Diabetes Pharm Part 1 Flashcards
(24 cards)
What are the three main categories of Diabetes medications?
Oral Glucose lowering
Non-insulin injectables
Insulin
Biguanides
- drug name
- major SE
- how to dose
- MOA
- other SE
- CI
- Metformin
- Diarrhea (where will you be when it hits??)
- Dose: start low and titrate up.
- MOA: inhibits hepatic glucose production (gluconeogensis and glycogenolysis) and improves insulin sensitivity.
- SE: n/v, flatulence, sx tend to decrease over time. ***can rarely cause lactic acidosis, this is increased risk if on glucocorticoids or with ETOH.
- CI: alcoholics (lactic acidosis)
- -renal dysfunction
- -if recieveing iodinated contrast (decreased perfusion to kidneys, may progress to shock, sepsis, CV failure, lactic acidosis)
- -Serum creatinine greater than 1.5M and 1.4F
- abnormal creatinine clearance from any cause
WHat are 6 reasons Metformin is first line therapy in DM?
- Glycemic efficacy
- no weight gain (may lose weight)
- no hypoglycemia
- may help improve lipids
- well tolderated
- favorable cost
Metformin BBW
- lactic acidosis, the risk in increased with acute congestive heart failure, dehydration, excessive alcohol intake, hepatic or renal impairment.
sx: abd distress, malaise, myalgia, resp. distress, solmnolence.
Sulfonylureas
- drug names
- major SE, who is most at risk of this?
- MOA
- when is this drug most effective
- how to dose
- other SE
- CI
- Ideal patient for this drug
- Glipizide (Glucotrol), Glyburide (Diabeta), or Glimepiride (Amaryl)
- major SE: Hypoglycemia, Elderly, ETOH, poor nutrition, and renal insufficiency are most at risk.
- MOA: bind to beta cell receptors and cause ATP-dependent potassium channels to close, the calcium channels then open leading to increased insulin release from pancreas. (stimulates insulin release from the pancreas)
- only effective in the first 5 years of disease, if disease has already progressed and you dont have any beta cells left its not going to increase insulin secretion.
- How to dose: start low and titrate up
- SE: weight gain from increased levels of insulin.
CI: sulfa allergy, high risk of hypoglycemia, ketoacidosis
Ideal pt:
- duration of disease less than 5years*
- close to normal body weight* (likely they have less insulin resistance)
- no sulfa allergy
- no hx of prior insulin therapy
Sulfonylureas
-what are the notable differences between each of the drugs?
- Glipizide (“slide down a short slide”) 14-16hr duration
- Glyburide: 20-24+ hrs
- Glimepiride: (goin on a ride, for awhile) 24+hrs
Thiazolidinediones aka TZD
- drug names
- major SE
- MOA
- utility of TZD
- does this cause hypoglycemia?
Drugs: Rosiglitazone (Avandia)
Pioglitazone (Actos)
-Major SE: cankles, causes a lot of water retention. peripheral edema, weight gain, hepatotoxicity
- MOA: increase insulin sensitivity in skeletal muscle and fat by bind to PPAR-gamma receptor thereby decreasing peripheral resistance. At higher doses may decrease hepatic glucose production.
- Can have positive effect on lipid profile*
- Utility: used as add-on therapy down the line
- Does not cause hypglycemia b/c its not increasing insulin production, just insulin sensitivity.
TZD BBW
-CONGESTIVE HEART FAILURE, these drugs cause or exacerbation of CHF.
TZD: Rosiglitazone BBW
-MYOCARDIAL INFARCTION
Alpha-glucosidase inhibitors
- drugs
- Major SE
- MOA
- most useful in which patients
- CI
- how to dose
- Acarbose (Precose)
- Miglitol (Glyset)
- major SE: gas, abd bloating, distention, diarrhea
- MOA: slows the absorption of carbs (decrease glucose?)
- Most useful in patietns with postprandial hyperglycemia and high A1C levels
- CI: patients with GI motility disorders**, cirrhosis, and disease of the bowel.
- Dose: dose with first bite of meal(TID), start at lowest dose and titrate up every 1-2mo as needed, monitor LFTs 1st year of therapy
Meglitinides
- drug names
- major side effects
- MOA
- uses
- Nateglinide (Starlix)
- Repaglinide (Prandin)
-Major SE: hypoglycemia
- MOA: increase insulin secretion from pancreas, similar to sulfonylureas.
- lowers post prandial glucose but does not change fasting plasma glucose.
- uses: generally not very effective, alternative for patients who are candidates for SU’s but have sulfa allergy
- good for pt with erratic eating schedule (take with meals, only take if they eat)
- for pts with acceptable fasting plasma glucose and elevated post prandial levels
Meglitinides
-drug interactions?
-drug interacctions with drugs metabolized through the CYP450 3A4 pathway
Dipeptidyl Peptidase-4 inhibitors
- drugs
- Major SE
- moa
- drug interactions
- other SE
Drugs: Sitagliptin(Januvia)
Saxtagliptin (Onglyza)
Linagliptin (Tradjenta)
Alogliptin (Nesina)
- Major SE: HA
- MOA: inhibit enzyme that breaks down GLP-1 therby increased amounts of GLP-1 leading to decreased hepatic glucose production.
- Drug interactions: Saxtagliptin is a potent CYP3A4/5 inhibitor avoid with ketoconazole, diltiazem, and erythromycin.
- Other SE: URI, UTI, hypoglycemis w/ SU, hypersensitivity rxn, elevated liver enzymes, pancreatitis
SGLT2 Inhibitor (Sodium glucose transporter)
- drugs
- Major Se
- MOA
- benefits
- other SE
Drugs: Canagliflozin (Invokana)
Dapaglifloxin (Farxiga)
Empagliflozin (Jardiance)
-SE: GU infections, candida infections
- MOA: block SGLT2 sites in the renal tubule which decreases glucose reabsorption in the kidney therefore causing glucosuria. GFR needs to be at least 45ml/min
- basically, to counteract your hyperglycemia you pee out the excess glucose.
- benefits: no hypoglycemia, promotes weight loss, effective in all stages of DM, targest the kidney so minimal risk for off target adverse effects.
- SE: polyuria, dehydration, low BP, increased LDL
GLP-1 Receptor Agonists
- drugs
- Main SE
- MOA
- which one of these medications is not yet approved for use with insulin?
Drugs: Exenatide (byetta)
Liraglutide (Victoza)
Albiglutide (Tanzeum)
Dulaglutide (Trulicity)
Main SE: GI upset*, N/V, diarrhea
MOA: they slow transit through the gut. Glucose dependent effects on insulin and therefore no hypoglycemia.
-Exanitide (Byetta) is not approved for use with insulin.
Amylinomimetic
- drugs
- used in which type of diabetes?
- MOA
- SE
Drugs: Pramlintide Acetate (Symlin)
-used in type 1 and 2 Diabetes
- MOA: synthetic anaolog of human amylin cosecreted with insulin by pancreatic beta cells.
- reduces postprandial glucose increases via the following mechanisms:
1. ) prolongation of gastric emptying
2. ) reduction of postprandial glucagon secretion
3. ) reduction of caloric intake through centrally-mediate appetite suppression.
-SE: n/v, hypoglycemia,
- CI:
- gastroparesis
- hypoglycemia unawareness
- poor compliance
- A1C greater than 9
- dont use with alpha-glucosidase inhibitors
What diabetes medications are most cost effective?
- metformin (biguanide)
- Gulfonylurease (glyburide, glipizide, glimepiride)
- TZD’s (Rosiglitazone, Pioglitazone)
they all are $20 or under
Step-wise approach to therapy: - for each new class of noninsulin agent added to initial therapy expect A1C lowering of \_\_\_%.
-0.9-1.1%
Glycemic Targets:
- preprandial
- postprandial
- tigher targets for younger and healthier
- looser targets for older, comorbidities
Pre-prandial Plasma Glucose less than 130
Post-prandial plasma glucose less than 180
Tighter: 6.0-6.5% A1C
Looser: 7.5-8.0% A1C
Anti-hyperglycemic therapy in T2D (Tx)
EVERY diabetic patient should be striving for healthier eating, weight control, increased physical activity & diabetes education.
- Start with monotherapy (Metformin) …..if HbA1C not achieved after 3 mo proceed to a 2 drug combo
- Metformin and sulfonylurea(Cheapest)…if HbA1C not achieved after 3 mo of dual therapy proceed to 3 drug combo
- Metformin, SU, and SGLT-2…. if HbA1C not achieved in 3mo proceed to combination injectable therapy.
- Basal insulin + Mealtime Insulin or GLP-1 Receptor Agonist
If A1C at 10% will metformin alone get you to goal?
What if A1C starts in the teens? What medication therapy would you start with?
No. Anything greater than 9% youre not going to get to goal with just one therapy, you need to use dual or triple therapy.
-Start at Combo injectable therapy.
If trying to avoid hypoglycemia which classes of drugs would you get rid of and which would you keep?
- Get rid of sulfonylureas, insulin (& Meglitinides but not on her chart)
- Keep TZD, DPP-4inhib, SGLT2inhib, GLP-1 RA
If trying to avoid weight gain which classes of drugs would you avoid? which would you keep?
- avoid sulfonylureas, insulin, TZD, and GLP-1
- Keep DPP-4inhib,SGLT2inhib & GLP-1RA (only as dual therapy)
What is the go to drug for T2D?
Metformin
