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OU Module Endo Fall 2018 > Pharmacotherapy of Oral Diabetes Medications Exam 2 > Flashcards

Pharmacotherapy of Oral Diabetes Medications Exam 2 Flashcards

1
Q

What is the role of self-monitoring blood glucose (SMBG)?

A
  • Assessment of current glycemic status
  • Confirms hypo- or hyperglycemia symptoms
  • Assessment of current therapy
  • Assessment of impact of intervention on glycemic control
  • Evaluation for trends in control
  • Quicker feedback than A1c
  • Identification of asymptomatic hypoglycemia
  • Identify A1c mismatch with perceived glycemic control
  • Evaluation of food and other factors on glycemia
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2
Q

What would be a reason to set an alternate A1c goal from normal?

A
  • High risk for hypoglycemia
  • High risk of complication if hypoglycemia occurs: Fall risk, hypo unawareness, etc.
  • Barriers to drug therapy required for optimal control
  • Lower risk for chronic complications (short life expectancy)
  • Elderly
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3
Q

Biguanide PK

A
  • decreases hepatic glucose production

- insulin sensitization in muscle and fat

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4
Q

Biguanide use

A

Should always be used in type 2 unless there is a C/I

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5
Q

Metformin dosing

A

most people don’t get a clinical response over 2000mg per day

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6
Q

Metformin renal dosing

A
  • eGFR ≥45 – 59: Monitor renal function every 3-6 months
  • eGFR ≥30-44: Use caution, consider 50% dose reduction, no new therapy
  • eGFR <30: Use C/I
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7
Q

Biguanide ADE

A
  • Diarrhea

* Decreased B12

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8
Q

What are risk factors for lactic acidosis? (not underlined; FYI)

A
  • acute CHF
  • dehydration
  • excessive alcohol intake
  • hepatic or renal impairment
  • sepsis
  • note: stop 48 hrs prior to imaging proc; contrast dye can put pt in acute kidney injury which would also increase risk of lactic acidosis
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9
Q

Biguanide monitoring parameters

A
  • Renal function

* B12

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10
Q

Biguanide pearls

A
  • Start low dose and titrate up
  • CVD events UKPDS
  • Can improve lipid profile
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11
Q

Sulfonylurea PK

A

increases insulin secretion

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12
Q

Glipizide dosing

A
  • for the BID dosing, should tailor medication to what time the problem of the day happens to the pt
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13
Q

Glyburide renal dosing

A

Not recommended if eGFR<60

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14
Q

Sulfonylurea ADE

A
  • Hypoglycemia

* Weight gain

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15
Q

Sulfonylurea C/I

A

Sulfa allergy

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16
Q

Sulfonylurea Place in Therapy

A
  • 2nd or 3rd line

- A1c lowering 1-2% when started as monotherapy; not as good when added as adjunct therapy

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17
Q

Sulfonylurea pearls

A

Glyburide is on the Beer’s List of Drugs to AVOID in elderly

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18
Q

Metglitinides PK

A

increases insulin secretion (glucose dependent)

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19
Q

Metglitinides dosing

A
  • dosing with meals

- no renal considerations

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20
Q

Metglitinide ADE

A
  • Hypoglycemia

* Weight gain

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21
Q

Metglitinide C/I

A

Don’t use with

gemfibrozil (decreases metabolism of metglitinide)

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22
Q

Metglitinide Place in Therapy

A

2nd or 3rd line

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23
Q

Metglitinide Pearls

A

Skip if patient skips meal

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24
Q

Thiazolidinediones PK

A
  • Max clinical effect not apparent for 6-12 wks

* Increased insulin sensitivity

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25
Q

TZDs Hepatic Considerations

A
  • Pioglitazone: If liver function test (LFT) are >3 x ULN, discontinue therapy. Do not reinitiate therapy if due to drug
  • Rosiglitazone: Do not initiate if active liver disease or LFTs >2.5 x ULN
  • no renal dosing
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26
Q

TZD ADE

A
  • Peripheral edema / fluid retention

* Elevated LFTs

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27
Q

TZD C/I

A
  • NYHA III or IV heart failure (for initiation of therapy)

* DI: gemfibrozil (decreases TZD metabolism)

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28
Q

TZD Warnings

A
  • Can exacerbate HF at any stage with fluid retention (BBW)

* Hepatotoxicity

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29
Q

TZD Monitoring parameters

A
  • LFT
  • Alkaline phosphatase
  • Total bilirubin at baseline
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30
Q

TZD Pearls

A
  • Can take up to 12 weeks to see effect

* Pioglitazone preferred over rosiglitazone

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31
Q

GLP-1 PK

A
  • increase insulin secretion
  • decrease glucagon secretion (glucose dependent)
  • slows gastric emptying
  • increases satiety
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32
Q

GLP-1 dosing

A

there are different dosing frequency anywhere from once daily to once weekly

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33
Q

Exenatide renal dosing

A

CrCl <30 stop

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34
Q

GLP-1 ADE

A

GI upset (nausea, vomiting, diarrhea)

35
Q

GLP-1 C/I

A

Personal or family history of medullary thyroid carcinoma (BBW) (Except Lixisenatide)

36
Q

GLP-1 warnings

A
  • Acute pancreatitis
  • Gallbladder disease
  • Gastroparesis
37
Q

GLP-1 Place in Therapy

A
  • Patient must be okay with injections

* CVD (Liraglutide) benefits

38
Q

GLP-1 Pearls

A
  • Promote weight loss

* CV protection

39
Q

LEADER

A
  • specific to liraglutide
  • reduced CV events and CV deaths
  • reduced all cause mortality
  • FDA added indication: risk reduction of MACE (major adverse CV events) in adults with DMII and established CVD
40
Q

DDP4 Inhibitor PK

A
  • indirectly increases insulin secretion
  • decreases glucagon secretion
  • glucose dependent
41
Q

DDP4 Inhibitor renal dosing

A

All but Tradjenta

42
Q

DDP4 Inhibitor ADE

A

Increased LFT’s

43
Q

DDP4 Inhibitor Warnings

A

• Heart failure
(saxagliptin and alogliptin) added April 2016
• Hepatotoxicity

44
Q

DDP4 Inhibitor Pearls

A

No weight gain

45
Q

SGLT-2 Inhibitor PK

A

blocks glucose reabsorption by the kidney

46
Q

SGLT-2 Inhibitor renal dosing

A

just know that they all have renal dosing

47
Q

SGLT-2 Inhibitor ADE

A

Urinary tract infections

48
Q

SGLT-2 Inhibitor C/I

A

eGFR <30

49
Q

SGLT-2 Inhibitor Warnings

A
  • Increased risk of bone fractures
  • Ketoacidosis
  • Bladder cancer (dapagliflozin)
  • Lower limb amputations (BBW) (canagliflozin)
  • Fournier’s Gangrene
  • Pancreatitis
50
Q

SGLT-2 Inhibitor Pearls (not underlined)

A
  • CV protection (empagliflozin)
  • No weight gain
  • Pleiotropic effects (decreased BP, decreased uric acid)
51
Q

EMPA-REG

A
  • specific to empagliflozin
  • reduction in: primary endpoint, CV death, all cause mortality, heart failure
  • FDA added indication: risk reduction of CV mortality in adults with type 2 and CVD
52
Q

Alpha Glucosidase Inhibitors PK

A

slows intestinal CHO digestion / absorption

53
Q

Alpha Glucosidase Inhibitors dosing

A
  • 25mg TID with meals

- skip if meal is skipped

54
Q

Alpha Glucosidase Inhibitors ADE

A

Significant GI upset (increase in gas (74%) due to fermentation of unabsorbed CHO, bloating, diarrhea)

55
Q

Alpha Glucosidase Inhibitors C/I

A
  • Inflammatory bowel disease
  • colonic ulceration
  • intestinal obstruction
  • malabsorption disorders
56
Q

Alpha Glucosidase Inhibitors Warnings

A
  • Hepatoxicity

* Renal impairment

57
Q

Amylin Analogue PK

A

reduces postprandial elevations by prolonging gastric emptying, suppresses glucagon secretion and produces satiety

58
Q

Amylin Analogue ADE

A
  • Significant hypoglycemia (BBW)
  • Headache
  • Nausea
  • Anorexia
59
Q

Amylin Analogue C/I

A

Gastroparesis

60
Q

Amylin Analogue Warnings

A

Hypoglycemia

61
Q

Amylin Analogue Place in Therapy

A

Must be okay with injections

62
Q

Place in Pearls

A
  • Weight loss

* BBW Severe hypoglycemia when co-administered with insulin (decrease mealtime insulin by 50%)

63
Q

Dopamine-2 Agonist PK

A

increases insulin sensitivity

64
Q

Dopamine-2 Agonist dosing

A
  • once daily in the morning

- no renal dosing

65
Q

Dopamine-2 Agonists ADE

A

Hypoglycemia

66
Q

Dopamine-2 Agonists Warnings

A

CV effects (not expected with Cycloset)

67
Q

Bile Acid Sequestrant (BAS) PK

A
  • 4-6 weeks onset

* decrease hepatic glucose production and increase incretin levels

68
Q

Bile Acid Sequestrant (BAS) Warnings

A

Gastroparesis

69
Q

Which medications should be used if patient is having trouble with their fasting blood glucose?

A
  • biguanide
  • TZD’s
  • SU’s
  • SGLT-2
  • Dopamine agonists
  • Bromocriptine
  • DPP4 inhibitors
70
Q

Which medications should be used if patient is having trouble with their post-prandial blood glucose?

A
  • metglitinide
  • DPP-4 inhibitors
  • GLP-1
  • AGi
71
Q

When should you measure a post-prandial blood glucose?

A

2 hrs after same meal or before the next meal

72
Q

initiation of oral therapy

A
  • Lifestyle therapy (diet and exercise) stressed for all patients
  • Start metformin and other adjunct therapy if needed
  • The rest of the order of adding medication use the step-wise thought process and think about patientcentered factors
  • Titrate medications where there is room to titrate
73
Q

Which drugs has a contraindication for Heart failure?

A
  • TZD

- DPP4 inhibitors

74
Q

Which drugs has a contraindication for Renal impairment?

A

metformin

75
Q

Which drugs has a contraindication for GI Disorders?

A
  • Agi

- GLP1

76
Q

Which drugs has a contraindication for Bone Fractures?

A
  • SLGT2

- TZD

77
Q

Which drugs has a contraindication for Hepatotoxicity?

A
  • TZD
  • DPP4
  • AGi
78
Q

Which drugs has a contraindication for Thyroid carcinoma?

A

GLP1

79
Q

ADA Recommendations in Prediabetes

A
  • Target A1c goal of 5.7-6.4%
  • Encourage lifestyle changes: 7% weight loss, increase physical activity (150min/wk)
  • Consider metformin if: BMI >35, Age <60, Women with prior GDM
80
Q

Common Barriers to Monitoring and Control

A
  • Concurrent health conditions
  • Life stressors with higher priority
  • Inadequate knowledge of why and how
  • Inadequate access or cost to meds / supplies / food
  • Poor adherence to monitoring, follow up, or meds
  • Fear of hypoglycemia, injections, monitoring or discomfort
  • World view / life view undervaluing health or future health
  • Health professional inertia
81
Q

Which medications have possible β-cell preservation?

A
  • TZD
  • GLP-1
  • DPP-4 inhibitors
82
Q

What are the meds that decrease A1c by < 1%?

A
  • GLP-1
  • Dopamine-2 Agonists
  • DDP4 Inhibitor
  • BAS
  • AGi
  • Amylin Analogue
  • Metglitinide
  • SGLT-2 Inhibitor
83
Q

What are the meds that decrease A1c by > 1%?

A
  • GLP-1
  • Dopamine-2 Agonists
  • TZD
  • Biguanide
  • Sulfonylurea

OU Module Endo Fall 2018 (27 decks)

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