Non-Insulin Therapies Part 1

Question 1

A1c Less than 7%

Answer 1

At goal

Question 2

A1c less than 7.5%

Answer 2

Mildly elevated

Question 3

A1c between 7.6-9.0%

Answer 3

Moderately elevated

Question 4

A1c greater than 9.0%

Answer 4

Significantly elevated

Question 5

Metformin MOA

Answer 5

Reduces hepatic gluconeogenesis

Insulin sensitizer

Question 6

Metformin Benefits

Answer 6

	Good A1c reduction
	Inexpensive
	Well tolerated
	Some weight loss
	Some lipid

Question 7

Metformin Risk/Issues

Answer 7

 GI: cramping, diarrhea, N/V
 Severe but rare: lactic acidosis
 B12 deficiency

Question 8

Metformin CI

Answer 8

 Renal function: eGFR

Question 9

Sulfonylureas MOA

Answer 9

Stimulation of insulin secretion through pancreatic beta-cells

Question 10

Sulfonylureas Drugs

Answer 10

 Glyburide
 Glipizide
 Glimepiride

Question 11

Sulfonylureas Benefits

Answer 11

 Both fasting and post-prandial glucose
 Inexpensive
 Good A1c decrease

Question 12

Sulfonylureas Risks/Issues

Answer 12

 AE: Weight gain, Hypoglycemia, Rash, GI complaints, SIADH (rare)
 Beta-cell function loss
 Differing renal doses

Question 13

Sulfonylureas Good Candidate

Answer 13

 A1c moderately elevated
 Indigent patient (cheap)
 Short duration or DM diagnosis

Question 14

Sulfonylureas Bad Candidate

Answer 14

 H/o hypoglycemia
 Increased weight not wanted
 Long duration of DM

Question 15

Meglitinides MOA

Answer 15

Glucose-dependent activty via pancreatic beta cells

Question 16

Meglitinides Drugs

Answer 16

 Repaglinide

 Nateglinide

Question 17

Meglitinides Benefits

Answer 17

 Post-prandial BG
 Activity is glucose-dependent (less hypoglycemia)
 Can use if renal impairment exist

Question 18

Meglitinides Risks/Issues

Answer 18

 Weight gain
 Hypoglycemia
 Cost!!!
 Mealtime dosing (TID)

Question 19

Meglitinides Good Candidate

Answer 19

 Significant post-prandial BG issues

Question 20

Meglitinides Bad Candidate

Answer 20

	Already taking a SU 
	H/O hypoglycemia
	Increased weight not wanted
	Compliance issues (TID)
	Cost!!

Question 21

Thiazolidinediones MOA

Answer 21

Improve insulin sensitivity in many places especially the muscles

Question 22

Thiazolidinediones Drugs

Answer 22

Pioglitazones

Rosiglitazone

Question 23

Thiazolidinediones Benefits

Answer 23

	Good A1c reduction
	Fasting and Post-prandial 
	Improved insulin sensitivity
	Cheap
	Beta cell function

Question 24

Thiazolidinediones Risk/Issues

Answer 24

 Weight gain
 Edema
 Exacerbate CHF
 Proximal bone fracture risk

Question 25

Thiazolidinediones Good Candidate

Answer 25

 Moderate elevated A1c  Indigent (cheap)  Significant insulin resistance

Question 26

***Thiazolidinediones Bad Candidate

Answer 26

```  HF  H/O osteopenia/osteoporosis  Weight gain  H/O bladder cancer  Existing edema (esp if on insulin too) ```

Question 27

DPP-4 Inhibitors MOA

Answer 27

Increase pancreatic insulin secretion in the GI tract

Question 28

DPP-4 Inhibitors Drugs

Answer 28

 Sitagliptin  Aloglipitin  Linagliptin  Saxagliptin

Question 29

DPP-4 Inhibitors Benefits

Answer 29

 Post-prandial  Once daily  Well tolerated  Weight neutral

Question 30

DPP-4 Inhibitors Risks/Issues

Answer 30

```  Modest reduction in A1c  Expensive  No titration  Pancreatitis  Renal dose adjustment ```

Question 31

DPP-4 Inhibitors Good Candidate

Answer 31

 Mildly elevated A1c  Compliance issues  Weight gain is an issue

Question 32

DPP-4 Inhibitors Bad Candidate

Answer 32

 Indigent |  Moderately elevated A1c

Question 33

SGLT-2 Inhibitors MOA

Answer 33

Increase urinary glucose excretion by blocking reabsorption via the kidneys

Question 34

SGLT-2 Inhibitors Drugs

Answer 34

 Dapagliflozin  Canagliflozin  Empagliflozin

Question 35

SGLT-2 Inhibitors Benefits

Answer 35

```  Oral, once daily  Moderate A1c reduction  Fasting and Post-prandial  Weight REDUCTION  Minimal hypoglycemia  Mild effects on BP ```

Question 36

SGLT-2 Inhibitors Risk/Issues

Answer 36

 Renal dose adjustments  Expensive  Urinary and genital infections  Diuresis/polyuria

Question 37

SGLT-2 Inhibitors Good Candidate

Answer 37

 Moderately elevated A1c  Compliance issue  Weight loss wanted/needed

Question 38

SGLT-2 Inhibitors Bad Candidate

Answer 38

 Indigent (expensive)  H/O frequent genital yeast infections  Difficulty urinating  Renal dysfunction

Question 39

SGLT-2 Inhibitors CI

Answer 39

 Renal impairment • Increase hyperkalemia risk  H/O Genital mycotic infections  H/O Bladder CA

Question 40

GLP-1 Agonists MOA

Answer 40

glucose-dependent insulin secretion, reduction in glucagon secretion, reduced gastric emptying

Question 41

GLP-1 Agonists Drugs

Answer 41

 Exenatide  Liraglutide  Dulaglutide  Albigultide

Question 42

GLP-1 Agonists Benefits

Answer 42

```  Good A1c reduction  Low hypoglycemia  Some effect on lipid/BP  Weight reduction  Preserves beta-cell function  Once weekly agents: fasting and post-prandial  QD/BID agents: post-prandial ```

Question 43

GLP-1 Agonists Risk/Issues

Answer 43

 Injectable  Expensive  Lots of N/V  Pancreatic risk  Renal impairment differs between agents  Hypoglycemia risk if added to SU or insulin  Thyroid carcinoma (only in animals)

Question 44

GLP-1 Agonists Good Candidate

Answer 44

 Moderately elevated A1c  Weight loss  Compliance issue  Post-prandial BG issue

Question 45

GLP-1 Agonists Bad Candidate

Answer 45

```  H/O pancreatitis  Can’t handle injections  Poor renal function  H/O gastroparesis  Indigent (expensive) ```

Question 46

GLP-1 Agonists Once Weekly Options

Answer 46

Exenatide, dulaglutide, albigulutide | Can be given any time of the day

Question 47

Exenatide BID Dosing

Answer 47

60 minutes before meals Avoid if CrCl less than 30 Can NOT be mixed

Question 48

Lireglutide Dosing

Answer 48

Without regards to meals No CrCl cut off Can NOT be mixed

Question 49

CI to Weekly GLP-1 Agonists

Answer 49

Renal impairment

Question 50

GLP-1 Agonists Missed Dose

Answer 50

 Next dose at least 3 days away  give right away |  Next dose within 1-2 days  skip and resume normal schedule

Question 51

GLP-1 Agonists Changing Day of Week

Answer 51

 Last dose within 3 days  hold |  Last dose was at least 3 days ago  change to desired day