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Type 2 Diabetes Management Flashcards

(63 cards)

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1
Q

Core management of T2DM consists of…

A

Self-management
Lifestyle modifications
Pharmacotherapy

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2
Q

When choosing therapy for T2DM, assess the following…

BG? other factors? lifestyle?

A

Glycemic control, CV + renal status, dietary patterns and weight changes.

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3
Q

Individualized A1C targets can be chosen using…

A

The Canadian Diabetes A1C calculator

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4
Q

There are three options when beginning therapy for T2DM:

A

Lifestyle changes; no pharmacotherapy
Starting metformin (+ second agent if A1C is 1.5% above target)
Starting insulin + metformin for symptomatic hyperglycemia

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5
Q

If A1C is not at target at 3 months, next steps include…

A

Starting metformin if not on pharmacotherapy
Adjust or advance therapy

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6
Q

The MOA of metformin involves the following…

3 components

A

Decreasing hepatic glucose production
Enhancing sensitivity to insulin + increase glucose utilization
Some anti-inflammatory, effect on gut microbiome

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7
Q

Dosing of metformin should be initiated slowly, at…

A

250-500mg once daily

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8
Q

Metformin can be titrated by ____ weekly, if there are no GI side effects.

A

500mg weekly

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9
Q

Desired dosing for metformin is…

A

850-1000mg BID

Max dose: 850mg TID

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10
Q

The XR formulation of metformin can be dosed…

A

Once or twice daily

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11
Q

Metformin’s efficacy on A1C is…

What about TG, LDL, HDL? Clinical outcomes?

A

1-1.5% (up to 2% in certain patients)

Shown to lower TG, LDL, and slightly increase HDL

Lowered MI + mortality in T2 patients with obesity

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12
Q

Metformin has a negative interaction with alcohol as it can…

A

Potentiate metformin’s effect on lactate metabolism (lactic acidosis)
Enhance hypoglycemic effect

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13
Q

Common adverse effects with metformin include:

A

GI - diarrhea, nausea, abdominal discomfort

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14
Q

If GI side effects are bothersome from metformin, we can try…

A

Taking it with food, or try the XR formulation (Glumetza)

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15
Q

Less common adverse effects that may result from metformin include:

A

Metallic taste (lasting for a few weeks)
Vitamin B12 deficiency with long-term use (>5 years)

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16
Q

Signs of B12 deficiency involve…

A

Anemia, peripheral neuropathy

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17
Q

Risk of hypoglycemia with metformin is…

A

Very low when used as monotherapy, perhaps with concomitant factors (alcohol, not eating, usage with sulfonylurea)

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18
Q

Metformin effect on weight is…

A

Weight neutral to modest weight loss

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19
Q

Metformin max effect is reached in…

A

~2 weeks

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20
Q

Lactic acidosis is a condition where…

A

Arterial pH is lowered, and accumulation of serum lactate is present

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21
Q

S/Sx’s of lactic acidosis include…

A

Weakness, malaise, myalgias, and heavy laboured breathing

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22
Q

Metformin is potentially correlated with lactic acidosis, due to…

A

Inhibiting the conversion of lactate into glucose in the liver

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23
Q

Those who are primarily at risk of lactic acidosis with metformin are those who have…

Kidney

A

Reduced eGFR - lactate is eliminated unchanged by the kidneys, so there will be reduced elimination

THEREFORE dose is reduced with impaired renal function

May be withheld or d/c depending on certain precautions

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24
Q

Renal impairment doses start when Clcr is below…

A

<60 mL/min

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25
eGFR between 45-59 warrants metformin dosing of...
1500 mg/day in divided doses
26
eGFR between 30-44 warrants metformin dosing of...
1000mg/day in divided doses | Check eGFR every 3 months
27
Metformin is CI when eGFR is ____. However, new studies have shown that with eGFR of ____, metformin could be continued at 500mg od but not started.
CI when eGFR is <30 mL/min. eGFR of 15-30 mL/min, do not start but can continue at metformin 500mg od
28
Risk factors for lactic acidosis involve the kidney or liver, such as...
Severe liver disease or alcohol abuse, acute illness, or severe dehydration | Also consider history of lactic acidosis
29
The MOA of sulfonylureas involve... | AKA insulin secratagogues
Enhancing secretion of insulin via binding to SU receptors on the beta cells of the pancreas | Stimulate both basal + meal-stimulated insulin release
30
2nd generation sulfonylureas include these three drugs...
Glyburide Gliclazide Glimepiride
31
These two sulfonylureas ARE on the formulary:
Glyburide and gliclazide MR
32
Usual dosing for glyburide is...
5mg BID, up to 10mg BID
33
Usual dosing for gliclazide MR is...
30-120mg OD
34
Are sulfonylureas CI in renal failure? | Discussing formulary ones
Glyburide is CI in eGFR <60 mL/min. Gliclazide is cautioned in 30-60 mL/min, CI in eGFR <30 mL/min
35
Sulfonylurea effect on A1C is...
1-1.5%, (up to 2% in drug naive and elevated A1C)
36
Sulfonylureas work quickly, and doses can be titrated...
After 2 weeks based on fasting BG, then titrate every 1-2 weeks
37
The max effective dose is reached at about ____ of the maximum dosage
60-75%
38
Long-term durability/efficacy of sulfonylureas is poor because...
Overtime, the pancreas will produce less insulin | Therefore, better response may be achieved if initiated early
39
How do sulfonylureas compare with CV outcomes?
Microvascular benefit, but neutral for macrovascular benefit
40
Hypoglycemia risk with sulfonylureas is...
High incidence, 2-30%
41
Do sulfonylureas affect weight?
Yes, weight gain ~2kg
42
Which sulfonylureas are more likely to cause hypoglycemia?
Glyburide > glimepiride > gliclazide
43
If sulfonylureas are used in the elderly, what needs to be done with the dose to help prevent hypoglycemia?
Initiate at half normal dose, and titrate up
44
Less freqent adverse effects that occur with sulfonylureas include...
Nausea Rash, photosensitivity | Cross-sensitivity with those with a sulfa allergy is very rare
45
Sulfonylureas are contraindicated in...
Pregnancy/breast-feeding Severe hepatic/renal impairment
46
Sulfonylureas should be held in acute illness due to...
Higher risk of hypoglycemia
47
Drug interactions with sulfonylureas that may increase risk of hypoglycemia include...
**Other sulfonamides, alcohol** Salicylates, warfarin, NSAID's, beta-blockers, MAOI's | Bold = important ones
48
Some drugs used with sulfonylureas may lead to lessened effects, and increased BG, such as...
Phenytoin Rifampin Colesevelam
49
Repaglinide is in a group of drugs known as ... | Short-acting, or non-SU insulin secretagogues
Meglitinides
50
Repaglinide's MOA is to...
Bind to site adjacent to SU receptor, resulting in stimulation of secretion of insulin from the pancreas
51
Repaglinide differs from other sulfonylureas because... | PK? When is it supposed to be taken?
It has a faster onset and shorter duration of action; works primarily to decrease PPG | Peak levels within 1 hour, and half-life is 1 hour
52
Repaglinide's effect on A1C is... | Differs in how it affects BG !
1 to 1.5%; primarily decreases PPG - intended to be taken before meals to improve bolus insulin release
53
Repaglinide dosing should be initiated based on... | Does it differ based on patient condition?
A1C: If below 8%, start at 0.5mg doses and titrate up. If above 8%, start at 1-2mg doses and titrate up. | LOW doses
54
Repaglinide should be titrated every...
1-2 weeks until target BG is achieved
55
Max dose of repaglinide should be:
4mg, before each meal: max dose of 16mg/day
56
Due to its short duration of action, repaglinide needs to be administered...
Right before a meal, within 30 minutes
57
Repaglinide is unique as it provides some flexibility, where a patient can...
Skip a meal, skip a dose; add a meal, add a dose
58
Repaglinides relationship to hypoglycemia is...
Higher risk, especially when combined with other agents | Lesser extent compared to SU's, and flexibility with meal dosing
59
Do repaglinides affect weight?
Yes, weight gain ~0.3 to 1kg | Similar to SU's but to a lesser extent
60
Another common adverse effect with repaglinide are...
Headaches
61
Repaglinide needs to be used with caution in... | Impairment
CrCl < 30mL/min Caution in moderate hepatic impairment and CI in severe liver disease | Clearance significantly reduced in hepatic impairment: CYP450
62
Repaglinide concentrations increase when used with: | Which CYP enzymes??
3A4 and 2C8 inhibitors | ...Repaglinide conc. decreased with 3A4 inducers
63

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