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Endocrinology > T2DM Drugs > Flashcards

T2DM Drugs Flashcards

1
Q

Examples of SGLT2 inhibitors

A

“flozins”

  • Dapagliflozin
  • Canagliflozin
  • Empagliflozin
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2
Q

Examples of DPP-2 inhibitors

A

“gliptins”

  • Alogliptin
  • Linagliptin
  • Saxagliptin
  • Sitagliptin
  • Vildagliptin
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3
Q

Examples of GLP-1

A
  • Dulaglutide
  • Exenatide
  • Liraglutide
  • Lixisenatide
  • Semaglutide
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4
Q

Examples of Sulfonylurea’s

A
  • Gliclazide
  • Glimepiride
  • Glipzide
  • Tolbutamide
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5
Q

Contraindications of DPP-4 inhibitors “gliptins”

A

Ketoacidosis

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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
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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
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8
Q

Contraindications of SGLT2 inhibitors “flozins”

A

Ketoacidosis

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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.
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10
Q

DPP-4 inhibitors (“Gliptins”) effect on weight

A

None

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11
Q

GLP-1 effect on weight

A

Loss

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12
Q

Insulin effect on weight

A

Gain

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13
Q

Pioglitazone effect on weight

A

Gain

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14
Q

SGLT-2 inhibitor effect on weight

A

Loss

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15
Q

Sulfonyylurea effect on weight

A

Gain

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16
Q

DPP-4 inhibitors (“Gliptins”) risk of Hypoglycaemia

A

Low

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17
Q

GLP-1 risk of Hypoglycaemia

A

Low

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18
Q

Insulin risk of Hypoglycaemia

A

High

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19
Q

Pioglitazone risk of Hypoglycaemia

A

Low

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20
Q

SGLT2 inhibitors (“flozins”) risk of Hypoglycaemia

A

Low

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21
Q

Sulfonylurea risk of Hypoglycaemia

A

Moderate, High in older people

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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
Q

Renal impairment with Pioglitazone

A

No warnings

26
Q

Renal impairment with SGLT2 inhibitors (“flozins”)

A

Dose reduction or caution or avoid (check eGFR thresholds)

27
Q

Renal impairment with Sulfonylurea

A

Dose reduction or caution or avoid (check eGFR thresholds)

28
Q

Hepatic impairment with DPP-4 inhibitor (“Gliptins”)

A

Caution or avoid (not for linagliptin and sitagliptin)

29
Q

Hepatic impairment with GLP-1

A

Caution or avoid (not for Dulaglutide, exenatide and lixisenatide)

30
Q

Hepatic impairment with Insulin

A

Dose reduction

31
Q

Hepatic impairment with SGLT2 inhibitors (flozins”)

A

Caution or avoid

32
Q

Hepatic impairment with Pioglitazone

A

Avoid

33
Q

Hepatic impairment with Sulfonylurea

A

Caution or avoid

34
Q

Contraindications of Metformin

A

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
Q

Metformin effect on weight

A

None

36
Q

Metformin hypoglycaemia risk

A

Low

37
Q

Renal impairment with Metformin

A

Dose reduction or avoid (check eGFR thresholds)

38
Q

Hepatic impairment with Metformin

A

Withdraw if tissue hypoxia likely

39
Q

What T2DM drug has a proven cardiovascular benefit

A

SGLT2 inhibitors
(Sodium-glucose co-transporter 2 inhibitors)

40
Q

What is the first line pharmacological treatment of T2DM

A

Metformin

Or metformin MR if GI disturbance

41
Q

First line treatment for T2DM in patients with Chronic heart failure or established atherosclerotic CVD

A

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
Q

First line treatment for T2DM in patients with High risk of CVD or

A

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
Q

What is the first-line pharmacological treatment of T2DM if there is no high CVD risk and Metformin in contraindicated

A
  • 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
Q

What is the “rescue” therapy in a patient with T2DM

A

For symptomatic hyperglycaemia, consider insulin or Sulfonylurea and review when blood glucose control has been achieved

45
Q

Further treatment for T2DM at any point if HBA1c not controlled or below individually agreed threshold

A

Switch or add treatments:
Consider:

  • DPP-4 inhibitor “Gliptin” or
  • Pioglitazone or
  • Sulfonylurea

SGLT2 inhibitors optional in dual or triple therapy

46
Q

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)

A

Switch or add SGLT2 inhibitor

47
Q

When to give GLP-1 mimetic treatments

A

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
Q

Side effects of GLP-1 agonists

A
  • Nausea and vomiting
  • Acute pancreatitis (rare)
  • Lipodystrophy at site of injections if injection sites aren’t rotated
49
Q

Side effects of Sulfonylureas

A

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
Q

Side effects of SGLT2 inhibitors “flozin”

A
  • 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
Q

Example of a Thiazolindinedione

A

Pioglitazione

52
Q

Side effects of Pioglitazone

A
  • 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
Q

Side effects of Metformin

A
  • 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
Q

Monitoring requirements with Metformin

A

Renal function before starting treatment and at least annually thereafter

Endocrinology (6 decks)

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