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104 Cards in this Set
- Front
- Back
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Metformin Brand
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Glucophage, Fortamet
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Metformin MOA
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Decrease hepatic glucose production
Decrease intestinal glucose absorption Improve insulin sensitivity by increasing peripheral glucose uptake and utilization |
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Metformin ADE
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Weight loss
NVD Cramping Flatulence Decreased b12 and folic acid absorption Lactic Acidosis: muscle pain, SOB, weakness, fatique |
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Metformin Contraindications
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Renal dysfunction
Heart failure Metabolic Acidosis |
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Metformin Monitoring parameters
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A1C quarterly
SMBG ADE Renal function (SCR, CrCl) baseline and annually |
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Metformin initial and titration dose
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500mg d x 1 week,
increase to bid Titrate to 2000mg d as tolerated |
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Metformin administration
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To reduce GI effects, take with meals and start with low dose
Titrate every 1 to 2 weeks |
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Sulfonylurea MOA
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Stimulate insulin release from B cells of pancreas
Binds to receptor on ATP dependent potassium channel, causing depolarization of the cell membrane, leading to opening and increased intracellular Ca and insulin release |
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Sulfonylurea ADE
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Hypoglycemia
Weight gain Disulfuram reaction and flushing |
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Sulfonylurea Contraindications
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Type 1 Diabetes
DKA Anaphylactic sulfa allergy |
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Sulfonylurea Administration
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20-30 minutes ac
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Sulfonylurea Monitoring Parameters
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A1C quarterly
SMBG ADE Renal function at baseline and annually |
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Glipizide Brand
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Glucotrol
Glucotrol XL |
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Glipizide Dose and titration
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IR: 5-40mg d (dividing into bid)
XL: 5-20 mg d (Don't use if CrCl <10ml/min) |
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Glyburide Brand
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Micronase
Diabeta |
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Glyburide Dose and Titration
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2.5 - 20mg d (divided into bid)
(Do not use if CrCl <50ml/min) |
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Glimepiride Brand
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Amaryl
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Glimepiride Dose and Titration
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1-8mg
(Don't use if CrCl <30ml/min daily) |
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Short Acting Insulin Secretagogues
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Repaglinide, Nateglinide
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Insulin Secretagogues MOA
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Stimulates insulin secretion from B cells
Insulin release seems to be glucose dependent and diminish low glucose levels Targets post prandial glucose spikes to reduce prandial glucose |
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Insulin Secretagogues ADE
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Hypoglycemia
Weight gain |
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Insulin Secretagogues Administration
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Up to 30 minutes prior to each meal
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Insulin Secretagogues Monitoring Parameters
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A1C quarterly
SMBG ADe |
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Repaglinide Brand
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Prandin
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Nateglinide Brand
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Starlix
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Nateglinide dose
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120mg tid with each meal
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Glucagon-like Peptide 1 (GLP 1 Agonists)
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Exenatide
Liraglutide |
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GLP 1 MOA
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Agonist at GLP 1 Receptor
Enhances glucose-dependent insulin secretion Slows gastric emptying |
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GLP 1 ADE
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NVD
Acute pancreatitis Thyroid Tumor in Victoza |
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GLP 1 Contraindications
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Exenatide: GI disease, Renal insufficiency
Liraglutide: Family hx of thyroid or endocrine cancer |
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GLP 1 Adminitration
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Exenatide: within 60 minutes of meals
Liraglutide: once a day, no regards to meals |
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GLP 1 Monitoring Parameters
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A1C quarterly
SMBG ADE |
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Exenatide Brand
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Byetta
Bydureon |
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Exenatide Dosing
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IR: 5 mcg bid
Increase to 10mcg bid ER: 2 mg weekly |
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Liraglutide Dosing
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0.6mg d for 1 week
Increase to 1.2 mg d |
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Dipeptidyl Peptidase Inhibitors
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Sitagliptin
Saxagliptin Linagliptin |
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DPPI MOA
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Inhibits dipeptidyl peptidase IV, to inhibit degredation of incretins (GLP and GLP1)
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DPPI ADE
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URI
Nasopharyngitis Headache Acute Pancreatitis |
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DPPI Administration
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No regards to meals
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DPPI Monitoring Parameters
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A1C quarterly
SMBG ADE |
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Sitagliptan Brand
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Januvia
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Sitagliptin Dose
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100mg d
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Saxagliptin Brand
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Onglyza
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Saxagliptin Dose
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5 mg d
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Linagliptin Brand
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Trajenta
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Linagliptin Dose
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5mg d
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SGLT2 Inhibitor
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Canglifozin
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Canaglifozin Brand
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Invokana
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Canaglifozin MOA
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Reduces re-absorbtion of glucose
Lowers renal threshold for glucose |
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Canaglifozin ADE
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Hyperkalemia
Increased urination Dehydration UTI Genital mycotic infections Hypoglycemia Hypotension Renal Insufficiency |
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Canaglifozin Contraindications
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Renal impairment, including ESRD or on dialysis
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Canaglifozin dosing
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100-300 d
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Canaglifozin Administration
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Dosed before first meal
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Canaglifozin Monitoring Parameters
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A1C quarterly
SMBG ADE LDL Mg, K Phos BP |
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Thiazolidinediones (TZD)
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Pioglitazone
Rosiglitazone |
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Thiazolidinedione MOA
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Bind to peroxisome proliferator activator receptor gamma
Enhances insulin sensitivity Reduces free fatty acids Increase various proteins to increase glucose uptake |
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Thiazolidinedione ADE
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Fluid Retention
Weight gain Increased fractures Ovulation in pre menopausal women Risk of bladder cancer Hepatotoxicity |
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Thiazolidinedione Contraindications
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Class III or IV heart failure
Elevated AST/ALT at baseline |
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Thiazolidinedione Administration
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Without regards to meals
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Thiazolidinedione Monitoring Parameters
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A1C quarterly
SMBG ADE Hepatic Function Baseline and Annually |
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Pioglitazone Brand
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Actos
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Pioglitazone Dose
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Initial 15mg daily
Max: 45mg daily |
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Alpha-glycosidase inhibitor
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Acarbose
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Acarbose Brand
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Precose
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Acarbose MOA
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Reversible inhibition of intestinal alpha-glucosidases to inhibit hydrolizing saccharides to monosaccharides for absorption.
Leads to prolonged absorption of carbohydrates |
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Acarbose Adverse Effects
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Cramping and Flatulance
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Acarbose Dosing
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25 mg up to tid
Max dose 100mg tid |
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Acarbose dosing
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Dosed just prior to meals
Should be titrated very slowly |
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Acarbose Monitoring Parameters
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A1C quarterly
SMBG ADE Renal function baseline and annually |
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Amylinomimetic
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Pramlintide
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Pramlintide Brand
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Symlin
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Pramlintide MOA
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Suppresses high postprandial glucose secretion
Increases satiety Slows gastric emptying |
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Pramlintide ADE
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NV
Hypoglycemia |
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Pramlintide Contraindications
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Gastroparesis
Hypoglycemic unawareness Peds |
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Pramlintide Dose
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60mcg prior to major meals
Increase to 120mcg as tolerated |
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Pramlintide Administration
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Prior to meals
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Pramlintide Monitoring Parameters
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A1C quarterly
SMBG ADE |
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Dopamine agonist
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Bromocriptine (only quick release approved for DM)
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Bromocriptine Brand
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Cycloset
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Bromocriptine MOA
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unknown
ergot derived dopamine agonist |
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Bromocriptine ADE
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NV
dizziness HA Syncopal migraine |
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Bromocriptine Dose
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0.8mg d
Max dose 4.8mg d |
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Bromocriptine Administration
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Within 2 hours of waking. take with food
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Bromocriptine Monitoring Parameters
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A1C quarterly
SMBG ADE BP!! |
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Bile Acide Sequestrant
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Colesevalam (Welchol)
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Insulin Therapy most commonly used in Type 2
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Basal: glargine, detemir, sometimes NPH
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When to initiate insulin therapy in Type 2
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As initial therapy if A1C > 9%
advancing dual or triple combo therapy Early initiation with weightloss, severe symptoms, glucose > 250-300mg/dl |
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Insulin dose for Type 2
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10 Units once daily
0.2U/kg daily Same for glargine, detemir, NPH |
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What meds are usually d/c after insulin therapy?
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TZD due to recent safety issues
Secretory agents (Sulfonylureas, meglitinides) due to B-cell failure |
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Risk Factors for Type 2 Diabetes
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Lifestyle
Ethnicity Family History Co-morbidities Gestational DM |
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Primary problem in Type 2 Diabetes
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Insulin resistance with resultant relative insulin deficiency
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Metabolic defects of Type 2 DM
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Insulin resistance
Relative Insulin Deficiency Glucose Toxicity |
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ADA recommendations for Testing in ASYMPTOMATIC Adults
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>/= 45 years
BMI >/= 25 with other risk factors: Inactivity First degree relative High risk ethnicity Delivering a baby > 9 lbs Gestational DM HTN HDL <35mg/dl TG >250 PCOS A1C >5.7% Signs of insulin resistance CVD |
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ADA Recommendatins for Testing in Asymptomatic Children
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Age 10 years or onset of puberty
Overweight plus 2 of the following: Family history of Type 2 diabetes in 1st or 2nd degree relative High risk ethnicity Signs of insulin resistance or conditions associated ( HTN, Dyslipidemia, PCOS) |
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How often to repeat if results are normal?
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Every 3 years
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Presentation of DM
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Often asymptomatic
Insidious Sx of Hyperglycemia: lethargy, nocturia, polyuria, polydipsia, polyphagia Weight loss |
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Pre diabetes A1C
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5.7-6.4%
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Pre diabetes FPG
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100-125mg/dl
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Pre-diabetes 2 hour plasma glucose during OGTT
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140-199mg/dl
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Pre-diabetes Random Plasma Glucose (RPG)
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<200mg/dl
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Type 2 Goals of therapy
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Reduce risk of microvascular and macrovascular complicatons
Relieve symptoms Reduce mortality Improve QOL |
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Non glycemic goals
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BP < 140/80mmHg
LDL < 100 HDL > 50 for women, >40mg for men TG <150mg/dl |
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Flu Immunization Recomendation
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Yearly for all diagnosed over 6 mos
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Pneumococcal Vaccination
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At least 1 lifetime vaccine
Revaccination when: > 64 if previously immunized when they were </= 65 years if vaccine was administered 5 years ago |
