T2DM Drugs Flashcards
(54 cards)
1
Q
Examples of SGLT2 inhibitors
A
“flozins”
- Dapagliflozin
- Canagliflozin
- Empagliflozin
2
Q
Examples of DPP-2 inhibitors
A
“gliptins”
- Alogliptin
- Linagliptin
- Saxagliptin
- Sitagliptin
- Vildagliptin
3
Q
Examples of GLP-1
A
- Dulaglutide
- Exenatide
- Liraglutide
- Lixisenatide
- Semaglutide
4
Q
Examples of Sulfonylurea’s
A
- Gliclazide
- Glimepiride
- Glipzide
- Tolbutamide
5
Q
Contraindications of DPP-4 inhibitors “gliptins”
A
Ketoacidosis
6
Q
Contraindications of GLP-1
A
- Ketoacidosis
- Severe GI disease (not for liraglutide or semaglutide)
- Liraglutide: diabetic gastroparesis, IBD
- Use with caution in patients with a history if acute pancreatitis and diabetic retinopathy
7
Q
Contraindications of Pioglitazone
A
- History of HF
- Bladder cancer (previous or current)
- Uninvestigated macroscopic haematuria
use with caution in:
- elderly
- patients at risk of bone fractures
8
Q
Contraindications of SGLT2 inhibitors “flozins”
A
Ketoacidosis
9
Q
Contraindications of Sulfonylurea
A
- Pregnancy
- Ketoacidosis
- Acute porphyrias
- Caution in the elderly and those with G6PD deficiency
- When used as a monotherapy (which is not recommended due to adverse effects), gliclazide increases the risk of cardiovascular disease and myocardial infarction.
10
Q
DPP-4 inhibitors (“Gliptins”) effect on weight
A
None
11
Q
GLP-1 effect on weight
A
Loss
12
Q
Insulin effect on weight
A
Gain
13
Q
Pioglitazone effect on weight
A
Gain
14
Q
SGLT-2 inhibitor effect on weight
A
Loss
15
Q
Sulfonyylurea effect on weight
A
Gain
16
Q
DPP-4 inhibitors (“Gliptins”) risk of Hypoglycaemia
A
Low
17
Q
GLP-1 risk of Hypoglycaemia
A
Low
18
Q
Insulin risk of Hypoglycaemia
A
High
19
Q
Pioglitazone risk of Hypoglycaemia
A
Low
20
Q
SGLT2 inhibitors (“flozins”) risk of Hypoglycaemia
A
Low
21
Q
Sulfonylurea risk of Hypoglycaemia
A
Moderate, High in older people
22
Q
Renal impairment with DPP-4 inhibitors (“Gliptins”)
A
Dose reduction or caution (not for linagliptin)
23
Q
Renal impairment with GLP-1
A
Dose reduction or caution or avoid (depends on eGFR thresholds)
24
Q
Renal impairment with Insulin
A
Dose reduction
25
Renal impairment with **Pioglitazone**
No warnings
26
Renal impairment with **SGLT2 inhibitors** (“flozins”)
Dose reduction or caution or avoid (check eGFR thresholds)
27
Renal impairment with **Sulfonylurea**
Dose reduction or caution or avoid (check eGFR thresholds)
28
Hepatic impairment with **DPP-4 inhibitor** (“Gliptins”)
Caution or avoid (not for linagliptin and sitagliptin)
29
Hepatic impairment with **GLP-1**
Caution or avoid (not for Dulaglutide, exenatide and lixisenatide)
30
Hepatic impairment with **Insulin**
Dose reduction
31
Hepatic impairment with **SGLT2 inhibitors** (flozins”)
Caution or avoid
32
Hepatic impairment with **Pioglitazone**
Avoid
33
Hepatic impairment with **Sulfonylurea**
Caution or avoid
34
Contraindications of **Metformin**
Acute metabolic acidosis (including lactic acidosis and diabetic ketoacidosis).
Use with caution in patients at risk of lactic acidosis (e.g., chronic heart failure, chronic alcohol abuse) and in patients with an eGFR less than 30.
35
**Metformin** effect on weight
None
36
**Metformin** hypoglycaemia risk
Low
37
Renal impairment with **Metformin**
Dose reduction or avoid (check eGFR thresholds)
38
Hepatic impairment with **Metformin**
Withdraw if tissue hypoxia likely
39
What T2DM drug has a proven cardiovascular benefit
SGLT2 inhibitors
(Sodium-glucose co-transporter 2 inhibitors)
40
What is the first line pharmacological treatment of T2DM
**Metformin**
Or metformin MR if GI disturbance
41
**First line** treatment for T2DM in patients with **Chronic heart failure or established atherosclerotic CVD**
Start Metformin alone to assess tolerability THEN add a SGLT2 inhibitor (“flozin”) as it has a proven cardiovascular benefit
*Offer SGLT2 alone of Metformin contraindicated*
42
**First line** treatment for T2DM in patients with **High risk of CVD** or
Start Metformin alone to assess tolerability THEN add a SGLT2 inhibitor (“flozin”) as it has a proven cardiovascular benefit QRISK of 10% or higher or elevated lifetime risk
*Offer SGLT2 alone of Metformin contraindicated*
43
What is the **first-line** pharmacological treatment of T2DM if there is **no high CVD risk and Metformin in contraindicated**
- DPP-4 inhibitor “Gliptin”
- Pioglitazone
- Sulfonylurea
- an SGLT2 inhibitor for some people
*Only a monotherapy in those who have contraindications to Metformin and if only a DPP-4 would otherwise be prescribed and a Sulfonylurea or Pioglitazone is not appropriate*
44
What is the **“rescue” therapy** in a patient with T2DM
For symptomatic hyperglycaemia, consider insulin or Sulfonylurea and review when blood glucose control has been achieved
45
Further treatment for T2DM at any point if HBA1c not controlled or below individually agreed threshold
Switch or add treatments:
Consider:
- DPP-4 inhibitor “Gliptin” *or*
- Pioglitazone *or*
- Sulfonylurea
SGLT2 inhibitors optional in dual or triple therapy
46
Further treatment for T2DM at any point if cardiovascular risk or status changes e.g. person has or develops chronic HF or established atherosclerotic CVD or if a person has or develops high risk if CVD (QRISK >10% or elevated lifetime risk)
Switch or add SGLT2 inhibitor
47
When to give GLP-1 mimetic treatments
If triple therapy with Metformin and 2 other oral drugs is not effective, not tolerated or contraindicated = consider triple therapy by switching one drug with GLP-1 mimetic for adults with type 2 DM who:
- BMI 35 or higher (adjust according to ethnicity)
- BMI<35 **BUT** insulin is not suitable or weight loss would benefit other significant obesity related comorbidities
48
Side effects of GLP-1 agonists
- Nausea and vomiting
- Acute pancreatitis (rare)
- Lipodystrophy at site of injections if injection sites aren't rotated
49
Side effects of Sulfonylureas
Common side effects of sulfonylureas include:
- Hypoglycaemia
- Weight gain
Less common side effects include:
- Hyponatraemia secondary to syndrome of inappropriate ADH secretion (SIADH)
- Hepatotoxicity
- Peripheral neuropathy.
50
Side effects of SGLT2 inhibitors "flozin"
- Genital and urinary tract infections
- Hypoglycaemia
- (Rarely) euglycaemic diabetic ketoacidosis
It is therefore important to have a low index of suspicion of this in any unwell diabetic patient on a gliflozin, regardless of them having a normal blood glucose level.
- They may also cause weight loss, which may be useful in patients with type 2 diabetes mellitus.
51
Example of a Thiazolindinedione
Pioglitazione
52
Side effects of Pioglitazone
- Weight gain
- Liver impairment (LFTs before treatment and therafter)
- Bone fracture
- Fluid retention (they are therefore contraindicated in heart failure)
- Increased risk of bladder cancer
*They are less commonly used due to their adverse effect profile.*
53
Side effects of Metformin
- GI upset (diarrhoea and abdominal pain). This is intolerable in 20% of patients and may be discontinued due to this. Modified-release metformin should be considered instead. In order to reduce the incidence of gastrointestinal side-effects, the dose of metformin should be titrated up slowly.
- Lactic acidosis. This is a rare side effect, and mainly in patients with severe liver disease and renal failure, or if taken during a period where there is tissue hypoxia. For example, sepsis, acute kidney injury (AKI), severe dehydration or recent myocardial infarction.
*Notably, it does not typically cause hypoglycaemia or weight changes.*
54
Monitoring requirements with Metformin
**Renal function** before starting treatment and at least annually thereafter
