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Pharm T2DM
Endocrine Type II DM
| Question | Answer |
|---|---|
| 3 causes of T2DM | Impaired insulin secretion, insulin resistance, Incretin Defect |
| Diabetes lose which response? | First phase insulin response |
| Is a fingerstick okay for diagnosis? | No, must be done by venipuncture. Finger stick can be off by 20% |
| Factor that change A1C | Anemia |
| Pre-diabetes FBG | 100-125 |
| Diabetes FBG | > or equal to 126 |
| Random blood glucose value of _____ + symptoms in diabetes | >200 |
| Every 1% change in A1C represents a _______mg/dL change in mean plasma glucose | 35mg/dL |
| Drugs not to be used in TYPE 1 | GLP-Agonists, DPP IV inhibitors, Sulfonylureas, Meglitinides |
| Insulin Secretagogues | Sulfonylureas - hug pancreas all dayMeglitinides - hugs with one quick squeeze to cover ingested food; dosed when patient is going to eat |
| Sulfonylureas burn out the pancreas if used more than _______ years | 3-5 |
| Glipizide, Glyburide and Glimepiride are _____generatinon Sulfonylureas | 2nd |
| How often should sulfonylurea doses be titrated? | Every 3-4 weeks as tolerated; start low, go slow. |
| Which sulfonylurea can be used in renal impairment? | Glipizide or Glimepiride |
| Sulfonylureas have a ________ effect. | ceiling. Very little change when you are moving from half max to max dose. |
| Which insulin secretagogue has higher rates of hypoglycemia? | Sulfonylureas |
| Name both meglitinides | Repaglinide (Prandin), Nateglinide (Starlix) |
| How are meglitinides dosed? | Only with meals. Don't take if you skip a meal! |
| Insulin Secretagogues Contraindications/Cautions | Liver Dz, Renal Dz (Glyburide cannot be given), Elderly/debilitated, severe trauma/infection, pregnancy, breastfeeding (no orals, just give insulin) |
| Which Second Generation Sulfonylurea cannot be given to a patient with renal disease? | Glyburide |
| What is the MOA of Nateglinide? | Stimulates panreatic insulin secretion |
| Name the only biguanide | Metformin |
| What is the MOA of metformin? | Primary job: inhibit hepatic glucose output. Also: Promotes glucose uptake byfat and muscle and has a minor impact on decreasing intestinal absorption of glucose |
| How is do you adjust metformin in a patient receiving IV contrast? | Hold 24 hours before and 48 hours after |
| Contraindications of Metformin | HEART FAILURE, kidney disease, alcohol abuse, elderly, IV contrast, liver disease |
| What is the biggest AE of metformin? | GI (30%). Other AEs include: lactic acidosis, loss of appetite/anorexia, Vit. B12 depletion |
| How should metformin be taken? | with meals |
| What are the symptoms of lactic acidosis? | looks like the flu with achy muscles, fatigue, malaise, but no fever |
| Does metformin cause weight gain? | It is considered a weight-neutral drug |
| Does metformin cross the placenta? | Yes, but women who have taken it during pregnancy have seen no issues |
| What is the MOA of TZD's/Glitazones? | Promotes glucose uptake by fat and muscles and inhibits hepatic glucose output |
| Name the two TZDs | Pioglitazone (actos), Rosiglitazone (avandia) |
| What is black box warning of TZD's? | Heart Failure! |
| What is a common AE in TZDs? | Substantial weight gain |
| How long does a patient need to wait before seeing best efficacy in a TZD? | 6-12 weeks. These drugs cost $200-300/month, so you need to educate patients b/c if they don't see results they will probably stop it before it gets working. |
| Which TZD is associated with higher risk of CV death and MI? | Rosiglitazone (avandia)- not looking so rosy anymore |
| What is the biggest concern with alpha-glucosidase inhibitors? | Flatulence. Acarbose (precose) and Miglitol (glyset) |
| What is the MOA of incretins? | Increases glucose dependent insulin secretion, decreases glucagon secretion, decreases rate of nutrient absorption and thus reducing gastric emptying time, increases satiety |
| What is the positive AE of incretin? | Weight loss; patients must eat slowly though |
| what are the limitations of GLP-1? | Rapid inactivation by DPP-4, requires continuous SQ injection |
| Byetta is a ______ agonist | GLP-1 Agonist (modified protein to prevent breakdown) |
| DPP-4 Inhibitors MOA and drug names | Inhibits the DPP-4 enzyme from rapidly breaking down GLP-1. Januvia (sitaglilptin) and Galvus (Vildagliptin). Oral and weight neutral |
| Which oral drug can be used in patients with severe renal insufficiency? | Januvia (sitagliptin) |
| Which is the only oral drug that can be taken in patients with liver dysfunction? | Januvia (sitagliptin) |
| Januvia is approved for use in combination with what? | Metformin and/or TZDs. Januvia hits the incretin effect while TZDs or metformin cover the insulin resistance |
| Which drug was made from the saliva of the helamonster? | Byetta (exenatide) |
| What are the injection sites for Byetta? | Thigh, abdomen, upper arm. Available as 5mcg and 10mcg pens |
| What is the main AE of Byetta? | Nausea and Vomitting. Positive AE is weight loss, which was not attributed to N/V |
| How should Byetta be dosed? | Taken with 2 meals 6 hours apart. Take within 60mn of a meal. If you skip a meal, skip the dose. If taking in combination with a sulfonylurea, decrease the sulfonylurea by 1/2 to reduce hypoglycemia risk |
| Metformin works best on what kind of sugars? | Fasting sugars |
| Meglitinides, Byetta and Januvia work best on what kind of sugars? | post-prandial |
| How should Byetta be stored? | If unopened: refrigeratedIf opened: refrigerated or room temp up to 30 days |
| How should oral pain meds be given to patient taking Byetta or Pramlintide? | Administer oral pain med at least 1 hour prior. Byetta and Pramlintide slow down digestion and thus absorption of things you want to work rapidly. |
| When should you put a patient on Byetta? | When oral agents have failedIf HbA1C is between 7-11 |
| Who cannot be given Byetta? | Type I diabetics, ESRD patients or Crcl<30ml/min, Pancreatitis pts or pts with severe GI disease. |
| How much does Byetta decrease HbA1C? | 1% |
| What strength dosage pen of Pramlintide would a Type1 pt receive? A Type 2 patient? | Type 1: 60mcgType 2: 120mcg |
| What is the MOA of Pramlintide (Symlin)? | Amylin agonist. Suppresses glucagon secretion from pancreatic cells and restricts gastric emptying |
| How do you adjust meal-time insulin with Pramlintide (symlin)? | Decrease meal time insulin by half |
| How do you convert mcg's to units for Pramlintide (symlin) dosing? | Divide by 6. Ex: 60 units/day is 10 units for each meal |
| When and where should Pramlintide be taken? | Take immediately prior to a meal of 30 grams of carbs or more; Only inject in abdomen or thigh. This CANNOT be mixed with insulin |
| Which drugs have associated weight loss? | Byetta (exenatide) and Pramlintide |
| When is a Type 2 diabetic an insulin candidate? | When it takes more than 3 agents to control blood sugar they are a definite insulin candidate. Anytime A1C is greater than 8, consider adding a long-acting basal insulin |
| Which drug brings down blood sugar most effectively with the least AEs? | Insulin |
| How long after initiating insulin should A1C levels be checked? | 2-3 months |
| What does pre-mixed insulin mean? | Basal and Bolus are already mixed together |
| Can metformin be used in CHF? | Yes, but ONLY if it is STABLE |
| What do you have to monitor with TZDs? | LFT's. TZD's can also induce CHF and are contraindicated in CHF with a black box warning. |
| What symptoms need to be reported by a patient on TZDs? | SOB and weight gain. Concern is CHF |
| What type of sugars do alpha glucosidase inhibitors address? | Post-prandial |
| What are the AEs for Januvia? | relatively mild urticaria and angioedema |
| What are the dosage pens for Byetta? | 5mcg and 10mcg. Remain on 5mcg for at least 30 days before bumping it up. |
| Insulin initial amounts in Type II | either 10 units 2x/day or .2units/kg (this is different than dosing in type1) |
| If A1C is between 8-10 | consider insulin |
| If A1C is between 8-12 | Strongly consider insulin |
| If A1C is between 12-14 | Get an injection that day and go home with it. |
| Amylin is only added on with | Insulin |
Created by:
ltm12