Tx of T2DM - Oral Agents Flashcards
(40 cards)
What are the outcomes of large diabetes prevention studies based on lifestyle changes and meds?
- studies have shown that the biggest impact on preventing DM is lifestyle changes: increase exercise, decrease calories and fat, and losing weight
- Da Qing Study
- Finnish DM Prevention Study: 58% RRR incidence of DM
- DM Prevention Program: 58% RRR
- Toranomon Study
- Indian DPP
- studies show that meds can also prevent DM but not as effectively as lifestyle changes: TRIPOD, STOP-NIDDM, DPP, DREAM
given a pt at risk for DM, apply the lifestyle change outcomes to reduce or prevent profession to DM
- counsel of weight loss (5-10%)
- increase physical activity (at least 150 min/week)
Given a pt at risk for DM, select the medication to reduce or prevent progression to DM based on the outcomes of the prevention studies
metformin
ADA criteria for the use of metformin for prevention of DM in a pt at high risk for DM/preDM
- ADA recommends considering metformin for those at the highest risk:
- IFG + IGT plus other risk factors:
- A1c > 6%
- HTN
- positive family hx
- obese
- <60
- low HDL
- high TG
State the outcomes of the DCCT on the development or progression of microvascular diabetes complications
this study proved normalizing blood glucose could prevent or delay progression of diabetic complications
- in the primary prevention group:
- 76% RRR in the development of retinopathy
- 34% reduction in nephropathy
- 60% reduction in neuropathy
- secondary prevention group:
- 54% RRR in retinopathy
- 43% reduction in nephropathy
state the outcome of the UKPDS concerning the reduction of microvascular complications
- drug therapy group vs. diet group to control blood glucose
- outcome: 25% reduction in microvascular complications
glycemic goals of therapy for a nonpregnant adult with T2DM
- a1c
- preprandial blood glucose
- A1c: <7%
- BG: 80-130
identify pts who may safely achieve an A1c of < or equal to 6.5%
- those with a short duration of DM
- long life expectancy
- no significant cardiovascular dz
identify the pts who need less stringent A1c goals
- people who are at risk for severe hypoglycemia
- have a limited life expectancy
- have advanced complications and/or severe co-morbid diseases
- have had DM for many years and have trouble achieving <7% despite use of multiple glucose lowering meds
What are patient risk factors for the development of prediabetes/diabetes
- impaired fasting glucose
- impaired glucose tolerance test
- A1c > 5.7-6.4%
- BMI > 30
- < 60 yo
- women w/ hx of gestational DM
given a pt w/ prediabetes, choose a tx plan to reduce their risk for developing DM
- lifestyle changes are tx of choice
- if meds needed: metformin
- tx other cardiovascular risk factors: BP, lipids, smoking
- monitor for development of DM annually
Place in therapy for metformin in the tx of T2D
if lifestyle changes fail to achieve glycemic goals and have not achieved an A1c <7.5% then metformin is the drug of choice
expected clinical effect of metformin on the patient’s blood glucose control
- lowers fasting plasma glucose concentrations by about 55 mg/dl
- reduces A1c by 1-2%
- no hypoglycemia
- no weight gain
contraindications to metformin
- renal function
- unstable CHF
- liver dz
- alcohol abuse
- pregnancy/lactation
renal function guidelines for metformin use
- DO NOT use in CKD stages 4 and 5
- do not initiate therapy at stage 3B but may continue use at 1000mg max dose
- avoid initiating therapy at stage 3A if expected to become unstable but may continue use at 2000mg max
- CKD stages 1 and 2: max dose 2550 mg
initial dose of metformin
500 mg once or twice daily (Letassy said she starts w/ once daily)
titration dose of metformin
- start at 500 mg daily
- dose should be increased at the rate of 1 tab weekly
- up to a max dose of 2500 mg per day
*her example:
500mg daily x 1 week; increase to 500 mg BID x 1 month; then add 500 mg where needed
MoA of metformin
- decreases hepatic glucose production from gluconeogenesis and glycogenolysis
- increases glucose uptake in the muscle by increasing movement of glucose transporters to the cell membrane and by increasing their sensitivity to insulin and glucose
ADRs of metformin
GI are MC
- early satiety and anorexia
- nausea w/ or w/o vomiting, anorexia, diarrhea, bloating, and abdominal discomfort
what needs to be monitored when taking metformin?
- B12 concentrations
- some pts may need replacement
what is the expected clinical effect of the sulfonylureas (SU) and meglitinides on the pts BG control?
- fasting BG to drop 60-70 mg/dl
- A1c reduction of 1-2%
contraindications to SUs and meglitinides
- T1D
- DM d/t pancreatic resection
- hx of adverse rxns to SUs or sulfa drugs
- stress: emotional, severe infection, trauma, major surgery
- significant renal or hepatic dz
- those predisposed to significant hypoglycemia
MoA of SUs and meglitinides
-stimulate beta cells to release more insulin
ADRs associated w/ SUs and meglitinides
- GI: nausea, heartburn
- Derm: rash and puritis; sulfa structure and hypersensitivity
- hypoglycemia
