Pharmacologic Management T2DM

Question 1

Pharmacologic Management T2DM

What are two common sulfonylureas?

Answer 1

Glyburide

Gliciazide

Question 2

Pharmacologic Management T2DM

How do insulin secretagogues or sulfonylureas work? What is the most efficient dose?

Answer 2

Increase beta-cell secretion of insulin

Most efficient dose is 50% max

Question 3

Pharmacologic Management T2DM

Renal impairment is a contraindication to sulfonylureas. True/False

Answer 3

True

Question 4

Pharmacologic Management T2DM

What are the Sick Day Medications?

Answer 4

S sulfonylureas
A ACE-i
D diuretics, direct renin inhibitors

M Metformin
A ARBs
N NSAID
S SGLT2-i

Question 5

Pharmacologic Management T2DM

Drug of choice in pregnancy

Answer 5

• Insulin

- Metformin is also considered acceptable (2nd line)

Question 6

Contraindications to sulfonylureas

Answer 6

• severe renal or hepatic impairment
• Hypersensitivity to sulfonylureas or sulfas
• Uncontrolled infection/burn/trauma
• Type 1 DM
• Adrenal/pituitary insufficiency
• pregnancy

Question 7

Pharmacologic Management T2DM

Most common/serious adverse rxn to sulfonylureas

Answer 7

• Hypoglycemia (higher risk w/ glyburide)

- Weight gain

Question 8

Pharmacologic Management T2DM

Patient counselling re: sulfonylureas

Answer 8

• Hypoglycemia
• Numerous interactions
• SMBG
• Photosensitivity
• Avoid alcohol
• Take with food at the same time each day

Question 9

Pharmacologic Management T2DM

What are some basal insulins, their duration of action and dosing frequency?

Answer 9

NPH

• 24 hours
• daily/BID

glargine (Basaglar, Lantus)

• 24 hours
• daily/BID

glargine hc 300 u/ml (Toujeo)

• 36 hours
• daily

detemir (Levemir)

• 6 to 24 hours
• daily or BID

degludec (100u/ml or 200u/ml)

• up to 42 hours
• daily

Question 10

Pharmacologic Management T2DM

What are some bolus insulins?

Answer 10

• regular
• aspart
• lispro

Question 11

Pharmacologic Management T2DM

Interactions for sulfonylureas (Risk x)

Answer 11

• metiglinide
• mecamylamine
• aminolevulinic acid (oral)

Question 12

Pharmacologic Management T2DM

What are some thiazolinediones?

Answer 12

• glitazones
• pioglitazone
• rosiglitazone
• troglitazone

Question 13

Pharmacologic Management T2DM

How do thiazolinediones work?

Answer 13

• improves insulin action in the cell (ie. decrease insulin resistance)

Question 14

Pharmacologic Management T2DM

What are some contraindications to thiazolindediones?

Answer 14

• hypersensitivity
• heart failure
• acute coronary events
• pregnancy

Question 15

Pharmacologic Management T2DM

Thiazolinediones drug interactions

Answer 15

• OCP’s (reduces by 30%)

- pioglitazone CYP 450 drug: +++ interactions including quinolones, azoles, etc

Question 16

Pharmacologic Management T2DM

What is the action of alpha glucosidase inhibitors (Acarbose, Miglitol)? How do you take it? What are some contraindications? Major drug interactions? What do you do if you have hypoglycaemia?

Answer 16

Inhibits CHO absorption

• TID before meals, take with the first bite!
• Contraindications: IBD, colonic ulceration, digestive disorders, GFR<25
• Major interactions: warfarin (risk bleeding), digoxin
• Reversal of hypoglycemia should be with dextrose, or if severe then IV glucose or glucagon. Sucrose, fructose, or starches will not be absorbed.

Question 17

Pharmacologic Management T2DM

What are meglitinides (repaglinide, nateglinide)? what is the indication for use?

Answer 17

insulin secretagogues, to be used if sulfonylureas not effective/successful

Question 18

Pharmacologic Management T2DM

What are the SGLT2-i drugs?

Answer 18

Canagliflozin
dapagliflozin
empagliflozin
ertugliflozin

Question 19

Pharmacologic Management T2DM

What are SGLT2-i adverse reactions?

Answer 19

Major
DKA (euglycemic)
UTIs/urosepsis/pyelo
nephrotoxicity can occur

Common
hypotension/intravascular volume depletion
increased LDL
VVC
drop in GFR up to 15% expected when initiated

Question 20

Pharmacologic Management T2DM

Amylin agonists (pramlintide) how do you take it and how do they work?

Answer 20

Modulates gastric emptying (amylinomimetic) –> improves satiety & prevents post prandial glucagon and glucose –> reduced calorie intake & weight loss

Subcut injection - avoid the arm!

Do not use in gastroparesis

Question 21

Pharmacologic Management T2DM

What are DPP4i (trade names, MOA)

Answer 21

• gliptins (sitagliptin, saxagliptin, linagliptin, Alogliptin)
• GLP-1 is an incretin hormone that stim glucose-dependent insulin secretion, increases insulin biosynthesis, and reduces appetite and food-intake. DPP-4 prevents the breakdown. It is weight neutral. Reverses microalbuminuria.

*hint incretin=secretion (insulin, also synthesis)

Question 22

Pharmacologic Management T2DM

GLP-1 agonists (Trade names, MOA, administration)

Answer 22

• Liraglutide, Exenatide, Semaglutide
• incretin hormone (increases insulin production, decreases appetite)
• subcut injection - BID dosing or weekly (extended)

Question 23

Pharmacologic Management T2DM

What are some contraindications to GLP-1?

Answer 23

IBD
pancreatitis
gastroparesis
Thyroid conditions (hyperplasia or thyroid C Cell tumour has been associated)

Question 24

Pharmacologic Management T2DM

Biguanides
MOA
Indication
Contraindications

Answer 24

• Metformin
• increases peripheral insulin uptake and utilization (improved insulin sensitivity), decreases hepatic glucose production, decreases intestinal absorption of glucose
• 1st line T2DM

CI

• GFR< 30
• HOLD 48 hours before/after radiographic dye

Precautions

• check renal fntn post imaging before restarting
• nursing infants can have hypoglycaemia