve fasting glucose goal
92
Guide to Type II DM Dosing—if using Split/Mixed Regimens
Premixed insulin
- Start 70/30 at supper or NPH/Regular at supper especially if glucose high at bedtime and fasting
- Increase dose by 10-20% every 3-5 days to
achieve glucose goal, or
- Start 70/30 at breakfast and supper especially if glucose high throughout day and not candidate for oral therapy
93
Guide to Type II DM Specific Dosing if
Prescribing Split/Mixed Regimens:
NPH/Regular before breakfast and dinner—or NPH-like + a fast-acting insulin
Use 0.6 units/kg/day as total insulin dose
2/3 total dose ac breakfast; 1/3 ac supper
Divide each morning and evening dose so that 2/3 is NPH [or NPH-Like] and 1/3 is Regular [or fast acting]
94
How often should you monitor Hbg A1c
baseline and every 3 months
95
Continuous Insulin Delivery—Insulin Pumps
Currently we used Lispro, Aspart or buffered regular [formulated to reduce aggregation—Velosulin®™]Synthetic
96
Synthetic Amylin Analogs
Amylin is a hormone that is co-secreted with insulin from the beta cells after food is eaten
Amylin delays gastric emptying, decreases
postprandial glucagon secretion and improvessatiety—its production is decreased in diabetes
Amylin, GLP-1 and DPP-4 are a group of endocrine hormones referred to an incretins
97
General Considerations—for all
| Incretins
- stimulate glucose dependent insulin secretion
- suppresses inappropriate glucagon secretion
- thought to increase ℬ cell growth and replication
- slows gastric empyting
98
Incretin Hormones—GIP and GLP-1
GLP-1 secreted from L cells in the small intestine
- Stimulated by oral nutrients
- Stimulates insulin secretion
- Suppresses secretion of glucagon
- Slows gastric emptying; reduces food intake & promotes weight loss
➢ In Type 2 diabetes, they lack the glucose lowering response; circulating levels of postprandial GLP-1 are deficient
99
Incretin Hormones- Pramlintide [Symlin]
```
Approved by FDA in 2005, a
synthetic amylin analogue that is
indicated as an add on to
mealtime insulin therapy in those
with Type I or Type II DM
It is given SQ right before meals
When started—the dose of
mealtime insulin should be
decreased by 50% to avoid
severe low BS
```
100
Side effects: Pramlintide [Symlin]
ADEs—nausea, anorexia, vomiting, dizziness, pharyngitis
Avoid in those with gastroparesis or hypoglycemic unawareness
It can potentially cause weight loss—as it slows gastric emptying, and effect that last for about 3 hours after each dose—it reduces the initial postprandial increase
in BS, but does not alter the absorption of CHOs, fats or other nutrients
101
Primary Action of Insulin
Promotes glucose storage and
metabolism
Promotes peripheral glucose uptake
Promotes protein and fat synthesis
102
Primary Action of Amylin
Regulates rate of gastric emptying
Regulates hypersecretion of postprandial glucagon
Promotes reduction of food intake
103
Primary Action of Glucagon
Stimulates breakdown of liver glycogen
Promotes hepatic gluconeogenesis
Promotes hepatic ketogenesis
104
Primary Action of GLP-1 (Glucagon-like peptide)
Stimulate glucose-dependent insulin
secretion
Regulates rate of gastric emptying
Regulates hypersecretion of
postprandial glucagon
Promotes reduction of food intake
Inhibits gastric acid secretion
105
Primary Action of GIP (gastric inhibitory peptide)
Stimulate glucose-dependent insulin
secretion
Inhibits gastric acid secretion
106
GLP-1 Agonists—General Considerations
- Oral intake of glucose causes higher secretion of insulin than what occurs when and equal load of glucose is given IV—this is called the “incretin effect”—and is markedly reduced in Type II DM
- This “incretin effect” occurs because the gut releases incretinm hormones—glucagon-like peptide-1 [GLP-1] and glucosedependent-insulinotropic polypeptide [GIP] in response to a meal
- Incretin hormones are responsible for 60-70% of postprandial insulin
release
Injectable GLP-1 receptor agonists are used to treat Type II DM—and Liraglutide is also approved to reduce the risk of CV events and CV deaths in those with Type II DM
and cardiovascular disease
Exenatide [Byetta]—prototype
107
Examples of GLP- 1 Agonists
Aligulutie (Tanzeum)
Dulaglutide(Trulicity)
Lixisenatie (Adlxin)
108
MOA GLP-1 agonists
These drugs exert their activity by improving glucosedependent insulin secretion, slowing gastric emptying time, reducing food intake as they increase satiety, decrease the postprandial glucagon secretion and promoting beta cell proliferation
Postprandial elevated BS is reduced; weight is reduced; and weight loss occurs
109
Pharmacokinetics GLP-1 agonists
- Most are given SQ as they are polypeptides
Abiglutide, Dulaglutide and Semaglutide are given SQ weekly
- Liraglutide is given SQ once daily
- Lixisenatide is also given SQ daily, but is considered a short acting agent, as is
- Exenatide—which is given SQ twice daily
• Semaglutide comes in a short-acting oral form
- Exenatide does come in an ER form—that is given once weekly
• Exenatide should not be used in those with renal impairment
110
ADEs of GLP-1 Agonists
Nausea, vomiting, diarrhea, constipation [constipation is very common]
Prototype drug has been associated with pancreatitis—so do not prescribe to those who have a history of pancreatitis
In the animal trials, there was an association with thyroid C-cell
cancers, so do not prescribe to those with history of medullary
thyroid cancer or multiple endocrine neoplasia type II
111
Exenatide— Prototype Drug
| GLP 1 agonist
- First GLP-1 analog FDA approved [2005], but not usedas often as some of the newer agents, as the CV data are not as compelling
- Exenatide enhances insulin secretion by pancreatic beta cells, slows gastric emptying, and suppresses glucagon secretion—it binds to and activates GLP-1
receptor, which increases synthesis and secretion of
insulin
112
Exenatide-antidiabetic RX
| GLP 1 agonist
onset: 30 minutes
duration: 10 hrs
SE: n/diarrhea/constipation/dizziness/headache/dyspepsia
DO NOT USE IN RENAL DISEASE, HX PANCREATITIS, USE CAUTION IN THOSE WITH SEVERE GASTROPARESIS
113
Liraglutide-antidiabetic RX
| GLP 1 agonist
- helping the pancreas to release the right amount of insulin when blood sugar levels are high.
- It is a long-acting GLP-1 agonist with the same MOA as Exenatide—branded as Victoza
- Like Exenatide, is causes weight loss—and in high dose [as Saxenda] it is approved as a weight loss agent
- Also thought to improve beta cell function and rejuvenation
- Has FDA labeling—shown to reduce CV events i nadults
Peak 8-12 hrs and 1/2 life is 13 hours
- High dose Liraglutide—3 mg SQ daily is approved for adults and children aged 12 and older for
long-term treatment of obesity in non-diabetics
DO NOT USE IN PREGNANCY
114
Albiglutide (Tanzeum) GLP -1 AGONIST
Another once per week GLP-1— but did not capture a large market share, so production in the US halted—and no longer available here
115
Dulaglutide (Trulicity) GLP 1 agonist
- for DM II
- no for pregnancy
- subQ one a week
116
Lixisenatide (Adlyxn) GLP 1 agonist
- for adults
- do not use with GFR <15
- only agent in family without a BB for medullary thyroid cancer in Men
- subQ after 1st meal of day within 1 hour
117
Semaglutie (Ozempic-injection) (Rybelsus-PO) GLP 1 agonist
--SQ weekly for DM II
- nausea big SE
-caution with those with retinopathy
-When added to Metformin, 14 mg
of oral Semaglutide (oral) lowered A1C
more than did adding a SGLT2
agent
118
Sulfonylureas
Classed as insulin secretagogues, as the promote insulin release from the beta cells of the pancreas
119
Candidate for sulfonylureas
Type II diabetic without severe dyslipidemia
Diabetic of normal weight
Diabetic having elevated BS, in spite of meal planning and exercise
Patient who is willing and able to follow LSM
Has had disease <5 years
Older than age 30
120
MOA of sulfonylureas
- Stimulate insulin release from the beta cells of the pancreas
- May reduce hepatic glucose production and increase peripheral insulin sensitivity
- will lower A1C by about 1%
121
Pharmacokinetics of sulfonylureas
-Given orally, these agents bind to serum
proteins, are metabolized by the liver, and areexcreted in the urine and feces
-Duration of action is from 12-24 hours
122
ADEs of sulfonylureas
- Hypoglycemia and weight gain
- Hyperinsulinemia
- Use with caution in renal and liver disease
-Glipizide or Glimepiride are better
options in older adults and in those with
renal disease
123
First Generation Sulfonylureas
- Tolbutamide is dosed at 500-3000 mg per day in divided doses
- Onset of action is 1 hour; ½ life is 6-8 hours; duration of action is 12-18 hours
- Metabolized in the liver and excreted via the renal system
- Again, difficult to find, as it is not prescribed often in the US
124
Second generation sulfonylureas: GLYBURIDE - prototype
With the regular preparation, start with 2.5-5 mg per day, which can be increased weekly up to 20 mg/day
With the micronized preparation, start with 1.5-3 mg per day, which can be titrated up weekly up to 12 mg/day
Onset of action in 90 minutes, with maximum effect seen in 60 minutes; ½ life is 10 hours [regardless of the preparation]; duration of action is 12-24 hours [micronized] or 16-24 hours [nonmicronized]
Not approved for use in children; it does cross the placenta, so use caution in women of childbearing age
125
Glimepiride-sulfonylureas
-Prescribed in 1-4 mg per day; with a maximum dose of 8 mg per day
=Taken with breakfast [or 1st meal of the day
-Onset of action is 2-3 hours; ½ life is 5-9 hours; maximum effect is seen in 2-6 hours; duration of action is 24 hours
-Can be used in children aged 8 years and older
-Also crosses placenta, so use caution in women of child-bearing age
126
Glipizide -sulfonylureas
Start at 2.5 mg; can be titrated up to 40 mg per day for standard preparation or 20 mg per day of the extended-release preparation
•Standard preparation is prescribed 3 times per day
•ER preparation is taken once per day
Onset of action for both preparations is 3.5-6 hours; maximum effect is obtained within 1 hour; duration of action if 12-24 hours; ½ life is 2-5 hours
Not approved for use in children; does cross the placenta and can affect a fetus
127
SEs of sulfonylureas
- Low blood sugar and weight gain
- Less common ADEs—skin rash, GI disturbances
- Use care when treating malnourished, debilitated and older adults—as these groups are particular risk for hypoglycemia
128
Timing of Sulfonylureas
- Most sulfonylureas should be taken with
breakfast or with the first main meal of the
day to obtain the maximum effect and
safety
- Patients on this type of medication should
carry a rapid-acting glucose source—such
as tablets or gel, in order to swiftly treat
hypoglycemia—at the initial signs of low BS
- Advise these patient regarding safe use of
alcohol—it lowers BS
129
Drugs that my effect sulfonylureas, leading to loss of glucose control
- atypical antipsychotics
- corticosteroids
- diuretics
- niacin
- phenothiazines
- sympathomimetics
130
Drugs that my potentiate the effects of sulfonylureas leading to hypoglycemia
- azole antifungals
- B blockers
- chlorampheimcol
- clarithromycin
- monoamine oxidase inhibitors
- probenecid
- salicylates
- sulfonamides
131
Nonsulfonylurea Secretagogues
It inhibits the amount of glucose produced by the liver, increases the insulin-receptor binding and stimulates tissue uptake of glucose.
132
Candidate for Nonsulfonylurea Secretagogues
a Type II diabetic, for which LSM alone or in combination with another agent has not obtained normoglycemia
**These agents are not for use in Type I diabetes,ketoacidosis, severe infections, surgical or trauma patients
133
MOA of Nonsulfonylurea Secretagogues—
Short-acting insulin secretagogues
Stimulate insulin release rapidly and have a short duration of action
Very effective in the early release of insulin that occurs after a meal—they are known as
postprandial glucose regulators
Should NOT be used with sulfonylureas
134
Pharmacokinetics of Nonsulfonylurea Secretagogues—
Taken prior to a meal; are well metabolized after oral administration
If the patient is not going to consume 70 grams of CHO with the meal—the
drug should be skipped
135
ADEs of Nonsulfonylurea Secretagogues—
Hypoglycemia and weight gain—but to a lesser degree than do sulfonylureas
Do NOT prescribe Gemfibrozil with the agents—can markedly increase their effects
Use with caution in those with
liver disease
136
Repaglinide—Prototype
Nonsulfonylurea Secretagogues
-Closes ATP dependent K+ channels in the beta cell membrane, which
depolarizes the beta cell and leads to opening of calcium channels—
resulting in increased Ca++ influx causing insulin secretion
-Action of this agent is highly tissue selective, with low affinity for heart
and skeletal muscle
-Best results occur when drug is taken within 15-30 minutes of a meal—
leading to greater insulin release during the 1st phase
- Onset of action is 15-60 minutes; ½ life is 1 hour; duration 4 hours
- It is excreted in the feces
- Can be used as monotherapy or with Metformin, TZD or both
137
Nonsulfonylurea Secretagogues-Natelinide
Rapid acting amino-acid derivative known as Dphenylalanine
MOA is similar to the prototype
Like Repaglinide, the extent of insulin release is glucose dependent—and it diminishes with low glucose levels
Rapidly absorbed after oral ingestion—onset is within 20 minutes; ½ life is 90 minutes; duration of action 4 hours
Like the prototype, it is excreted in the feces; can be used alone, with Metformin or TZD or both
- not safe for pregnancy
-SEs:bronchitis, rhinitis, nausea,
vomiting, diarrhea or constipation, headache, chest pain, UTI, back pain, dizziness
138
Nonsulfonylurea Secretagogues
| Biguanides
Considered an insulin sensitizer
Metformin increases glucose uptake and use bytarget tissues, thereby decreasing insulin secretion
Also used in the treatment of PCOS
139
MOA of Biguanides
Reduces hepatic gluconeogenesis—the liver is a major source of high BS in Type II DM, accounting for high fasting BS
Metformin slows intestinal absorption of sugars and improves peripheral glucose uptake and utilization
Weight loss can occur as it causes loss of appetite
The drug does not cause low BS—unless the patient is taking insulin or another secretagogue
140
Pharmacokinetics of Biguanides
Well absorbed after oral ingestion, is not bound toserum proteins, and is not
metabolized
Excreted via the urine
141
ADEs of Biguanides
Mainly GI—diarrhea, nausea, vomiting
These ADEs can be muted by slow titration—and use of the ER version of the drug, which causes far fewer GI SE
Should be taken with food to reduce ADEs
Metallic taste—when initiating
Contraindicated in renal dysfunction—due to risk of lactic acidosis
142
When should you stop Biguanides?
acute MI, exacerbation of HF, sepsis or other d/o that could cause acute RF
143
Use Biguanides in caution with
patients >80 years and those with HF or alcohol use
144
When should you hold Biguanides?
Procedures requiring IV contrast
145
What is long term Biguanides associated with
What is long term Biguanides associated with
146
Biguanides:
| METFORMIN what does it do?
- Preferred 1st line agent in those with Type II DM—it lowers both basal and
postprandial glucoses and improves glucose tolerance
- Metformin inhibits hepatic glucose production and intestinal absorption of
glucose; it also increases peripheral glucose uptake and utilization
- It does not cause elevated insulin levels
- Again, it causes weight loss—and it is associated with a lower risk of CV
events in diabetics with reduced renal function—compared to sulfonylureas
147
Candidates for metformin
The ideal candidate has Type II DM, is obese, has dyslipidemia and has elevated BS
It is approved for adults and children aged 10 and older; it can be used in pregnancy
148
Metformin (Biguanides)
The drug should always be started with the evening meal and titrated upwards—it is most often given in 2 divided doses
Onset of action is within days, but peak effect is within 4 hours
[for both SA and ER formulations]
Duration of action is 6 hours for the SA and 24 hours for the ER
½ life of both formulations is 4-9 hours
Not metabolized by the liver; renal tubular secretion is route of
elimination
149
Metformin Extended Release
This drug—same compound, but with a different release mechanism, that essentially prevents most of the GI side effects
Currently, it is priced the same as the SA
formulation—and is preferred—as it allows for titration up to the 2000 mg per day dosing that is needed for full therapeutic effect
At this dosing—A1C reduction is 1-1.5%
ER product is ALWAYS preferred—it is dosed the same as the SA
product—no difference in efficacy—but unlikely to reach full therapeutic dose with SA formula—as the GI SE are dose dependent and do not abate with duration of use of the SA formula
Will LOWER cholesterol, triglycerides and LDL and causes weight loss in
most
150
With Metformin, watch for...
- Hold for situations that cause dehydration—as this predisposes the patient to lactic acidosis [acute illness, gastroenteritis, NPO for procedures, etc.]
- Hold for 48 hours after radiology testing that utilized iodinated contrast
- This drug is contraindicated in men with creatinine 1.5 mg/dL or greater and women with creatinine of 1.4 mg/dL or more
- Should not be started in those with creatinine clearance <46 cc/min;
and in those on the drug, if the creatinine clearance falls to <30 cc/min, the drug must be stopped
- Calculate eGFR before starting the drug—do not start if this value is between 30-45 cc/minute
- Check creatinine and calculate eGFR annually in all patients on Metformin—more frequently in those at risk, such as the older adult
- In those on the drug—assess the risk/benefit ratio if the eGFR falls below 46 cc/minute to decide upon continuation—but stop when eGFR is 30 cc/minute or less
- At risk patients—those with liver dysfunction; those with a history of alcohol abuse or binge drinking; those with COPD or unstable HF should not receive Metformin due to lactate accumulation in these
hypoxic states
- Lactic acidosis—rare—but deadly
151
Thiazolidinediones
-Pioglitazone—Actos [not really the prototype—but only agent left on
the market in US that is prescribed commonly in the class]
- Rosiglitazone—Avandia [rarely prescribed, and usually only by endo in the US—b/c of increased risk of MI and angina with this agent]
- Drugs in this class are also considered insulin sensitizers
- Insulin is required for their action—TZDs do not promote insulin release
```
These agents do not cause
hypoglycemia
These agents reduce BS, insulin
levels and triglyceride levels
There is increased responsiveness
of insulin-dependent tissues
Can be used as monotherapy or
with Metformin, a SU, a
secretagogue and/or insulin
```
152
MOA of Thiazolidinediones—also known as TZDs
Decrease insulin resistance by acting as an agonist for peroxisome proliferator-activated receptor gamma [PPARγ]—a nuclear receptor
Activating PPARγ causes increased insulin sensitivity in adipose tissues, liver and skeletal muscles
These are 2nd or 3rd line agents that can lower A1C about 1%
153
Pharmacokinetics of Thiazolidinediones—also known as TZDs
Well absorbed after oral administration
Extensively bound to serum albumin
154
ADEs of Thiazolidinediones—also known as TZDs
- Liver toxicity—but rare
- Baseline and periodic management of LFTs is required
- Weight gain—these drugs increase SQ fat
and they cause fluid retention
- Should not be used in those with HF
- Osteopenia and increased fracture in
women
- Increased risk of bladder cancer with Actos
155
Thiazolidinediones : Pioglitazone
- Approved for adults and children >15 years with Type II diabetes; avoid in pregnancy
- Contraindicated in—active liver disease or ALT levels greater than 2.5 times ULN; NYH class III or class IV HF [BB warning]; jaundice; Type I diabetes; DKA
- Onset of action is not known; peak effect is in 2 hours [this is delayed by food]; ½ life is 16-24 hours
- Excreted into the bile unchanged and eliminated in the feces
156
With Pioglitazone watch for...
Weight gain
Increased total cholesterol
Fluid retention; headache; arthralgias; back pain; nausea and diarrhea
Atorvastatin—can decrease effectiveness of both Atorvastatin and Actos
Actos reduces effectiveness of OCP
Ketoconazole inhibits the breakdown of Actos
Change—elevation of LFTs
157
Alpha-Glucosidase Inhibitors
- Acarbose—Precose—prototype
- Miglitol—Glyset
- Ideal candidate for one of these drugs is a Type II diabetic who is obese, has dyslipidemia and postprandial hyperglycemia
- These drugs reduce insulinotropic and weight increasing effects of
SU
158
MOA Alpha-Glucosidase Inhibitors
Located in the brush border of the intestine—alpha-glucosidase enzymes breakdown CHO into glucose and other simple sugars that can be absorbed
- These drugs reversibly inhibit alpha-glucosidase enzymes—thus
delaying the digesting of CHOs leading to lower postprandial BS levels
- Taken at the start of a meal; these drugs do not cause hypoglycemia
[unless used with insulin or a secretagogue—and remember if low BS were to occur in this scenario—must use glucose—NOT sucrose [as its breakdown is inhibited by these drugs]
159
Pharmacokinetics of Alpha-Glucosidase Inhibitors
- Acarbose poorly absorbed—excreted in the urine
- Miglitol is very well absorbed—but no systemic effects—excreted unchanged by the kidney
- In the US, these drugs lower A1C by .5% —while in other countries— where these agents are used more commonly, lower A1C by 1%
160
ADEs of Alpha-Glucosidase Inhibitors
Flatulence, diarrhea, abdominal cramping
These limit the use of these agents in the US
Do not use in those with inflammatory bowel disease, colonic ulceration or intestinal obstruction, cirrhosis, creatine levels of >2 mg
Avoid use in pregnancy or lactation
161
Alpha-Glucosidase Inhibitors --Acarbose
-prototype
Taken right before each meal
Onset of action is immediate; peaks in 1 hour; duration is near 6 hours; ½ life of the drug is 2 hours
162
Alpha-Glucosidase Inhibitors--Miglitol
- take before each meal
| - rapid onset of action; peaks in 2 hours; duration of action is near 4 hours
163
With Alpha-Glucosidase Inhibitors watch for....
Effects of these drugs are altered by
charcoal products
These drugs reduce bioavailability of
Ranitidine, Propranolol and Digoxin
These drugs reduce the efficacy of—
CCBs, corticosteroids, estrogens, INH,
nicotinic acid, Phenytoin [and its
derivatives], thiazides
164
Timing considerations of Alpha-Glucosidase Inhibitors
Must take—essentially, with the first bite of food with each meal
If the patient is on insulin or a SU and one of these agents—and low BS occurs—treat with simple sugar sources—glucose tablets or gels—they should always have these on hand if the patient is on a secretagogue and an alpha-glucosidase inhibitor
165
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
| Inhibitors]—also known as Gliptins
These agents slow the inactivation of incretin hormones
166
Examples of Dipeptidyl Peptidase-4 Inhibitors
Sitagliptin—Januvia [prototype]
Saxagliptin—Onglyza
Linagliptin—Tradjenta
Alogliptin—Nesina
167
MOA Dipeptidyl Peptidase-4 Inhibitors
Well absorbed after oral administration
Alogliptin and Sitagliptin are excreted unchanged in the urine
Linagliptin eliminated by enterohepatic system
Saxagliptin metabolized by CYP450-3A4/5 to an active metabolite; metabolite is excreted renally
All gliptins except Linagliptin [Tradjenta] require dose adjustments for renal disease
168
ADEs of Dipeptidyl Peptidase-4 Inhibitors
Generally, well tolerated
Can cause nasopharyngitis, headache and pancreatitis, severe joint pain
Alogliptin and Saxagliptin have been shown to increase the risk of
HF hospitalizations
Do not use in those with HF or at risk for such; do not use in those with a history of pancreatitis; not to be used in pregnancy or in children
169
Pharmacokinetics of Dipeptidyl Peptidase-4 Inhibitors
Well absorbed after oral administration
Alogliptin and Sitagliptin are excreted unchanged in the urine
Linagliptin eliminated by enterohepatic system
Saxagliptin metabolized by CYP450-3A4/5 to an active metabolite; metabolite is excreted renally
All gliptins except Linagliptin [Tradjenta] require dose adjustments for renal disease
170
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
SITAGLIPTIN (PROTYPE)
Given once per day at 100 mg per day; if eGFR is 30-50 cc/minute, the dose is 50 mg per day; and if eGFR is <30 cc/minute the dose is 25 mg per day
Rapidly absorbed, with peak action in 1-4 hours; duration of action is 24 hours; ½ life is 12 hours
Most common side effects are nasopharyngitis or URI; headache;
abdominal pain; diarrhea or nausea
Severe necrotizing pancreatitis has been reported—this agent is thought to double the risk of developing pancreatitis for all who take it
171
What is Sitagliptin associated with/
- precanerous cellular changes of the pancreas
| - pancreatitis
172
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
Saxagliptin
Dosed as 5 mg per day; 2.5 mg dose is used in those with moderate-severe renal disease
Peaks in 2 hours; duration of action is 24 hours; metabolized hepatically
Common SE and ADEs are the same as the prototype
Latest FDA safety review found that this agent can increase the risk of HF, particularly in those with CV or renal disease
173
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
Linagliptin
Approved by FDA in 2011
If given with a secretagogue, the dose of the secretagogue should be reduced—to prevent low BS
Rapidly absorbed after oral administration—onset of action 90 minutes; duration of action is 24 hours
No dosage change in liver or renal disease
Common SE and ADEs same as prototype
174
Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
Alogliptin
-Approved by FDA in 2013—given once daily
as a 25 mg tablet or 12.5 mg if the patient
has renal disease
- Common SE and ADEs are the same as the
prototype
- In 2016, FDA found that this agent may
increase the risk of HF in diabetics with heart or renal disease
175
Timing considerations of Dipeptidyl Peptidase-4 Inhibitors [DPP-4
Inhibitors]
These agents can be taken any time during the day—regardless of food intake
176
Sodium-Glucose Cotransporter 2
| Inhibitors [SGLT2 Inhibitors]—also known as Flozins
Sodium-Glucose Cotransporter 2
| Inhibitors [SGLT2 Inhibitors]—also known as Flozins
177
Examples of Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Canagliflozin—Invokana [prototype]
Dapagliflozin—Farxiga
Empagliflozin—Jardiance
Ertugliflozin—Steglatro
178
MOA Sodium-Glucose Cotransporter 2
| Inhibitors aka Flozins
By inhibiting SGLT2, these drugs decrease the resorption of glucose, increase urinary glucose excretion and lower BS
Inhibition of SGLT2 also decreases resorption of sodium and causes
osmotic diuresis—in some this will lower blood pressure
Approved for adults; should avoid in pregnancy
Will lower A1C 1%
179
Pharmacokinetics Sodium-Glucose Cotransporter 2 Inhibitors aka Flozins
- Given once daily in the morning
- Canagliflozin should be taken before the first meal of the day
- All are metabolized by glucuronidation to inactive metabolites
- Avoid these drugs in those with renal disease, history of UTIs or at risk
of them [those with renal stones, neurogenic bladder and BPH]
180
ADEs of Sodium-Glucose Cotransporter 2 Inhibitors aka Flozins
Genital mycotic infections, severe UTIs, urinary frequency, low blood pressure in older patients and in those on diuretics, ketoacidosis without elevated BS,
Fournier’s gangrene**, increased risk of LE
amputation*, bone fractures, acute kidney injury, electrolyte abnormalities
**should NOT use this family of drugs in patients who have decreased arterial
flow below the femoral vessels [as assessed by poor or absent pulses]
181
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Canagliflozin—Invokana [prototype]
100 or 300 mg tablets
Take before 1st meal of the day; use 100 mg per day if
eGFR <60 cc/minute
Do not use in eGFR <30 cc/minute; do not use in severe liver disease
Highest risk of LE amputation with this SGLT2 inhibitor
Some beneficial effects for risk reduction of CV events in diabetics with CV disease and progression of renal disease to ESRD
Hold for 3 days before procedures and surgery
182
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Dapagliflozin—Farxiga
10 and 25 mg tablets
Once a day in the AM—with or without food
Do not give if eGFR is <45 cc/minute
Robust data for prevention of hospitalization from HF in those
with risk factors or those with a HF diagnosis—diabetic and nondiabetic
Evaluate volume status before initiating; stop for 3 days before surgery and procedures that could cause
dehydration and alcohol abuse—all of these scenarios predispose the diabetic to ketoacidosis without an elevated
blood sugar
183
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Empagliflozin—Jardiance
- 5 and 10 mg tablets
- Once a day in the AM—with or without food
- Do not give if eGFR is <45 cc/minute
- Strong data for reduced risk of adverse CV events—including death in diabetics with CV
disease
- Evaluate volume status before initiating; stop for 3 days before surgery and proceduresm that could cause dehydration and alcohol abuse—all of these scenarios predispose them diabetic to ketoacidosis without an elevated blood sugar
184
Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—
Ertugliflozin—Steglatro
5 and 15 mg tablets
Once a day in the AM—with or without food
Do not give if eGFR is <60 cc/minute
No specific data for cardiovascular, renal or HF risk reduction for this agent, at this time
Evaluate volume status before initiating; stop for 3 days before surgery and procedures that could cause
dehydration and alcohol abuse—all of these scenarios predispose the diabetic to ketoacidosis without an elevated
blood sugar
185
With Sodium-Glucose Cotransporter 2 Inhibitors [SGLT2 Inhibitors]—watch for..
Elevated potassium
Renal insufficiency [from the diuretic effect]
Ketoacidosis with BS < 250 mg/dL [yes, ketoacidosis in Type II diabetic—which is not something that is seen—and true mechanism is not well understood]
Severe UTIs
Genital yeast infections
186
Bromocriptine—Cycloset
Ergot derivative that stimulates the dopamine receptors—MOA in diabetes is unknown
Start with 0.8 mg each AM with food; increase by 0.8 mg per week [diabetic dose is 1.6 – 4.8 mg per day]
Contraindications—syncope, migraines, pregnancy, lactation, psychosis
Common side effects—GI upset, nausea, headache, orthostatic
hypotension
187
Combination Preparations—General
| Considerations
Ideal patient for combination preparations is being treated with 2 separate families of antidiabetic medications
But combination therapy is not totally risk free—contraindications and ADEs of both agents must be considered
Combination medications are only available in fixed dosages and may not meet the needs of every patient—and sometimes the
combinations are more expensive than the 2 separate agents
188
Sulfyonylureas
1. glimepiride
2. glipizide
3. glyburide
MOA: stimulates insulin secretion
Effect on plasma insulin: increases
Risk of Hypoglycemia: yes
Comments: well established hx of effectiveness. Weight gain can occur. Hypoglycemia most common with this class of oral agents
189
GLINIDES
1. Nateglinide
2. Repaglinide
MOA: stimulates insulin secretion
Effect on Plasma Insulin: increase
Risk of Hypoglycemia: yes (rare)
Comments: taken with meals. short action with less hypoglycemia. postprandial effect.
190
BIGUANIDES
| 1. Metformin
MOA: decrease hepatic production of glucose
Effect on Plasma Insulin: decrease
Risk of Hypoglycemia: no
Comments: preferred agent for type 2 DM. well est. hx of effectivness. weight loss my occur. Monitor renal function and Vit B12 levels.
191
THIAZOLIDNESDIONES
1. Pioglitazone
2. Rosiglitazone
MOA: binds to peroxisome proliferator-activated receptor in muscle, fat, and liver to decrease insulin resistance
Effect on Plasma Insulin: decrease
Risk of Hypoglycemia: no
Comments: Effective i highly insulin-resistant patients. Once daily dosing for pioglitazone. Check liver function before initiation. Avoid in liver disease or heart failure.
192
⍺ Glucosidase Inhibitors
1. Acarbose
2. Miglitol
MOA: decease glucose absorption
Effect on Plasma Insulin: same
Risk of Hypoglycemia: No
Comments: taken with meals. Adverse gastrointestinal effects. Not a preferred therapy. .Reserve for pts unablet o tolerate other agents.
193
```
DPP 4 inhibitors
1 . Alogliptin
2. Linagliptin
3. Sitagliptin
4. Saxaogliptin
```
MOA: increase glucose dependent insulin insulin release; decrease secretion of glucagon
Effect on Plasma Insulin: increase
Risk of Hypoglycemia: no
Comments: once daily dosing. may be taken with or without food. Well tolerated. Risk of pancreatitis.
194
SGLT2 inhibitors
1. Canagliflozin
2. Dapagliflozin
3. Dmpagliflozin
4. Ertugliflozin
MOA: increase urinary glucose secretion
Effect on Plasma Insulin: same
Risk of Hypoglycemia: no
Comments: once daily dosing in the morning. Risk of hypotension, genitourinary infections. Avoid in severe renal impairment. Empagliflozin is approved to reduce cardiovascular evens in pts with DM II
195
GLP-1 receptor agonist
1. Albiglutide
2. Dulaglutide
3. Exenatide
4. Liraglutide
5. Lixisenatide
6. Semaglutide
MOA: increase glucose-dependent insulin release; decrease secretion of glucagon; slows gastric emptying; increase satiety
Effect on Plasma Insulin: increase
Risk of Hypoglycemia: no
Comments: Injection formulation. Liraglutide and Lixisenatide are dose once daily. Albiglutide, dulaglutide, and semaglutdie are dosed once weekly.
Liraglutide is approved to reduce cardiovascular events in pts with DM II
Weight loss my occur. Risk of pancreatitis.
Contraindicated in pts with hx of medullary thyroid carcinoma
196
Advantage and Disadvantage of
| METFORMIN
```
AD:
Weight neutral
No hypoglycemia
Improve lipids
Dec micro-macro risks
Dec hyperinsulinemia
```
```
DISAD:
Number of
contraindications
Adverse GI effects
Rarely, lactic acidosis
B12 deficiency
```
197
Advantage and Disadvantage SULFONYLUREAS
AD:
Convenient dosing
Inexpensive
Well-established efficacy
DISAD:
Hypoglycemia
Weight gain
198
Advantage and Disadvantage
| TZDs
```
AD:
No hypoglycemia
Improved lipids
Improved endothelial function
Increased fibrinolysis
Convenient dosing
```
```
DISAD:
Inc risk for CHF
Edema
Weight gain
Liver function monitoring
Other adverse effects
```
199
Advantage and Disadvantage
| GLINIDES
```
AD:
Short duration of action
Low incidence of
hypoglycemia
Less wt gain than SUs
```
DISAD:
Frequent dosing
Expensive
200
Advantage and Disadvantage
| ALPHA GLUCOSIDASE INHIBITORS
```
AD:
No weight gain
Targets PP glycemia
No hypoglycemia
Nonsystemic
```
DISAD:
Frequent GI adverse effects
Frequent dosing
Expensive
201
Advantage and Disadvantage
| DPP-4 INHIBITORS
AD:
Low rate of Adv effects
Convenient dosing
No weight gain
DISAD:
Minimal reduction in A1C
Pancreatitis risk
Expensive
202
Advantage and Disadvantage
| GLP-1 AGONIST
AD:
Weight loss
```
DISAD:
Injections
Slight risk of pancreatitis
GI adverse effects
Expensive
```
203
Herbs that can lower CBG
Aloe Vera, Ginseng, Ginger, Turmeric
Bilberry, Cinnamon Bark, Milk Thistle
Kudzu, Blond Psyllium
204
Herbs that can increase CBG
Ma Huang
Licorice
Rosemary
205
Cautions with these herbs:
```
Garlic
Ginger
Ginseng
Hawthorn
Ma Huang
Nettle
Licorice
Rosemary
Saw Palmetto
Valerian
Tea Tree Oil
Primrose
Turmeric
Stevia
```
206
• If ASCVD predominates—
reach for a GLP-1 agonist; best evidence is for Liraglutide, Semaglutide or ER Exenatide [in order of strongest to weakest
evidence]
207
• If HF or chronic kidney disease predominates
reach for SGLT2 inhibitor; best evidence is for Dapagliflozin, Empagliflozin or Canagliflozin [in order of strongest to weakest]
208
General considerations for prescribing antidiabetic meds
- If the patient does not have established ASCVD, HF or renal disease, the
recommendations are driven by factors such as weight gain, risk of low BS or cost
- If hypoglycemia prevention is the most compelling concern—then add a
GLP-1 agonist, or an SGLT2 inhibitor, a TZD or a DPP-4 inhibitor
- If you need the patient to lose weight—then go to the GLP-1 agonist,
followed by a SGLT2 inhibitor—as both of these cause weight loss
- If cost is a large issue—then the next agent to add is
a SU or a TZD
209
Insulin Therapy Updates—Consider GLP-1
| Agonists before Insulin in Type II Diabetes
Most recent diabetic standards recommend that most patients with Type II diabetes who continue tohave elevated A1C in spite treatment with 2 or 3 drugs—should receive a GLP-1 agonist BEFORE insulin
GLP-1s are as good or better than insulin at lowering A1C, they cause weight loss and do not cause low BS
Insulin, of course, is still used without a trial of a GLP-1 agonist in Type I diabetes and in the Type II diabetics with A1C values >11%
Insulin can also be used in Type II diabetes already on a GLP-1 who are still not controlled [insulin is added]; those
who cannot take a GLP-1 and for those who prefer insulin over a GLP-1
210
Geriatric considerations-less is more
The latest diabetes guidelines also recommend a deintensification [or simplification] of therapy in those older than
65 years
Recent evidence revealed that patients >50 years with an A1C less than 9% while on Metformin gained only modest benefits
from intensifying treatment [adding insulin]—while the patient’s perception of treatment burden has a large impact on the net
benefit of therapy
In those >75 years, the increased treatment
burden—including an increased risk of low BS—of more intensive therapy resulted in a net effect of harm rather than benefit.
Given the risk of low BS and the medication burden that older adults may have, the ADA now provides formal guidance on deintensifying therapy
211
Risks for ASCVD:
```
Obesity
HTN
dyslipidemia
soking
FH of CAD
CKD
Albuminuria
```
