EXAM 4 Diabetes Drugs Dr. Hess

Question 1

What is the backbone of treating Prediabetes and T2DM?

Answer 1

-Medical nutrition therapy -> individualized meals (dietitian) -> weight loss
-Exercise

Question 2

MOA of Metformin

Answer 2

Insulin Sensitizer (reducing Insulin resistance)

-reduces hepatic glucose production and glucose absorption in the gut

Question 3

What is the most common side effect of Metformin?

Answer 3

Diarrhea
-it reduces glucose absorption in the gut -> glucose stays in the gut where bacteria comes in

Question 4

What are ways to reduce the adverse effects of diarrhea when taking Metformin?

Answer 4

-take with food
-titrate weekly (increase by 500 mg)
-use the ER formulation

Question 5

What is the maximum dose of Metformin?

Answer 5

2550 mg/day (850mg TID)

the maximum dose that is actually effective and seen in practice is 2000 mg

-titrate up until 2000 mg or control of blood glucose
-if blood glucose is controlled then don’t need to go to 2000 mg and potentially cause diarrhea (dose-depndent)

Question 6

How much does Metformin lower A1c?

Answer 6

on average 1-2%

(reducing A1c by more than 1% is considered high efficacy)

Question 7

What is the risk of Hypoglycemia of Metformin?

Answer 7

Low

-since it doesn’t stimulate insulin release but increases sensitivity

Question 8

How does Metformin affect weight?

Answer 8

weight-neutral

Question 9

Contraindications of Metformin

Answer 9

-Renal disease (eGFR < 30)
->excreted 100% in the kidney

-use of contrast dye - nephrotoxic (eGFR < 60)

-BBW: Lactic acidosis (don’t give if hx of Lactic acidosis)

-reduces Vitamin B12 absorption

Question 10

A patient’s eGFR on Metformin has decreased to 35, what is the medical approach to it?

Answer 10

eGFR: 30-45
-if they were not on Metformin don’t start
-if they are on Metformin: consider a 50% dose reduction and close monitoring

if the eGFR is below 30: CONTRAINDICATED

if eGFR is over 45: it is OK to start or continue

Question 11

MOA of SGLT2i

Answer 11

blocking glucose reabsorption in the kidney
-> excreted via urine

Question 12

Efficacy of SGLT2i

Answer 12

0.5 - 1% (moderate)

Question 13

What are the other protective effects of SGLT2i?

Answer 13

-Cardiovascular protective (heart failure)
-Renal protective (CKD)

Question 14

Hypoglycemia risk for SGT2i

Answer 14

Low

Question 15

Adverse effects of SGLT2i

Answer 15

Mycotic infections, UTI
-Polyuria
-dehydration (mild diuretic)
-Hypotension
-Weight loss !!!
-Euglycemic diabetic ketoacidosis (rare)

Question 16

Why may patients on SGLT2i develop Euglycemic diabetic ketoacidosis?

Answer 16

the blood glucose is normal (normal-high) but they are acidic

they pee out the sugar which lowers the blood glucose

Question 17

When are SGLT2i contraindicated?

Answer 17

severe renal dysfunction (eGFR < 20)

Question 18

Which SGLT2i is indicated for T2DM with ASCVD, HF, and CKD?

Answer 18

Jardiance (Empagliflozin)

Question 19

What is the indication of Farxiga (dapagliflozin)?

Answer 19

T2DM
HF
CKD

Question 20

What is the indication of Invokana (Canagliflozin)?

Answer 20

T2DM
T2DM with ASCVD
T2DM with CKD

had a BBW for imputations, but it was removed
-not often used in practice

Question 21

What is the risk of hypoglycemia for SGLT2i when combined with other antidiabetics?

Answer 21

-SGLT2i has a low risk of hypoglycemia
-SU has a higher risk of hypoglycemia -> combined higher risk for hypoglycemia

reduce the dose of SU to reduce the risk of hypoglycemia

Question 22

Which SGLT2is have shown renal benefits?

Answer 22

Farxiga (dapagliflozin)
Invokana (canagliflozin)

Question 23

Which of the SGLT2i have HF benefits?

Answer 23

Farxiga (dapagliflozin)
Jardiance (empagliflozin)

Question 24

Which of the SGLT2i have CVD benefits?

Answer 24

Jardiance (empagliflozin)
Invokana (canagliflozin)

Question 25

Which drugs may cause weight loss?

Answer 25

SGLT2i (pee out 80g sugar per day) GLP-1 ..

Question 26

MOA of GLP-1 and GIP

Answer 26

activate GLP-1 receptors -> increase in insulin secretion (endegeounous GLP-1 comes from the gut) high efficacy: 0-75 - 1.5%

Question 27

How does GLP-1 cause weight loss?

Answer 27

it works in different parts of the body: Brain: reduced food intake, increased satiety Pancreas: GLP-1: increased insulin, decreased glucagon Stomach: reduced gastric emptying

Question 28

Why does GLP-1 have a low hypoglycemia risk despite increasing insulin release?

Answer 28

Because the insulin release is glucose-dependent

Question 29

What are the side effects of GLP-1?

Answer 29

-N/VD -Weight loss -Pancreatitis (rare) -Injection reactions

Question 30

What is the BBW for GLP-1?

Answer 30

-Hx of medullary thyroid carcinoma (MTC) seen in rats -not thyroids, but medullary thyroid cancer -> produces calcitonin -Hx of multiple endocrine neoplasm type 2 (MEN2)

Question 31

Patient population to be cautious when using GLP-1?

Answer 31

-poor renal function (should be over 30) -when they use Sulfonylurea -> hypoglycemia risk -Hx pancreatitits -Hx of gastroparesis or delayed gastric emptying

Question 32

Which GLP-1s have an indication for T2DM with ASCVD?

Answer 32

Victoza (liraglutide) -Ozempic (semaglutide) -Trulicity (dulaglutide)

Question 33

How are GLP-1 dosed?

Answer 33

weekly except for Vicotza

Question 34

How are SGLT2i dosed?

Answer 34

daily start dosing -> uptitration

Question 35

Which drug is a GIP and GLP-1 agonist?

Answer 35

Tirzepatide (Mounjaro)

Question 36

How is Tirzepatide (Mounjaro) dosed?

Answer 36

increase in the dose every month by 2.5 mg (if they tolerate it) it is taken once a week

Question 37

Which GLP-1 has the longest/shortest storage time at room temperature?

Answer 37

longest: Ozempic (56 days) shortest: Trulicity (14 days)

Question 38

Which GLP-1s have a storage time at room temperature of 28-30 days?

Answer 38

Bydureon BCise (exenatide LA): 28 days Byetta (exenatide): 30 days Victoza (Liraglutide): 30 days all of them including Ozempic, Trulicity and Mounjaro should be kept in the fridge prior using

Question 39

What is the orally formulated GLP-1 and how should it be taken?

Answer 39

Semaglutide (Rybelsus) -at least 30 minutes before the first food, beverage, or other oral medications -not more than 4 oz water -Keep in the original blister pack (protection from moisture)

Question 40

Which of the GLP-1s have CVD benefits?

Answer 40

-Victoza (liraglutide) -Ozempic (Semaglutide) -Trulicity (Dulaglutide)

Question 41

What is the first-line antidiabetic drug based on the guidelines?

Answer 41

if they have ASCVD risk, HF, or CKD -> go with SGLT2i or GLP-1 before metformin in practice, Metformin is often used first