Week 2: Oral therapies, injectables, insulin and dosing

Question 1

Strict targets

Answer 1

AACE
<65 w no CVD
A1C<6.5%
FBG <110
PPG<140

Question 2

Loose targets

Answer 2

ADA
A1C<7.5%
FBG 80-130
PPG<180

Question 3

Sulfonylurea drugs

Answer 3

Glyburide
Glipizide
Glimepiride

Question 4

which sulfonylureas are BEERs criteria

Answer 4

glyburide and glimepiride

Question 5

SU dosing

Answer 5

qd

Question 6

When is glyburide CI?

Answer 6

CrCl <50

Question 7

SU side effects

Answer 7

HYPOGLYCEMIA
WEIGHT GAIN
N/V
rash
cholestatic jaundice
hemolytic anemia

Question 8

SU drug interactions

Answer 8

alcohol
salicylates
clofibrate
other sulfonamides
allopurinol and probenecid

Question 9

SU contraindications

Answer 9

hypersens
DKA
CrCl <50 with glyburide
preggo near term
T1DM

Question 10

SU cautions

Answer 10

impaired renal or liver fxn
elderly
sulfonamide allergy

Question 11

SU counseling

Answer 11

take first thing in the morning
take glipizide 30 min pre brekky
avoid alcohol
ask ab hypoglycemia sx and weight gain

Question 12

which DM medications may blunt myocardial ischemia preconditioning

Answer 12

SU

Question 13

SU monitoring

Answer 13

hypoglycemia!

FBG, A1C,weight gain, allergic rxn, sun sensitivity

Question 14

Do SU or Meglitinides cause more hypoglycemia?

GI upset?

Answer 14

SU cause more hypoglycemia

Meglitinides cause more N/V/GI Disturbances

Question 15

Meglitinides drugs and brand names

Answer 15

Nateglinide (Starlix) and Repaglinide(Prandin)

Question 16

Nateglinide (Starlix)dosing

Answer 16

60-120mg po TID with meals

Question 17

Repaglinide (Prandin)dosing

Answer 17

0.5-2 mg TID dep on A1C

Question 18

Meglitinides (Nateglinide and Repaglinide) SE

Answer 18

GI DISTURBANCES (~4%)
hypoglycemia
weight gain
HA

Question 19

Nateglinide DDI

Answer 19

Mifepristone

Pazopanib

Question 20

Repaglinide DDI

Answer 20

Mifepristone
Gemfibrozil
NPH (NEVER COMBO)
SU

Question 21

Nono combos in DM

Answer 21

Repaglinide and NPH

DPP4i and GLP1-RA

Question 22

Meglitinides CI

Answer 22

hypersens
T1DM
DKA
NPH
caution in severe renal disease

Question 23

Meglitinides counseling

Answer 23

admin ~30 min before meals
skip a meal, skip the dose
avoid alcohol
ask ab hypog and weight gain

Question 24

Meglitinides monitoring

Answer 24

PPG
hypog
A1C
weight gain

Question 25

Biguanides (Metformin [glucophage]) renal dosing

Answer 25

GFR >45 none 30-45 1/2 dose <30 D/C ARF D/C until reversed

Question 26

Metformin titration

Answer 26

500 dinner 500 breakfast 500 dinner 500 breakfast 1000 dinner 1000 breakfast 1000 dinner

Question 27

Metformin SE

Answer 27

``` GI UPSET WEIGHT LOSS N/V/D discomfort anorexia Vit B12 deficiency ```

Question 28

Metformin DDI

Answer 28

``` Dofetilide Dalfampridine radioplaque contrast dyes cimetidine trimpethoprim tropsium corticosteroids danazol LH Lamictal ```

Question 29

Metformin CI

Answer 29

``` hypersens renal disease/dysfxn metabolic acidosis DKA Lactic acidosis caution in elderly, excessive alcohol, CHF requiring tx ```

Question 30

Metformin counseling

Answer 30

take with food! avoid alcohol GI upset ask ab: GI SE, weight loss

Question 31

Metformin monitoring

Answer 31

``` renal fxn GI tolerance FBG/PPG A1C B12 levels ```

Question 32

TZD drugs and brand names | primary MOA

Answer 32

Rosiglitazone (Avandra) and Pioglitazone (Actos) | increase glc sensitivity in periph muscle

Question 33

TZD dosing (Rosiglitazone and Pioglitazone)

Answer 33

Rosi 4-8mg qd | Pio 15-30 mg qd

Question 34

TZD SE

Answer 34

edema (worsens HF) weight gain **bladder cancer fractures no hypoglycemia:)

Question 35

TZD BBW

Answer 35

CHF (exacerbates) sx: rapid weight gain, dyspnea, edema MI - Rosiglitazone only

Question 36

TZD CI

Answer 36

``` hypersens T1DM DKA CHF ACS active bladder cancer MI ```

Question 37

TZDs monitoring

Answer 37

``` LFTs edema weight gain cholesterol panel FBG/PPG A1C fractures ```

Question 38

a-glucosidase inhibitors (AGis) drugs and MOA

Answer 38

Acarbose (Precose) and Miglitol | dec sucrose and complex carb breakdown in sm int brush border

Question 39

AGIs dosing

Answer 39

(Both) | 25mg po TID

Question 40

AGi SE

Answer 40

abdominal pain diarrhea flatulance bloating

Question 41

AGi CI

Answer 41

``` hypersens DKA cirrhosis IBS Crohn's colonic ulceration intestinal obstruction SCr >2.0 caution in impaired rfx ```

Question 42

AGi counseling

Answer 42

take w 1st bite of each meal | ask about GI upset and timing

Question 43

AGi monitoring

Answer 43

PPG A1C Gi sx needs to be taken with meals @ 1st bite!

Question 44

Gliptins/DPP4i drugs (brand and generic) and MOA

Answer 44

Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Alogliptin (Nesina) suppress glucagon secretion slow gastric emptying dec food intake promotes B cell prolif

Question 45

Which DPP4i does not require renal dosing

Answer 45

Linagliptin

Question 46

Linagliptin (DPP4i) DDI

Answer 46

phenytoin rifampin carbamazepine st johns wort

Question 47

Which DPP4is have increased risk of HF

Answer 47

Saxagliptin and Alogliptin

Question 48

DPP4i/GLiptins SE

Answer 48

``` nasopharyngitis URI abdominal pain HA N/V/D hepatotoxicity pancreatitis HF (saxa and alo) hypog ```

Question 49

Saxagliptin (DPP4i) DDI

Answer 49

Conivaptan

Question 50

DPP4i monitoring

Answer 50

FBG/PPG, A1C, URI, GI SE

Question 51

SGLT2i drugs

Answer 51

Canagliflozin (Invokana) Empagliflozin (Jardiance) | Dapagliflozin (Farxiga) Ertugliflozin

Question 52

SGLT2i SE

Answer 52

``` genital mycotic infections inc urination UTIs weight loss ketoacidosis gangrene lower limb amputation bladder cancer (dapa) hyperkalemia (cana) ```

Question 53

SGLT2i DDI

Answer 53

``` UGT enzyme inducers rifampin ritonavir phenytoin, phenbarbitol hypotension w ACEi or ARB or diuretic digoxin ```

Question 54

SGLT2i CI

Answer 54

dialysis renal failure GFR <30 ESRD

Question 55

SGLT2i FDA approvals

Answer 55

cana: ESRD and T2DM,dec ASCVD events in T2DM, adjunct to diet and exercise dapa: ESRD and T2DM, GFR, CV death, dec HF risk, adjunct to " empa: dec CV death in T2DM, adjunct to ", no renal or HF bennies ertu: adjunct to "

Question 56

SGLT2i counseling

Answer 56

``` at the same time qd take in morning hydrate bladder cancer hx rfxn status ```

Question 57

SGLT2i monitoring

Answer 57

``` FBG/PPG A1C eGFR hydration UTI sx yeast infxns BP weight LDL-C ```

Question 58

GLP1-RA drugs (brand and generic) | and MOA

Answer 58

SQ: Exenaltide IR (Byetta), Liraglutide (Victoza), Lixisenatide (Adyixin), Exenatide ER (Bydureon, Bcise), Dulaglutide (Trulicity), Semaglutide (Ozempic SQ) PO: semaglutide po (Rybelsus) dec glucagon secretion, increase insulin prod, dec gastric emptying, inc # B cells

Question 59

GLP1-RA SE

Answer 59

``` hypoglycemia N/V/D/GERD jittery HA URI/cough inj site rxn pancreatitis cholelithiasis ```

Question 60

GLP1-RA w CVD and T2DM bennies

Answer 60

Dulaglutide (Trulicity) Liraglutide (Victoza) Semaglutide (Ozempic)

Question 61

GLP1-RA DDI (hypo and hyer g)

Answer 61

hypog: androgens, ins/SU, pegvisomat hyperg: corticosteroids, danazol, LH RH, somatropin, thiazides

Question 62

GLP1-RA BBW

Answer 62

thyroid T cell multiple endocrine neoplasia syndrome type 2 (MEN2) medullary thyroid carcinoma

Question 63

GLP1-RA that needs renal dosing

Answer 63

Exenatide

Question 64

GLP1-RAs that need to be taken within 60 min of first meal

Answer 64

exenatide (B lixenatide semaglutide po

Question 65

GLP1-RA counseling

Answer 65

``` upset GI is SE but will dec w time eat small frequent meals store if fridge until using Rybelsus (Semaglutide po) NEEDS to be taken exacty 30 min before first meal ask ab: GI upset and timing ```

Question 66

GLP1-RA dosing

Answer 66

BID: exenatide IR qd: lixisenatide, liraglutide, semaglutide po qweek: exenatide ER, semaglutide, dulaglutide

Question 67

Ultra rapid acting insulins SQ or IV? mix w NPH? onset

Answer 67

Ins Aspart: SQ pumps, no IV Ins Lispro-aabc: can mix w NPH, SQ pumps, no IV onset ~15 min

Question 68

Rapid acting insulins (BOLUS) SQ or IV? mix w NPH? onset

Answer 68

``` Humalog and Novolog eat within 15 min of using can mix w NPH SQ pumps no IV onset 15-30 min ```

Question 69

Short-acting insulins aka? SQ or IV? mix w NPH? onset

Answer 69

``` regular insulins Humilin-R and Novolin-R clear colorless SQ pumps IV in DKA tx, TPN onset 30-150 min ```

Question 70

``` Intermediate acting insulins add ons? mix w? frosting? shake? onset ```

Answer 70

``` Humulin-NPH Novolin-NPH zinc and protamine can mix w regular, aspart, lispro, glulisine frosting = potency is lost do not shake! onset 2-4h ```

Question 71

Long-acting aka? 3 types, 6 drugs onset

Answer 71

``` BASAL insulin glargine, detemir, degludec glargine = Basaglar Lantus detemir = Levemir degludec = Tresiba, Toujeo (Semglee?) ``` onset 1-9h

Question 72

what is unique about tresiba

Answer 72

ins degludec 3-5d until s-s so can only titrate q5 days dont have to worry about stacking ins and can take at any time/be inconsistent

Question 73

insulin DDI

Answer 73

``` TZDs ACEi MAOi thiazides hormones BBs AGi ```

Question 74

insulin monitoring

Answer 74

``` FBG/PPG hypog weight gain inj site rxns cough ```

Question 75

factors that affect insulin absorption rate

Answer 75

insulin type | site: abdomen

Question 76

Which DM meds cause weight gain?

Answer 76

SU Meglitinides TZD insulin

Question 77

Which DM meds cause weight loss

Answer 77

Metformin SGLT2i GLP1-RA DPP4i

Question 78

71 yo female with PMH heart failure, T2DM, HTN and dyslipidemia which guideline? what is the target range and therapeutic goal? Drug options?

Answer 78

``` loose target--> ADA A1C <7.5% FBG 80-130 PPG <180 goal is to minimize hypoglycemia ``` Metformin then SGLT2 with HF benefits (Empa or Dapa)

Question 79

``` 60 yo male with PMH gout, T2DM x 2 years A1c = 8.0% which guideline? what is the target range and therapeutic goal? Drug options? ``` what if 3 months goes by and not at goal a1c?

Answer 79

``` strict target --> AACE A1C <6.5% FBG <110 PPG <140 goal is to minimize macro and micro vascular complications ``` dual or triple therapy (1 of the therapies is metformin) GLP1RA, SGLT2i, DPP4i, TZD, SU/GLN @ 3 mo with a1c above goal, add basal insulin a1c: <8% >8% 0. 1-0.2U/kg 0.2-0.3U/kg

Question 80

55 yo patient (81kg) PMH HTN, T2DM x 3 yrs Medications: Empagliflozin 10 mg po qd, Tresiba 30U qd, Lisinopril 20 mg po qd, Metformin 1000mg po BID, Ozempic A prandial insulin dose is to be added to the patients regimen since the a1c is still above goal even after basal insulin. What guideline and basal dose should be given? what are drug options? What side effects should be monitored?

Answer 80

use AACE guidelines since the patient is under 65--> strict targets 10% of basal = 30(0.10) = 3U Humalog or Novolog eat within 15 min of using, monitor FBG,PPG lipohypertrophy (rotate injections)

Question 81

How do we start basal and bolus at the same time according to AACE (strict) guidelines?

Answer 81

0.3-0.5U/kg/d 50% as basal 50% as bolus /3 = per meal

Question 82

How do we add a basal insulin according to ADA (loose) guidelines? Bolus?

Answer 82

basal is 0.1-0.2U/kg/day | bolus is 4U/day or 10% of basal at one meal