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Pharm II Exam 4 > Diabetes Pharmacology > Flashcards

Diabetes Pharmacology Flashcards

1
Q

Non-Pharm Treatment for Diabetes

A

goal group = Diabetes Self Management and Education & Support

Medical Nutrition Therapy (MNT)
- carb counting (used heavilty in T1DM)
- meal planning
- carbohydrate choices
- assessing protein and fat intake
- limit drinking alcohol
- sodium < 2300 mg/daily
- nonnutritive sweetener

education between carb counting and glucose spike

  • weight loss: 5% makes a big deal
  • physical activity
  • stop smoking

Psychosocila implications
sleep help!

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2
Q

A1C goal for DM pts

A

most nonpregnant adults: target an A1c of < 7%

strict goals for less than 6.5%: need to ensure they can do this without significant hypoglycemia (think younger, healthy pt.)

less strict goals for less than 8%:
- those with history of severe hypoglycemia
- life expectancy limitied
- advanced vascular complications
- extensive comorbidities

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3
Q

Medications to be used for…
- those with a + ASCVD
- thse with HIGH RISK for ASCVD

(what are the ascvd events and what meds should be used)

A

ASCVD means
- MI
- Stroke
- revascularization procedure
- TIA
- unstable angian
- amputation
- asymptomatic CAD

High Risk Individuals include
- those > 55 years old with 2+ of
- obesity
- hypertension
- smoking
- dyslipidemia
- albuminuria

GLP-1 receptor agonists: dulaglutide, liraglutide & semiglutide
AND/OR
SGLT2 inhibitors: empagliflozin, canagliflozin

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4
Q

Medications to be used for…
Heart Failure Patients
(HFpEF or HFrEF)

A

choose the SGLT2 inhibitors
- canagliflozin
- empagliflozin
- dapagliflozin
- ertugliflozin

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5
Q

Medications to be used for…
CKD pts (those with eGFR < 60 OR albuminuria)

A

SGLT2 inhibitors
- canagliflozin
- dapagliflozin
- empagliflozin

OR if the SGLT2 insnt an option or there is a CI

GLP-1’s can be used
- dulaglutide
- liraglutide
- semaglutide

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6
Q

Medications to be used for…
- specifically targeting glycemic lowering to get to target

what is always an option
what has “very high” lowering efficacy
“high”
“intermediate”

A

metformin can always be used
OR (in combo with each other or with metformin)

VERY HIGH (most successful)
- dulaglutide
- semaglutide
- tirzepatide (GLP, GIP combo)
- Insulin
- oral combo or injectable of a GLP and insulin together

HIGH
- the other GLP’s (liraglutide, exenatide, lixisenatide)
- metformin
- SGLT2i
- sulfonyureas
- TZDS

IMTERMEDIATE
- DPP-4 inhibitors

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7
Q

Medications for those who….
- need to target WEIGHT LOSS to manage their DM

A

those with High to Very High effiacy at managing weight loss

VERY HIGH
- semaglutide
- tirzepitide

HIGH
- dulaglutide
- liraglutide

INTERMED.
- exenatide
- lixisenatide
- SGLT2i

NO EFFECT ON WEIGHT
- metformin
- DPP-4i

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8
Q

Basic Principles of Treatment for those with DM

A
  • always tackle lifestyle modifications first
  • initial treatment shold tackle DM and assocaited comorbidities

Pharmacotherapy should be started at the first visit and diagnosis unless there are contraindications

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9
Q

Thearpy Choice depending on the A1C level

  • if A1C is > 1.5% above target
  • if A1C is > 10% OR BG > 300 or they have severe hyperglycemia
A

if A1C > 1.5% above target (so usually those with 8.5% or higher)
- start lifestyle changes
- start them on TWO MEDICATIONS: DUAL THERAPY INITIALLY

If A1C is > 10% or Blood Sugar > 300 or thye are severely hyperglycemic
- start lifestyle modifications
- start them on DUAL THERAPY: OF WHICH ONE IS BASAL INSULIN!!!
- example: metformin + basal insulin

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10
Q

Metformin
(class)
MOA
onset of action

A

Metformin
(the only biguanide)

MOA
- decreases hepatic glucose production
- decreases intestinal absorbtion of glucose
- increasing peripheral glucose uptake and utilization (targets the resistance part)

Onset of Action
- takes days to 2 weeks
- excreted via urine

Benefits
- works really well
- no risk of hypoglycemia
- weight neutral
- cheap

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11
Q

Metformin
Contraindications
Risks

A

Contraindicated in hypoperfusion states
- CI is GFR < 30: wont be cleared : risk of acidosis, hypoxia and dehydration

Risks
- watch metformin use with GFR 30-45: metformin wont cause renal dysfunction: but it wont get cleared as well through the kidneys and that can be an issue –> monitor kidney function well

Side Effects
- N/V
- diarrhea & bloating
- B12 deficiency
- lactic acidosis: if they already have bad kidneys this increases the risk

monitor the GFR annually!!

Iodine Contrast & Metformin
- temporarilty withhold metformin before contrast & reassess kidney function > 48 hours later
- because contrast impacts kidney function, hold metformin becuase if you dont lactic acidosis can occur

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12
Q

Metformin
how is it given

A
  • titrate dose
  • strat with 500 with food
  • then change every 5-7 days
  • goal = 1000
  • switch to extended release formulation can decrease side effect profile
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13
Q

Goals of DM Thearpy
Fasting plasma Glucose
Post-Prandial Glucose
A1C level

A

Fasting Plasma Glucose: 80-130
Post-Prandial Glucose: < 180 (2 hours after meal)
A1C: < 7%

reduce ASCVD risk and death

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14
Q

GLP-1 Receptor Agonists
Names
MOA

A

can come as daily or weekly injections
- semaglutide is the only one now avalible as a pill

Names
- exenatide
- liraglutide
- lixisentaide
- dulaglutide
- semaglutide

MOA (works at insulin and glucagon)
- work to change the way in which the body responds to glucose dependent insulin secretion
- decreases the unnecessary release of glucagon (since glucagon is release becuase essentially no insulin is being released– triggered glucagon)
- slow gastric emptying : helps with weight loss

Benefits
- high & very high efficacy
- no risk of hypoglycemia (because its not increasing insulin secretion)
- weight loss
- ASCVD helpful and CKD helpful (some)

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15
Q

GLP-1 receptor agonists
Risks & Side Effects

A

Risks
- black box warning: thyroid C-cell tumors (if history of this, avoid)

Side Effects
- nausea/vomiting/diarrhea
- pancreatitis + cholelithiasis/cholecystitis (if hx. of these; avoid these meds)
- injection site reaction

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16
Q

GIP & GLP-1 combo med
Tirzepatide

MOA
benefits
side effects

A

Tirzepitide: a GLP and GIP combo med

MOA
- alters glucose dependent insulin secretion
- decreases the glucagon response
- slows gastric emptying

Benefits
- highly effective
- assocaited weight loss
- no risk of hypoglycemia

Side Effects
- BBW: thyroid C-cell tumors
- N/V/diarrhea
- pancreatitis and cholecyctitis/stones risk
- injection site reaction

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17
Q

SGLT2 Inhibitors
Names
MOA

A

Names
- bexagliflozin
- canagliflozin
- dapagliflozin
- empagliflozin
- ertugliflozin

MOA
- reduce reabsorbtion of glucose in the lumen of kidney
- lowers teh renal threshold for emptying glucose
- overall increase excretion of glucose

Benefits
- intermed to high efficacy
- no risk of hypoglycemia
- weight loss (some)
- ASCVD, HF and CKD helpful

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18
Q

SGLT2 inhibitors

Risks & Side Effects

A

Risks
- UTI: fungal because sugary urine!
- volume depeletion & hypotension
- DKA (rare)
- fournier’s gangrene (rare)
- bone fractures risk: canagliflozin

RENAL ADJUSTMENTS
- need to consider renal adjustmenets with poor renal function & d/c once function is significantly decreased : since these meds work within the kidney

19
Q

DPP-4 Inhibitors
Names
MOA

A

Names: DPP4 = the Gliptins
- Alogliptin
- Linagliptin
- Saxagliptin
- Sitagliptin

MOA
- prolonged activity of the incretin hormones (stop their breakdown)
- therefore stops breakdown for GLP and GIP within the body so they have more of a chance to do their job

Benefits
- intermediate efficay
- no ris fo hypoglycemia
- weight neutral
- well tolerated

20
Q

DPP4 inhibitors

Risks & Side Effects

A

DONT USE GLP and DPP4’s TOGETHER: their MOA is too similar

Risks
- pancreatitis
- joint pain
- bullous pemphigoid
- avoid in HF: specifically saxigliptin

RENAL ADJUSTMENTS
- needed as kidney function declines in some pt.

21
Q

Thiazolidinnediones (TZDs)
Names
MOA

A

Names
- piglitazone
- rosiglitazone

MOA
- work at the PPAR gamma agonist: to improve the sensitivity to insulin at target cells

delayed onset of action: need to recheck blood sugar at 12 weeks to see if its working

Benefits
- works well
- no risk of hypoglycemia
- potential ASCVD decrease with piglitazone
- helpful in those with NASH: nonalcoholic steatohepatitis: inflammation + steatosis

22
Q

TZDs
Risks and Side Effects

A

Side Effects
BBW: heart failure
- increase fluid retention, edema dn therefore heart failure
- weight gain (edema + fat storage)
- bone fractures

Risks
- Bladder Cancer: piglitazone
- increased LDL with rosiglitazone : thats why its not helpful for ASCVD

23
Q

Sulfonyureas
Names
MOA

A

Names
- Glyburide
- Glipizide
- Glimepiride

MOA
- stimulate the insulin release from the beta cells
- reduce hepatic glucose output
- increase sensitivity to insulin

watch glyburide: has active metabolites: and in the urine they are excreted so if they have CKD or poor kidneys; this could be an issue

24
Q

Sulfonyureas
Risks & Side Effects

A

Risks
- hypoglcemia: since they’re just telling the beta cells to constantly pump out insulin!!!
- do not use glyburide in the elderly

Side Effects
- weight gain : adjustment like: if they stop eating as much this is less of an issue

increased CV mortality

25
Q

Metglitindies
Names
MOA
when are they used
Side Effects

A

Names : Glitinides
- nateglinide
- repaglinide

MUST be taken WITH MEALS

MOA
- stimulate insulin release from the beta cells: but in response to glucose
- these are glucose dependnt medications!!!!!

DO NOT USE with sulfonyureas!!! too similar in their MOA as they both act on the beta cells

when are they used
- taken with meals: there to help control post-prandial glucose spikes

Side Effects
- hypoglycemia
- dizzy
- URI

26
Q

Alpha-Glucosidase Inhibitors
Names
MOA
Place in Thearpy
Side Effects

A

Names
- Acarbose
- Miglitol
- taken with meals: help to control post prandial glucose

MOA
- inhibit the hydrolysis and ingestion of carbyhydrates, disaccharides and the absorbtion of glucose from the GI tract

Place In thearpy
- post-pradial gucose control

Side Effects: think GI issues
- flatulence
- diarrhea
- abd. pain

27
Q

Amylin Mimetic
Name
MOA
Place in Thearpy
Avoid in ….

A

Name
- Pramlintide

MOA
- taken before meals: there to help prolong gastric emptying & reduce the postpradial glucose spike: because less is being released over time
- can help with satiety too since its delaying teh emptying of stomach & decrese caloric intake

Place in thearpy
- postprandial glucose control
- taken with insulin: can reduce amount of bolus insulin needed by 50%

Side Effects
- BBW: severe hypoglycemia when its taken with insulin
- headache
- N/V
- anorexia

28
Q

Bolus Insulins

A

also called, coverage, pradial insulin

RAPID ACTING

  • Aspart (Novolog)
  • Lispro (Humalog)
  • Glulisine (Apidra or Lyumjev)

all the above bolus insulins peak quickly, within approx. 15-30 minutes to cover the post meal spike and then are gone within hours

SHORT ACTING

R (Regular insulin) = least like normal physiological insulin levels : in that it takes longer to peak and lasts longer in the system

29
Q

Basal Insulin

A

insulin which covers for the whole day

INTERMEDIATE ACTING

N (NPH) - may need to dose 2x daily
- peaks
- risk of hypoglycemia
- can be mixed physically with bolus insulin

Detemir (Levemir) = often dosed 2x daily has a flat peak

LONG ACTING

Glargine (Lantus) = peakless!!!
- no risk of hypoglycemia because its peakless

Degludec (Tresibia)

30
Q

Mixed Insulins
intermediate and Short/Rapid Acting

A

70/30
- NPH (intermediate insulin) + regular insulin or protamine aspart (a shorter acting insulin)

75/25

50/50

first # = intermediate
second # =short/rapid insulin

31
Q

Inhaled Insulin
what is it
contraindications
warnings

A

Inhaled Insulin (Afrezza)
a BOLUS insulin: therefore you still need basal coverage

Contraindicated in
- COPD
- asthma
- other chronic lung diseases

WARNINGs
- lung cancer
- pulmonary lung function
- smokers

32
Q

How to add or put someone with T2DM on insulin therapy

A
  • if A1c is > 10% at dx. put them on dual therapy: insulin + other (metformin usually)
  • if you have tried other medications and they are still not to goal, add on insulin

Always start with adding basal insulin!!!

  • start them on approx. 10 units a day or .1-.2 units per kg of body weight/per day
  • then increase/titrate up from there 2 units per 3 days until their fpg is at goal
33
Q

what do you have to monitor for those pts. on insulin therapy

levels & thresholds for glucose in hypoglycemia
symptoms of

A
  • weight gain
  • hypoglycemia

Hypoglycemia Levels

Level 1: glucose < 70
Level 2: glucose < 54
Levels 3: severe event
- AMS/phsycailly altered
- required assistance to treat

Symptoms of hypoglycemia
- tremor
- sweating
- tachycardic
- dizzy
- anxious
- thristy
- burry vision
- weak/fatigue
- HA
- irritable/confused
- syncope

alwasy check glucose level first before treating

34
Q

how do you treat hypoglycemia

A

For a Conscious Patient (glucose < 70)
15-15 rule
- give 15 grams of carbohydrates
- wait 15 minutes
- recheck sugar
- keep repeating until glucose increased
- then make sure they eat something

(15 grams carbs = 3/4 glucose tablets, 1/4 cup juice, 1/2 can regular soda, 8oz milk)

For Unconscious Patient
- glucagon pen

35
Q

Insulin Titration
how is it done

A

preferred way is patient to titrate themselves
- increase units every few days until FPG is within range
- example: increase 2 units every 3 days until goal FPG

Other Way = Provider Titrates
- increased dose by 2-4 units every 1xor 2x weekly

if hypoglycemic: decrease the dose by 10-20% then slowly up dose again

36
Q

Co-Morbid conditions to be aware of in DM pt.

A

CVD: hypertension, dyslipidemia, CHD
retinopathy
neuropathy
nephropathy

37
Q

Health Maintence to consider in DM pts.

A

Immunizations
- flu
- pneumococcal
- hepatitis
- zoster
- HPV
- COVID

dental visits Q6 months

yearly albumin:creatitine ratio

dilated eye exams

neuropathy screening (monofilament testing) yearly

38
Q

How to Adjust DM Thearpy
- how often should treatment be reassessed
- what do you consider

A

reassess treatment every 3-6 months

consider…
- fasting plasma glucose: should be between 80-130
- PPG: should be < 180
- amoutn of A1C lowering: should be around 7%

watch: adding noninsulin therapy to metformin may not lower A1c as much as you want if the A1c is so high

39
Q

What medications can be continued when adding insulin therapy to pts.

A

Metformin
- keep on board: helps with weight (avoids gain)
- adding this + insulin = good results

Sulfonureas take off
- controversial if you keep these on board
- discontinue if you use bolus thearpy for sure

TZDs take off
- decrease dose or discontinue if you start insulin
- increased peripheral edema risk

good to keep on board
- SGLT2
- DPP4
- GLP-1

40
Q

How do you adjust Insulin in those already on it for DM control

A

always adjust the insulin to change the glucose levels which are a result of whatver happened before
example: midmorning spike: due to breakfast poor control

(also consider food intake too while adjusting insulin)

Problem = fasting glucose
- too high? increase basal insulin
- too low? decreased basal

Problem = 2 hours post breakfast
- too high? increase bolus with breakfast
- too low? decrease bolus

same goes for lunch and dinner

41
Q

Whats the deal with premixed Insulin
- downsides
- upsides
- who is it good for

A

Downside
- decreased flexibility in timing and variety of meals and activities
- difficut to titrate dosing

upsides
- fewer injections

Good For
- those unwilling to inject multiple times a day
- those unwilling to check glucose multiple times a day
- those who have predicable/routine life & eat the same meals

always find appropriate dose first before switching

42
Q

How to swtich pt. from premixed to not premixed

A
  • start at intermdeiatie dose and decrease by 20%
  • then titrate up from there
43
Q

Adding Pradial Insulin

A

if they are having post-prandial spikes and it just after one meal!!!

  • can start with giving after largest meal or evenly split to every meal

start with 4 untis or 10% of their total daily dose of basal

then can titrate up 1-2 units or 10-15% twice weekly

Pharm II Exam 4 (4 decks)

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