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98 Cards in this Set
- Front
- Back
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What should type 2 diabetics also receive (in addition to glucose lowering medications)?
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-ACE-I to decrease BP
-aspirin -a statin |
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What do the first and second generation sulfonylureas do?
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-increase production of insulin by stimulating the beta cells of the pancreas
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What do the short acting secretagogues do?
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-increase insulin secretion at mealtime
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What do the biguanides do?
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-decrease production of glucose in the liver and increase muscle and fat absorption of insulin
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What do the alpha glucosidase inhibitors do?
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-decrease glucose absorption by the gut
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What do the thiazolidinediones do?
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-increase insulin sensitivity in peripheral tissue, sensitizes tissues to pull glucose in
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What do the DPP4 inhibitors do?
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-decrease in breakdown of GLP
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What is the MOA of sulfonylureas?
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they exert a hypoglycemic action by stimulating pancreatic secretion of insulin. They bind to the plasma membrane of beta cells
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What is the difference between first and second generation sulfonylureas?
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-their potency and side effects as well as protein binding (all equally effective in lowering blood glucose when given in equipotent doses)
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Can sulfonylureas be used in pregnancy?
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no (they are teratogenic in animals)
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At a certain glucose level, what do sulfonylureas do?
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-cause the release of insulin that is greater than would normally be released
-helps overcome insulin resistance |
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When should sulfonylureas be taken?
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30 minutes before a meal (can cause hypoglycemia)
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What can happen to beta cells as a result of the use of sulfonylureas?
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beta cell burnout (number of beta cells decreases and their function declines)
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What are some possible adverse side effects of sulfonylureas?
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weight gain
worsened cardiac event rates (due to hyperinsulinemia) |
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What is the concern with second generation sulfonylureas?
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if you take the med and do not eat, you can become hypoglycemic
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By how much will sulfonylureas and Metformin lower HgbA1C?
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1.5-2.0%
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What are the adverse effects of sulfonylureas?
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Hypoglycemia
Hyponatremia (seen with first generation SIADH) Weight Gain Skin rash GI upset |
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What can occur if alcohol is mixed with Tolbutamide or Chlorpropamide?
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*disulfiram reaction* - does not allow alcohol dehydrogenase to break down alcohol
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What 5 agents can cause an increased hypoglycemic effect when mixed with sulfonylureas?
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-NSAIDS
-sulfonamides -acute alcohol ingestion -ranitidine -cimetidine |
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What 3 agents can cause a decreased hypoglycemic effect when mixed with sulfonylureas?
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-steroids
-diuretics -thyroid hormone |
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Can most patients with a "sulfa" allergy tolerate sulfonylureas?
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yes
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What is the MOA of meglitinides (short acting secretagogues)?
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-stimulate insulin release from the pancreas
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What does insulin release depend on with the meglitinides?
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-glucose level (effects diminish at low glucose levels so potential for hypoglycemia is reduced)
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What are the meglitinides metabolized by?
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-CYP450
-Repaglinide by 3A4 -Nateglinide by 3A4 and 2C9 |
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How are meglitinides different from sulfonylureas?
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-supposed to produce more of a physiologic insulin release after a meal than the sulfonylureas
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When should meglitinides be taken?
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30 before meal
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Which meglitinide is more effective?
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Repaglinide
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What is the only biguanide marketed in the US?
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Metformin
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Why was Phenformin (another biguanide) pulled from the market?
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it was associated with lactic acidosis
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How does Metformin differ from the sulfonylureas and meglitinides? What is its MOA?
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-does not stimulate insulin production!
-decreases hepatic glucose production (reduce gluconeogenesis) -enhances glucose utilization by the muscle |
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What does Metformin not cause? (by itself)
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hypoglycemia
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What can metformin be combined with?
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-sulfonylurea
-glitazones |
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What is Glucovance approved for?
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initial and second-line treatment of type II DM
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What is Metaglip approved for?
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initial therapy or as second-line treatment when control is not adequate on metformin or sulfonylurea alone
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What is Avandamet approved for?
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only as second-line therapy for patients who are not well controlled on metformin alone or for patients already taking both metformin and rosiglitazone
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What are 4 other benefits of Metformin?
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It is weight neutral and may cause weight loss.
Lowers LDL cholesterol and triglycerides. Lowers macrovascular disease (MI) Improves ovulatory function in insulin resistant women with polycystic ovary syndrome. (they may not necessarily have DM) |
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What are 3 adverse effects of Metformin?
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Nausea/Vomiting/Diarrhea/Metallic taste.
These side effects are dose dependent, this drug should be initiated with a slow titration and should be taken with food. Metformin can cause a decrease absorption of B12 and folic acid |
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What are possible drug interactions with Metformin?
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Drugs that compete for renal tubular secretion which would increase metformin serum concentrations: Cimetidine, digoxin, quinidine and procainamide
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Which patients should not receive Metformin?
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Renal insufficiency (male Scr > 1.5 female Scr > 1.4)
Liver disease Shock Excess alcohol consumption Dehydration Metabolic Acidosis |
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What is the rule with Metformin and contrast dye studies?
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Metformin should be held prior to contrast dye studies and for 48 hours
after, until serum creatinine returns to normal |
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What is the association between lactic acidosis and Metformin?
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Metformin inhibits mitochondrial oxidation of lactic acid.
Lactic acidosis is rare, and typically occurs in patients with renal failure or with other hemodynamic compromise (hypoxemia, dehydration) |
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How should Metformin be monitored?
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Yearly serum creatinine and liver function tests
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What are the symptoms of lactic acidosis?
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Myalgia
Malaise Hyperventilation Somnolence Abdominal pain |
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What is a better indicator for CV risk than FBG?
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post-prandial glucose
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What is the MOA of alpha-glucosidase inhibitors?
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act in the intestine to delay absorption of carbohydrates. They inhibit the enzyme alpha-glucosidase which is located in the brush border of the proximal small intestinal epithelium
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What does alpha-glucosidase normally do?
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breaks complex carbohydrates down to monosaccharides, which is what is ultimately absorbed
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Are alpha-glucosidase inhibitors strong?
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-no
-HgbA1C reductions are less than other agents |
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What is the advantage of alpha-glucosidase inhibitors?
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reduce postprandial rise in blood glucose. Their effects on fasting blood glucose is mild
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Do alpha-glucosidase inhibitors cause hypoglycemia when used alone?
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no (not systemically absorbed)
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Which patients should not receive alpha-glucosidase inhibitors?
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patients with diseases of the GI tract
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What can alpha-glucosidase inhibitors be combined with?
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insulin or sulfonylureas (when combined, can cause hypoglycemia)
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Should Metformin be combined with alpha-glucosidase inhibitors?
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not recommended
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What are the adverse effects of alpha-glucosidase inhibitors?
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-Decreased iron absorption
-Cramps, abdominal distention, flatulence,diarrhea rumbling bowel sound. This is caused by bacterial fermentation of unabsorbed carbohydrates in the colon -Some patients cannot tolerate these side effects |
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When treating hypoglycemia with alpha-glucosidase inhibitors, what substance should be given?
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GLUCOSE, not sucrose
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What are glitazones known as?
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"insulin sensitizers"
-decrease insulin resistance at tissue level -increase peripheral insulin sensitivity |
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What do glitazones require to function?
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insulin
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How long does it take for glitazones to reach full effect?
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2-3 months
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What do glitazones have the same efficacy as?
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sulfonylureas, short acting secretagogues and metformin
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What are other beneficial effects of glitazones?
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Improves endothelial function, dyslipidemia, to a small extent blood pressure and microalbuminuria
Do not cause hypoglycemia when used alone |
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How are glitazones beneficial: cardiac
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IMPROVES EPITHELIAL FUNCTION AND DECREASES c-REACTIVE PROTEIN LEVELS
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How are glitazones beneficial: BP
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LOWERS BLOOD PRESSURE TO A SMALL DEGREE
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How are glitazones beneficial: lipids
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INCREASE HDL
LDL PARTICLES BECOME DENSE AND LARGER |
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How are glitazones beneficial: fat distribution
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DECREASES FAT DISTRIBUTION IN ABDOMINAL CAVITY
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How are glitazones beneficial: pancreatic beta cells
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MAY IMPROVE OR REJUVENATE B-CELL FUNCTION (THEORY)
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Who are glitazones often given to?
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Given as monotherapy to patients with early disease where there is sufficient Beta cell function and hyperinsulinemia. Frequently given in combination with other oral agents in later disease
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What are the adverse effects of glitazones?
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Edema and weight gain (these agents can expand the blood). **Not recommended in patients with advanced heart failure).
Increase LDL (may be due to an increase in LDL particle size) Increases HDL Lowers triglycerides ???Liver toxicity |
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What is recommended before giving glitazones?
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LFTs (because of the liver toxicity associated with Troglitazone)
-baseline ALT, AST -every 2 months for the first year and periodically thereafter |
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What are the parameters for LFTs for glitazones?
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If Baseline ALT is more than 2.5 times the upper limit of normal, therapy should not be initiated.
If during treatment ALT rises more than 3 time the upper limit of normal therapy should be withdrawn. |
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What are sx of liver injury associated with glitazones?
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nausea, vomiting, abdominal pain, fatigue, anorexia, dark urine and jaundice
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When are incretin hormones (GLP-1) released from the GI tract? What do they do?
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-in response to the ingestion of nutrients
-in the pancreas they enhance glucose stimulation of insulin they also suppress glucagon secretion, decreases gastric emptying, and maintains postprandial glucose homeostasis -They self regulate glucose control, it enhances insulin secretion only in the presence of hyperglycemia |
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What do incretin hormones do in the CNS?
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-control satiety and can reduce weight in diabetic patients
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What is the dilemma with natural GLP-1 (incretin hormone)?
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-Natural GLP-1 is short acting and gets deactivated by an enzyme DPP-IV
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What is Exetanide?
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long acting GLP-1 (gila monster). An incretin mimetic. Injection only. Causes weight loss
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What is Sitaglliptan?
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a DPP IV inhibitor which prevents the breakdown of GLP-1. Oral agent. Weight Neutral
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How is risk of hypoglycemia with both incretin hormone agents?
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Risk of hypoglycemia is low with both agents, unless combined with a sulfonylurea
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Is Exetanide approved for use with other meds?
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approved use with metformin and sulfonyurea as adjuntive treatment if still poor control, has been studied with TZD
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Is Sitagliptan approved for use with other meds?
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approved use with diet and exercise to improve glucose control in type 2 DM and approved to be used with oral agents such as metformin or a TZD
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When should Sitagliptan be taken?
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-1 hour before a meal, do not give after a meal
-Take meds (such as analgesics) 1 hour before injecting Byetta |
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What is Symlin?
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-a synthetic human hormone that is co-secreted with insulin by the beta cell (This hormone that is secreted in the body is known as amylin)
-Symlin is a antihyperglycemic drug that should be used in patients being treated with insulin who fail to achieve adequate glycemic control |
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Do diabetics have amylin?
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Amylin is deficient in diabetics, in Type I DM they have little to no amylin
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How often is Symlin given?
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2x daily before a major meal
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What are the benefits of Symlin?
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slows gastric emptying, decreases postprandial glucose concentrations, regulates food intake (appetite)
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What are the adverse effects of Symlin?
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Nausea and hypoglycemia
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Why is Symlin dangerous?
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Should only be used in patients that meet a criteria, can be dangerous because it is associated with severe hypoglycemia (boxed warning)!!
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How much should short acting insulin be decreased when using Symlin?
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Decrease short acting insulin by 50% because can cause hypoglycemia with insulin
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What should Symlin not be given with?
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Drugs that alter GI motility
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Who should not receive Symlin?
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Patients with poor compliance with insulin and monitoring blood glucose
A1C>9% Patients with recurring hypoglycemia Confirmed gastroparesis Pediatrics Use of drugs that stimulate GI motility |
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When should insulin be started in T2DM?
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-Not too soon
-Defect in insulin secretion may not be primary defect -Insulin therapy associated with higher risk for hypoglycemia -Insulin therapy can cause weight gain and chronic hyperinsulinemia |
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When should insulin be started in T2DM?
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-May not ensure sufficient glycemic control
-May be refused by patient |
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At what blood glucose level will pts begin to experience significant CNS sx?
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50 mg/DL
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At what BG should tx be given for elderly?
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70 mg/dL
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How often should BG be tested if hypoglycemia suspected?
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every 15 minutes repeating carbs if necessary until normal range is attained
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How should severe hypoglycemia be treated?
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-glucagon 1 mg SQ (arousal in 20 minutes)
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What are some side effects of glucagon?
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n/v
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Should glucagon be given to pts with hypoglycemia from starvation?
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No because starvation depletes glycogen and glucagon works by breaking down glycogen
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Which foods/drinks have 15 g equivalent of carbs?
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Lifesavers 8 candies
Sugar sweetened soft drink 4-6 oz Fruit Juice 4 oz Glucose tablets 2-4 tablets Glucose gel 1-2 tubes Skim Milk 8 oz |
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What is the Dawn Phenomenon?
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-A rise in plasma glucose and insulin requirements during early morning
-Associated with glucose production rather than impaired utilization -Caused by an elevation in counter regulatory hormones -Response is individualized -Depends on BG management, stress, illness, menses etc |
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What is the Somogyi Effect?
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Rebound hyperglycemia
Hyperglycemia following hypoglycemia Difficult to differentiate from the dawn phenomenon 2-3 AM BG for diagnosis Extremely dangerous |
