Diabetes

Question 1

Drugs used to treat diabetes

Answer 1

○ Biguanides/Metformin
○ Sulfonylureas
○ Thiazolidinediones (TZDs)
○ Dipeptidyl peptidase-4 (DDP-4) inhibitors
○ Glucagon-like peptide-1 (GLP-1) agonist
○ Sodium-glucose cotransporter-2 (SLGT-2) inhibitors
○ Insulin

Question 2

Biguanides example

Answer 2

Agents: Metformin (Glucophage™)
○ Immediate Release Formulation
○ Extended Release Formulation

Question 3

Biguanides MOA

Answer 3

Decreases hepatic glucose production, decreased intestinal
glucose absorption, and increases insulin sensitivity and peripheral glucose uptake and
utilization

Question 4

Biguanides preferred

Answer 4

Preferred initial agent for type 2 diabetes

Question 5

Biguanides efficacy

Answer 5

Efficacy: Decreases A1C approximately 1-1.5%

Question 6

Biguanides SE

Answer 6

○ GI Upset (diarrhea, nausea, upset stomach, flatulence)

○ B12 and other vitamin deficiencies

Question 7

Biguanides do what to avoid SE

Answer 7

take with food

Question 8

Biguanides Serious side effects

Answer 8

○ Lactic Acidosis

Question 9

Biguanides Monitoring

Answer 9

○ Side effects (mainly GI)
○ Renal Function
○ Lactic Acidosis
○ A1C, Fasting and 2-hour PP Blood glucose

Question 10

Biguanides Contraindications

Answer 10

○ eGFR <30mL/min

Question 11

Sulfonylureas - agents

Answer 11

glipizide (Glucotrol™), glimepiride (Amaryl™), and glyburide (Glynase™)

Question 12

Sulfonylureas - MOA

Answer 12

: Stimulates insulin secretion from functioning beta cells in the
pancreas, especially in response to a meal; may also increase insulin sensitivity and lower
hepatic glucose production

Question 13

Sulfonylureas - Efficacy

Answer 13

○ Hypoglycemia

○ Weight gain

Question 14

Sulfonylureas - Common side effects

Answer 14

○ Hypoglycemia - Avoid in elderly patients for fall risk

Question 15

Sulfonylureas - Serious side effects

Answer 15

○ Hypoglycemia!

○ A1C, blood glucose

Question 16

Sulfonylureas monitoring

Answer 16

○ Avoid in patients with G6PD deficiency

○ Glimepiride - Avoid in the elderly

Question 17

Sulfonylureas - place in therapy

Answer 17

○ Really fallen out of favor given newer agents with better benefits
○ Used when cost is a major issue (uninsured/underinsured)

Question 18

Sulfonylureas administration

Answer 18

○ Take with food for ER products and just before (30ish minutes) before a meal for IR products
○ ER tablets should not be crushed/chewed

Question 19

Sulfonylureas - Pearls

Answer 19

Inexpensive and generally well covered

Question 20

Biguanides - place in therapy

Answer 20

○ First line for management of Type 2 Diabetes

○ Should be continued for as long as possible

Question 21

Biguanides administartion

Answer 21

○ Take with food to reduce GI upset

Question 22

Biguanides - pearls

Answer 22

○ ER formulation less likely to cause GI upset
○ Osmotic ER formulation is rarely covered by insurance
○ Take with food

Question 23

Thiazolidinediones (TZDs) - Agents

Answer 23

pioglitazone (Actos™) and rosiglitazone (Avandia™)

Question 24

Thiazolidinediones (TZDs)

- MOA

Answer 24

: increases insulin-dependent glucose disposal and decreases

hepatic glucose output by decreasing insulin resistance in the periphery and in the liver

Question 25

Thiazolidinediones (TZDs) | Efficacay

Answer 25

Decreases A1C approximately 1-1.5%

Question 26

Thiazolidinediones (TZDs) | SE

Answer 26

○ Edema ○ Weight Gain ○ Headache

Question 27

Thiazolidinediones (TZDs) | - Seriously SE

Answer 27

Heart Failure | ○ LFT elevations

Question 28

Thiazolidinediones (TZDs) | Monitoring

Answer 28

○ LFTs prior to therapy ○ Signs/symptoms of heart failure ○ A1C, blood glucose

Question 29

Thiazolidinediones (TZDs) | - Precautions

Answer 29

History of heart failure ○ Severe edema ○ Generally not recommended with renal impairment - fluid retention

Question 30

Thiazolidinediones (TZDs) | Place in Therapy

Answer 30

Used less often, generally third line agent after metformin and another agent ○ Generally used when cost is a concern

Question 31

Thiazolidinediones (TZDs) | Administration

Answer 31

Can take with or without food

Question 32

Thiazolidinediones (TZDs) | Pearles

Answer 32

Avoid with patients with history of heart failure

Question 33

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Agents

Answer 33

Agents: sitagliptin (Januvia™), linagliptin (Tradjenta™), alogliptin (Nesina™), saxagliptin (Onglyza™) ○ The “gliptins”

Question 34

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - MOA

Answer 34

protects glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide (GLP-1) from inactivation by DPP-4, thereby enhancing their actions; Increases insulin release and decreases glucagon levels in the circulation in a glucose-dependent manner

Question 35

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Efficacy

Answer 35

Decreases A1C approximately 0.5-1%

Question 36

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Common Side Effects

Answer 36

○ Headache | ○ Nasopharyngitis

Question 37

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Serious Side Effects

Answer 37

Pancreatitis

Question 38

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Monitoring

Answer 38

○ Renal Function ■ Dosing Adjustments: sitagliptin, saxagliptin, alogliptin ○ A1C, Blood glucose

Question 39

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Contraindications

Answer 39

○ Concomitant use of sulfonylurea | ○ Heart Failure

Question 40

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Place in Therpay

Answer 40

○ More rarely used but sometimes used as a 3rd line option ○ Similar mechanism of action to GLP-1 agonists, so generally not used in combination with these agents

Question 41

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Administration

Answer 41

○ Take with or without food

Question 42

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors) - Pearls

Answer 42

Becoming increasingly well covered