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Ph T2DM
Pharm Endocrine
| Question | Answer |
|---|---|
| T2DM tx algorithm | diet & exercise (& metformin?); oral mono or combo tx (TZD / sulf; then poss alpha-gluc inhib or meglitinide or DPP4); incretin mimetics (GLP-1); insulin; amylin [insulin may be started at any time] |
| C-peptide test can tell: | if pt is producing insulin |
| Tx for impaired insulin secretion: | Sulfonylureas; meglitinides; insulin |
| Tx for insulin resistance: | biguanides; TZDs |
| Tx for decreased glucagon suppression: | GLP-1 agonist; DPP4 inhib; amylin agonist |
| Insulin secretagogues = | Sulfs (Glyburide, Glipizide, Glimepiride: hugs panc all day); meglitinides (Repaglinide, Nateglinide: quick panc hug to cover meal) |
| Sulfs: 1stG vs 2ndG: | Replace 1stG; 2ndG do not work better but fewer DI and no sulfa allergy concerns |
| Sulf mgmt | initial med: start low / slow; titrate q3-4 wks as poss, adjust for hep/renal dysfn; pt ed re: hypoglycemia; consider combo tx when tx nears max dose |
| Sulfs & renal dysfn: | Glipizide may be used in renal impairment; glyburide may worsen renal dysfn |
| Insulin secretagogues: CI | Liver / renal dz; elder / debilitated; Severe trauma / infxn; PG/ BF |
| Meglitinides: titrate: | at 1 wk by doubling dose up to 4 mg |
| Biguanide: MOA | Inhibit hepatic glu O/P; Promote glu uptake by fat & mx; Decreases intestinal absorption of glucose (minor) |
| Biguanide: CI | Kidney / Liver dz (Scr: M 1.5, F 1.4); Elderly; Alcohol Abuse; Unstable Heart Failure; IV Contrast Media |
| Biguanide: AE | GI (30%); Lactic acidosis; anorexia; Vit B12 depletion |
| Biguanide: Education: | GI effects should resolve within 14 days; Take with meals |
| Metformin & IV contrast | d/c drug 24 hr before procedure, restart 48 hrs after, or labs prove kidney fn is back to nml |
| Metformin: dose & titration | 500 – 850 QD or 500 BID; titrate 500 q7d & 850 q14d (no benefit >2000 mg / day) |
| Metformin XR: dose & titration | use XR if GI AE concerns; 500 QD w/ PM meal; titrate q7d |
| TZD MOA | Promotes glu uptake by fat & mx; Inhibits hepatic glucose output |
| TZD CI: | Liver dz; Heart failure (Black Box); PG & Lactation |
| TZD AE: | Liver tox; Fluid retention (not resolved by diuretics); Wt gain (20-30 lb?); HA, fatigue |
| TZD pt ed | Patience: 6-12 weeks for max efficacy; may have noticeable wt gain; Report to provider SOB with any activity |
| TZD titration | No sooner than 4 weeks |
| Alpha-gluc inhibs MOA | cause CHO to be absorbed more slowly |
| Alpha-gluc inhibs: CI | IBD / UC / obstruct bowel disorders; Liver / renal impairment; PG/BF |
| Alpha-gluc inhibs: AE | Flatulence, GI distress, diarrhea; Jaundice, elevated LFTs (acarbose) |
| Alpha-gluc inhibs: DI | Pancreatic enzymes |
| Alpha-gluc inhibs: Pt Ed | Take w/ meal; If have hypoglycemic event, must tx w/ glucose (tablet) or lactose (milk), not complex CHOs; GI AE will lessen over time |
| Incretins = | Peptide hormones released by the gut to normalize glucose profile; include GLP-1; GIP (no effect if given exogenously) |
| Limitations of GLP-1 | Rapid inactivation by DPP-IV; Requires continuous SQ injection |
| GLP-1 Bypass route: | GLP-1 Agonist: Modify protein to prevent breakdown; DPP-4 inhib: Limit enzyme activity |
| Januvia AE | urticaria & angioedema; poss severe pancreatitis |
| Januvia approved for use with: | metformin and/or TZDs (address impaired insulin secretion, insulin resistance, and dec glucagon suppression); can give to pt w/ impaired hepatic / renal fn |
| Saxagliptin AE | Peripheral edema (in combo w/ TZD); HA; UTI; Hypoglycemia with sulfonylureas |
| Only 2 oral agents can use for type 1 DM: | metformin and Actos |
| Time orientation: fasting blood sugars | Biguanide |
| Time orientation: postprandial blood sugars | meglitinides; alpha-gluc inhibs |
| Acceptable T2DM meds in renal impairment | TZDs; DPP-4 inhibs; Meglitinides; Glipizide IR; Glimepiride; Tolbutamide |
| Most cost-effective T2DM meds: | metformin, insulin, sulfs (TZDs effective but expensive) |
| Incretins MOA | inc glucose-dept insulin secretion; dec glucagon secretion; dec rate of nutrient absorption (so improved gastric emptying); inc satiety |
| Exenatide: available as: | 5 or 10 mcg pens; SQ; thigh, abd, upper arm |
| Exenatide dosing | At least 6 hrs apart; Inc dose after 30d, as tolerated, prn; Decrease sulf dose by half to reduce hypoglycemia risk; Must be on 5 for 30 d, before consider inc to 10 mcg; Take before meals |
| Exenatide benefits include: | Sig reduction in A1c; wt loss |
| Exenatide pt ed: | Injxn technique (1 time prime); Take within 60 min of meal (if skip meal, skip dose); Storage: Unopened: refrigerate; Opened: refrig rm temp (to 30 days) |
| Exenatide DI | Oral agent needing rapid onset (analgesics); meds needing threshold conc for efficacy (Abx, contraceptives); Administer oral med at least 1 hr prior |
| Liraglutide dosing | 0.6, 1.2 (after 1 wk), 1.8 pen; once daily, independent of meals; 0.6 mg not effective for glycemic control (only minimizes GI sx); Decrease sulf dose by half to reduce hypoglycemia risk; poss sig DI |
| GLP-1 AE | Inc hypoglycemia risk if combo w/ sulf; N/V; Diarrhea; Anxious / jittery; Pancreatitis; Wt loss; Thyroid C-cell tumors (liraglutide) |
| GLP-1 Pt selection | After oral agents have failed; HbA1c from 7-11% |
| GLP-1 CI | T1DM; ESRD / CrCl <30 ml/min; Pancreatitis; Severe GI dz; h/o medullary thyroid ca or Multiple Endocrine Neoplasia Syndrome (liraglutide only) |
| Pramlintide dosing: T2DM: | 60mcg (10 units) before meals; Decrease meal-time insulin by 50%; Increase to 120mcg (20 units) in 3-7 d, as tolerated |
| Which insulins are cloudy? | NPH; mixes |
| Which insulin may be given IV? | Regular |
| Non-prescription insulins | Regular; NPH; Novolin 70/30; Humulin 70/30 |
Created by:
Abarnard
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