Antidiabetics & Chf

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Regular Insulin (Novolin-R, Humulin-R) ;
Humalog (Lispro) ;
Novolog (Aspart)

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Onset: rapid
Duration: short-acting

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NPH Insulin (Novolin-N, Humulin-N)

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Intermediate-acting

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Levemir (Detemir) and Lantus (Glargine)

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Onset: Slow
Duration: Long-acting

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how is Regular Insulins, Lispro, and Aspart administered?

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Soluble - used IV in emergencies OR subQ for glycemic maintenance

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how is NPH insulins administered

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Not Very Soluble - subQ injection
Directions: once in the morning and once in the evening to provide basal level of insulin for 24 hours

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how are Detemir and Glargine administered

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Not Very Soluble - subQ injection
Directions: once a day to provide a basal level of insulin for 24hrs

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Insulin Secretory Drugs (Insulin Secretagogues)

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1. Glyburide (Diabeta, Micronase)
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Nateglinide (Starlix)

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Insulin-Sensitizing Drugs

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1. Metformin (Glucophage, Fortamet, Riomet)
2. Rosiglitazone (Avandia)
3. Pioglitazone (Actos)

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alpha-Glucosidase Inhibitors

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Acarbose (Precose)

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Incretin Mimetics

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Exenatide (Byetta)

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Dipeptidyl Peptidase IV Inhibitors

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Sitagliptin (Januvia)

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Amylin Analogs

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Pramlintide (Symlin)

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Type 1 Diabetes Mellitus

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deficiency of insulin production
1. destruction of beta cells due to autoimmune antibodies, viruses, or chemical toxins
2. not associated with obesity
3. high incidence of ketoacidosis

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Type 2 Diabetes Mellitus

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extrapancreatic peripheral tissues show resistance to certain actions of insulin
1. genetically determined and associated with obesity

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Main functions of endogenous insulin in the liver

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1. increased synthesis and insertion of additional glucose transporters into liver cell membranes which would then FACILITATE GLUCOSE UPTAKE
2. decreased hepatic output of glucose
3. decreases the conversion of fatty acids to keto acids in the liver

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Main functions of endogenous insulin in skeletal muscle

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1. increases glucose transport into muscle cells by causing more synthesis and insertion

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Main function of endogenous insulin in adipose tissue

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1. increasing glucose transport into the fat cells via increased synthesis and insertion of additional glucose transporters into fat cell membranes

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Unwanted Effects of Insulin Use

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1. Severe Hypoglycemia
2. allergy
3. Local Lipodystrophy
4. Weight gain

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How do you take care of severe hypoglycemia associated with insulin

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rapid administration of glucose or of glucagon

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Mechanism of Action of Glyburide and Glipizide

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stimulate the release of endogenous insulin
1. close certain potassium channels in pancreatic beta cell membrane - opens calcium channels (Independent of the level of blood glucose)
2. 2nd generation - more potent - work in T2D

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Mechanism of Action of Repaglinide and Nateglinide

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stimulate the release of endogenous insulin
1. close potassium channels in pancreatic beta cells - opens calcium channels (Dependent of the level of blood glucose)
2. work in T2D

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Metabolism and duration of Glyburide and Glipizide

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metabolized: liver
Excreted: liver or kidney
Duration: a few hours to many hours

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Metabolism and duration of Repaglinide and Nateglinide

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Metabolized: liver
Duration: rapid-acting

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Unwanted effects of Glyburide, Glipizide, Repaglinide, Nateglinide

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1. too much hypoglycemia
2. Weight gain
3. drug allergy (skin reaction)

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Mechanism of Action of Metformin

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Antihyperglycemic agent (not hypoglycemic)
1. reduces blood glucose by improving sensitivity of peripheral tissues to insulin action on glucose uptake and storage
2. decreases hepatic glucose output (PRIMARY MECHANISM)
3. decrease absorption of glucose and lower blood pressure and serum lipids)

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Metabolism of Metformin

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rapid renal excetion unchanged and requires good renal function

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Unwanted Effects of Metformin

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1. Gastrointestinal (nausea, anorexia, diarhea) common
2. Lactic Acidosis - rare

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Mechanism of Action of Rosiglitazone and Pioglitazone

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ANTIHYPERGLYCEMIC AGENT
1. activation of nuclear receptors known as peroxisome proliferator-activated receptors (PPARs)
2. leads to increased glucose uptake and decreased circulating glucose

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Metabolism of Rosiglitazone and Pioglitazone

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Require good liver function
Metabolism: Hepatic
Excretion: Biliary/Fecal

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Unwanted Effects of Rosiglitazone and Pioglitazone

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1. Vascular flui retention and some edema
2. increase risk of bone fractures in women
3. Weight Gain

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Black Box Warning of Rosiglitazone

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increase incidence of myocardial infarction

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Mechanism of Action of Acarbose

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USED AS ADJUNCTIVE THERAPY
1. lower plasma glucose by inhibiting intestinal alpha-glucosidase enzymes responsible for digestion of complex carbs
2. delay postprandial absorption of glucose = attenuation of postprandial increases in plasma glucose
BENEFITS: "smooth out" postprandial glucose peaks

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Metabolism of Acarbose

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minimally absorbed
Metabolized: by intestinal digestive enzymes
Excreted: in the urine
Duration: a few hours
Doses: no fixed dose, should be titrated per individual

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Unwanted Effects of Acarbose

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1. GI disturbances (flatulence, cramping, distension, diarrhea) = due to fermentable unabsorbed carbs)

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Mechanism of Action of Exenatide (Byetta)

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1. binds to and activates human GLP-1 receptors
2. enhances glucose dependent insulin secretion
3. inhibits glucagon secretion
4. slows gastric emptying
5. increases the sensation of satiety

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Administration of Exenatide (Byetta)

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SubQ before meals

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Unwanted Effects of Exenatide (Byetta)

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1. Hypoglycemia (when combined with a sulfonylurea)
2. high incidence of GI effects

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Mechanism of Action of Sitagliptin (Januvia)

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1. Rapidly inactivates endogenous incretin hormones after they are released from the intestines
2. increase glucose dependent insulin release
3. decrease glucagon release from the pancreas

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Administration of Sitagliptin (januvia)

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taken orally once daily

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Unwanted effects of Sitagliptin (Januvia)

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1. Hypoglycemia (combined with a sulfonylurea)
2. Upper respiratory infection, headache
3. hypersensitivity (RARE)

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Mechanism of Action of Pramlintide (Symlin)

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stable injectable peptide analog of amylin
1. slows gastric emptying
2. inhibits glucagon secretion
3. increases the sensation of satiety
*Used as adjunctive therapy in both T1D and T2D

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Administration of Pramlintide (Symlin)

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SubQ before meals

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Unwanted Effects of Pramlintide (Symlin)

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1. Hypoglycemia (combined with insulin)
2. GI side effects

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General Treatment Considerations of Type 1 Diabetes

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1. Dietary Instruction
2. parenteral Insulin administration
3. careful attention by the patient to things that change insulin requirements

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2 Medications often recommended in Type 1 Diabetes

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1. alpha-glucosidase inhibitor in combo with insulin taken orally before meals
2. injectable amylin analog Pramlintide

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General Treatment Considerations of Type 2 Diabetes

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1. Reduce Obesity
2. Lower Blood glucose by dietary means

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Medications often recommended in Type 2 Diabetes

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1. start with a sulfonylurea
2. add metformin, a glitazone, or insulin
3. can add on an alpha-glucosidase inhibitor if postprandial glucose peaks are still high
4. Exenatide, Pramlintide, Sitagliptin can be added

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Congestive Heart Failure

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Ventricles are unable to pump out all the blood normally being returned to them. Blood backs up in the lungs and systemic veins, left ventricle fails initially

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Signs and Symptoms of Left-Ventricular CHF

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1. Respiratory Wheezing (first indication)
2. nonproductive cough
3. dyspnea on exertion
4. fatigue, weakness, exercise intolerance

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Signs and Symptoms of Right Ventricular CHF

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1. Pitting Edema
2. Sacral Edema
3. Hepatomegaly & Hepatic Engorgement

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Factors that can influence Cardiac Output

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1. Intrinsic Contractility
2. Preload
3. Afterload
4. Heart Rate

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Compensatory Mechanisms in CHF

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1. Cardiac Hypertrophy
2. Increased Sympathetic Nervous System Activity
3. RAAS Activity

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Primary Objective of therapeutic management of CHF

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relieve symptoms and prolong life

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2 most important actions of digitalis glycosides for treatment of CHF

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1. increased myocardial contraction
2. decreased heart rate

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Primary mechanism of digitalis glycosides when increasing myocardial contractility

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1. inhibit Na/K pump, increases intracellular Na
2. blocks Na/Ca exchanger, increased intracellular Ca
3. increased contractility, increased cardiac output
4. excretion of Na and water, decreased congestion

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Vagal slowing in how digitalis glycosides decrease heart rate

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*reversal of SNS-induced reflex tachycardia*

can involve several sites (autonomic ganglia and cardiac sites and carotid baroreceptors

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Diuretic action of digitalis glycosides

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*produce copious urine output
*no notable direct effect on the renal tubules
*increased urine output is secondary consequence of improved hemodynamics due to cardiac actions

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Drug Interactions with Digitalis Glycosides

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1. Quinidine = increases levels of digoxin
2. Verapamil = inhibit renal clearance
3. antacid gels, sulfasalazine, bile acid binding resins

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General Digitalis Toxicity

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manifest toxicity on virtually all systems due to too much inhibition of Na/K-ATPase, thus too much intracellular concentration of free calcium

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Digitalis Toxicity

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1. GI = anorexia, nausea, vomiting, diarrhea
2. Cardiac = arrhythmia, tachycardias, fibrilliations
3. CNS = delirium
4. Blurred Vision

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Treatment of Digitalis Toxicity

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*Pay attention to Potassium levels*
1. potassium chloride orally or IV
2. Discontinue medication or decrease dose
3. Digoxin Antibody

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Digoxin Immune Fab (Digibind)

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*antigen binding fragments that bind to digoxin and form complex.......complex excreted in urine

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Dobutamine

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synthetic catecholamine-like B1 agonist given only IV in intensive care to treat severe, refractory congestive heart failure

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Side effects of Dobutamine and Dopamine

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tachycardia and increase in cardiac oxygen demand
*tolerance can develop*

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Dopamine

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endogenous catecholamine given only IV in intensive care to treat severe, refractory congestive heart failure

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Inamrinone and milrinone

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used intravenously for treatment of severe, refractory CHF or after tolerance to dopamine or dobutamine develops

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Mechanism of Action of Inamrinone and milrinone

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1. inhibition of cAMP inaction = increases ventricular cel cAMP content = increased free Ca availability
2. stimulates more SR Ca uptake during diastole
*little or no tolerance develops

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ACE Inhibitors used for CHF

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1. Captopril
2. Enalapril
3. Fosinopril
4. Quinapril

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problem with some ACE inhibitors in congestive heart failure

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some are prodrugs that are activated in the liver which may be congested in CHF

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Side effects of ACE inhibitors in CHF

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1. Non-Productive Cough (due to high levels of bradykinin)

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drug interactions with ACE inhibitors in CHF

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use with diuretics = too much reduction in arterial BP

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Angiotensin 2 Receptor Blockers used in CHF

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1. Losartan
2. Valsartan
3. Candesartan

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Mechanism of action of ACE inhibitors and ARBs

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decreases in vasoconstriction and aldosterone levels

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Diuretics used in CHF

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1. Thiazides
2. Loops
3. K-sparers

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how diuretics work in CHF

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1. marked retention of sodium and water
2. reduce extracellular fluid volume
3. reduce preload, relieve pulmonary congestion, and reduce peripheral edema

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Spironolactone and Epleronone

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multiple benefits in patients with CHF because aldosterone levels are very high

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how direct vasodilators work in CHF

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1. can inhibit vasoconstriction and reduce the impedance(afterload) and improve hemodynamic effect
2. can also decrease preload by increasing venous capacitance through venodilation

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Direct Vasodilators that work by reducing preload

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1. Nitroglycerin
2. Isosorbide Dinitrate

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Direct Vasodilators that work by reducing afterload

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1.hydralazine

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Direct Vasodilator that works by reducing preload and afterload

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Nitroprusside

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Direct Vasodilator and a diuretic

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Nesiritide = decreases arterial and venous smooth muscle tone by increasing intracellular levels of cGMP

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CHF patients most benefited from Vasodilators

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1. severe CHF refractory to other therapies
2. right after acute myocardial infarction with preexisting chronic CHF

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Beta Blockers used in CHF

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1. Bisoprolol
2. Metoprolol
3. Carvedilol

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why are Beta Blockers effective in CHF

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prevent chronic adverse effects of high endogenous catecholamines like:
1. prevent down regulation of beta receptor numbers and related functions
2. prevent excessive tachycardia and arrhythmias