T2DM Therapeutics Flashcards by Alanna Parker

Choice if someone has HF

sglt2 —- evidence of 2nd prevention (not primary)

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Drug of choice if someone has CKD

sglt2i or GLP-1a
—- both 2nd prevention; cardio renal protective

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drug of choice if someone has CVD

sglt2i or GLp-1a

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T or F: if someone is a new T2DM w eGFR < 30 , its okay to start on metformin

F- avoid starting if eGFR < 30

fully CI if eGFR < 15

dose adjust once less than 45 (MDD 1000mg)

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Metformin A1c lowering abilities

1-1.5%

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When it metformin CI

severe renal or liver dysfunction, severe infection or dehydration, CV collapse, previous lactic acidosis

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SEs of metformin

GI, metallic taste + lactic acidosis

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Metformins impact on weight

neutral + low hypo risk

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What vitamin can metformin impact the absorption of

B12

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What should all be monitored when on metformin

A1c, SCr, Hg, and B12

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Brand names of metformin

glucophage — IR
glumetza ER (may helps with Ses; take with evening meal)

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What is lactic acidosis

elevation of blood lactate < 5, decreased pH, electrolyte disturbances w/ increased anion gap

—- normally happens when on metformin ++++ respiratory failure or renal insuffiency
—- accumulation of metformin ; decrease conversion of lactate to glucose — increased lactate production

** don’t know if metformin is cause or just associated

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What drugs are the best options for weight loss

semaglutide (injection) or tirzepatide

other high; dulaglutide + liraglutide

mid: SGLT2, exenatide, lixisenatide

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Which drugs have the highest hypo risk

premixed insulin, glinide, SU, basal insulin

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Best A1C lowers w/ metformin

premixed insulin ; GLP-1a (lower by around 1)

mid: SGLT2, SU, TZDs

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Which of the SGLT2i have to be dosed before 1st meal of the day

Canagliflozin

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SEs of SGLT2i

volume depletion, GU infections (3-4X more likely), DKA (2X), thirst, need to pee more

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T or F: don’t start an sglt2 if eFGR is less than 20

T- if already on, can leave on

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Which sglt2i has an increased risk of amputations or fracture

cana

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T or F: SGLT2i provide 2nd prevention for CKD, HF, and CVD

T- not primary
— only studied to show benefit in those who already have these conditions + preventing progression

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What to monitor when on SGLT2i

Renal fxn, volume, A1c, DKA

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MoA of SGLT2

reduce glucose reabsorption in PCT
- in T2DM: lower renal threshold for when we stop reabsorbing glucose by 4-5 mmol/L (normally stop reabsorbing at 10)
—- this counteracts this and helps us “return to normal” and stop reabsorbing glucose at normal level

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Is if normal for SGLT2i to cause an initial decline in renal fxn

yes - decrease by 4-6 mL/min
—- if decreases by more than 15-20% ; stop or decrease dose

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Which GLP-1a injection is given daily

liraglutide - daily injection
semaglutide + dulaglutide - weekly (D has to be at the same time)

rybelsus: daily PO option (taken first thing in the am with water)

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When is GLP-1a CI

thyroid medullary cancer or MENS

T or F: SA GLP-1a have more SEs than LA

T or F: we don’t know whether or not rybelsus provides the same CV protection as the other GLP-1a

F- SOUL study showed it does help reduce risk of MACE

What is tirzepatide ?

GLP-1a + GIP — no CVD evidence yet but does show to be better at weight loss + lowering A1c than ozempic

Ozempic dosing

0.25mg SC weekly x 4 wk; increase to 0.5 ; max of 1 Rybelusus: 7-14mg once daily

What DPP-4 should we avoid in HF

saxagliptin (Savor time 53 study)

which DPP-4 doesn’t have to be renally dose adjusted

lingaliptin

T or F: DPP4s help improve PP glucose control

T- helps increase duration of our natural GLP-1 by preventing its breakdown —— all its fxn comes down to our body’s normal release of GLP-1 in response to glucose

T or F: DPP4 has some evidence of 2nd CV protection

F- CV neutral

T or F: DDP4i only help improve insulin release while GLP-1a help with that + delaying gastric emptying, decreasing appetite

T — DPP4 are less potent

SEs of DPP4s

headache and nasopharygnitis - no impact on weight or hypo risk

What TzD is still on the market

pioglitazone 15-45 mg once daily - must be taken at same time daily

SEs of TZDs

edema, HF (new and worsening) , weight gain R—- MI P— bladder cancer women— fractures CI if HF or RF for HF

What are one positives of Tzds

allow for longer duration of glycemic control —negative take 6-12 wks for max effect

WHen might TZds we used

post stroke or if someone has severe insulin R

What is repaglinide

Meglitinide —- must be dosed with each meal (16mg MDD) - skip if don’t have meal - stimulates insulin release

Ses of Meglitinides

hypo, weight gain, headache - less hypo risk than SU —- little impact on A1C — short duration + rapid onset

What are the 2nd gen SUs

Glyburide (safe in preg), gliclazide (normal + MR) and glimepiride

SEs of SUs

hypo risk (highest with glyburide, lowest with gliclazide) 1st gen: increase risk of CV mortality — mid A1c lowering: decrease efficacy overtime

T or F: you should decrease your dose of SUs if old or have CKD

What is acarbose

alpha-glucosidase inhibitor — must be taken with first bite of food - avoid if GI disorder — weight neutral + low hypo risk

Does acarbose have a benefit on CV health

no - neutral

T or F: if hypo and on acarbose, you should treat with glucagon

F- dextrose of glucose (simple sugars)

When do we start T2DM on insulin

- not meeting glycemic targets - metabolic decompensation (DKA ex//)

How do we start T2DM on insulin

1) start with basal - 10 units at HS (increase 1 unit daily until reach target if glargine; degludec — increase by 4 units a week/ 2 units every 3-4 days)

How do we know what to insulin dose to start a T2DM that is less than 50kg on

use 0.1-0.2 units/kg

When do we normal stop oral meds such as SUs when getting a T2DM started on insulin

normally once start them on bolus —- bolus with largest meal (10% of basal or 4 units)

Which insulin has less hypo risk in T2DM: degludec or glargine

degludec — less nocturnal, severe, symptomatic when comparing to U100 glargine

Differences bw glargine U100 and U300 in T2DM

U300- less overall hypo, nocturnal and symptomatic hypo than U100

T or F: there is a difference in the weight gain seen bw the different basal insulins

Insulin icodec starting dose: T2DM never been on insulin

70 units weekly

Insulin icodec dosing: T2DM on previous insulin

LD: 1.5 x basal x 7 days MD: basal x7 days

Insulin Icodec dosing T1DM

A1c>/=8 - LD: 2 x basal x7 days MD: basal x 7days A1c< 8 on glargine U300 or BID basal - LD: 1.5 x basal x 7 MD: basal x7

T or F: we have seen an increase in severe hypo in those on insulin icodec in comparison to the other basal insulins

T - increase in T1DM

Is insulin icodec better at lowering A1c than other basal insulins

yes - works just as good, if not better

what is the A1c target for most T1DM and T2DM

What is the A1c target of someone with a frailty index of 4-5

7.1-8% - functionally dependent

A1c target with frailty index of 6-8

7.1-8.5

Do we use A1c to monitor efficacy in end of life

What is the best way to measure BG

fingertip — senses more rapid changes — use if think hypo, following exercise or insulin admin alternative: palm, forearm, thigh (less BF + slower changes)

What do CGM measure

BG in interstitial fluid (slight delay)

What is fructosamine and how does it work

way to measure BG - reflects average BG control over last 2-3 wks ( based on a non-enzymatic glycation of serum proteins such as albumin) - not covered only use if A1c not reliable (blood loss) + for ST glucose monitoring

IF A1c is super high, what bg reading should we focus on controlling

FPG — once closer to 7 —. focus on PPG control (this has a larger impact on A1c now)

What are the ergregious eleven

1) decrease B cell fxn or mass 2) decrease incretin effect 3) alpha cell defect: unusual glucagon release 4) adipose: decrease insulin S 5) Muscle : decrease S 6) Liver: increase insulin R 7) Brain: 8) colon: increased gastric emptying 9) Immune dysregulation 10) Stomach or SI 11) kidney: increase glucose reabsorption

T2DM Therapeutics Flashcards

(68 cards)