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ORAL DM
Oral Anti Diabetes Mellitus Drugs + DM background
| Question | Answer |
|---|---|
| what's the blood pressure target in DM pt? | less than 140/90 |
| What's the drugs of choice in pt with DM, HTN and albuminuria? | ACEI or ARBs - compelling effect nephro-protective |
| which drug to add to a DM patient with Urinary albumin of 45mg/24hr ? | DM pt with Urinary albumin > 30 mg/24hr or Albumin/creatinine ratio> 30 should start ARBs or ACEi |
| DM pt with normal eye exam, when to follow-up? | Q 2y/r if exam is normal and blood glucose is well controlled |
| when recommends screening for retionpathy in DM women who got pregnant? | each trimester monitoring 1y/r postpartum |
| Drug of choice to tx diabetic retinopathy? | Ranibizumab ( lucentis) once/month as intravitreal injection |
| what are the types of neuropathy DM pt may develop? | peripheral neuropathy autonomic neuropathy screen Q 1y/r |
| DM pt with peripheral neuropath, drug of choice to add? | - duloxetine - pregabalin |
| most common fungal infection seen in DM patient? | Tinea pedis |
| Which vaccinations are recommended for pt with DM? | - flu vaccine Q 1y/r - pneumococcal vaccine: PPSV23 age < 64 then age > 65 PCV 13 --> 1yr later PPSV23 or PPSV23 -- 5 y/r later another PPSV 23 - Hep B vaccine EnergixB |
| Drug of choice to manage blood glucose in pregnant women? | insulin |
| which class of drug type I DM should be treated with? | insulin |
| what is the most common life threatening complication of DM type-1? | DKA 2/2 to the total deficiency of insulin & the muscle uses of fat causes ketone production |
| what is the initial presentation of type-1 DM | DKA |
| What are the factor determining the use of metformin in pre diabetic pt ? | 1- BMI> 35, age <60 2- GDM |
| What are the blood glucose goal for pre and post GDM? | = similar to normal person 1- FBG< 95 1hr BG 140 2hr BG 120 A1c< 5.7% |
| Which patients population should be tested for DM? when to retest a pt with normal result? | - obese + risk factors - all pt who turns 45 retest pt in 3y/r |
| What are the diagnosis of DM? | FBG>126 PPBG> 200 A1c>6.5% |
| Which drugs have compelled effect in DM pt with CVD? | - empagliflozin - liragultide |
| Which pt should receive high intensity statin? | - any pt with ASCVD - 40-70 DM Pt + ASCVD Risk factors |
| what are the alternative to high intensity statin in DM pt with ASCVD risk or ASCVD who can't tolerate therapy? | - moderate intensity statin + ezetimibe |
| What are the adult glycemic treatment goals? | - A1c< 7% - FBG: 80-130 - PPBG < 180 |
| What is the recommendation for assessing A1c? | - Q3 months for new pt/ recent change of meds - Q6 months when A1c stable |
| What is the eAG ( estimated average glucose)? | - eAG= A1c -2 * 30 eg: eAG= 6-2*30= 120 mg/dl - Increase of 1% A1c --> increases 28 mg/dl |
| Which classes of drug can induce hyperglycemia? | - beta blocker -- mask the hypoglycemia / hyperglycemia - steroid - thiazide/ loop diuretics - immunosuppressant - niacin - protease inhibitors - quinolones - atypical 2nd generation clozapine, olanzapine, quetiapine - statin |
| Which classes of drugs can induce hyperglycemia? | - azole anti fungal - beta agonist - cough otc - diazoxide - interferon alpha - octreotide |
| When to start pt on dual-oral therapy? | - A1c > 9% |
| When to start combination injectable therapy? basal insulin + meal time insulin OR basal insulin + GLP-i1injectable | - A1c>10% or TG > 300 |
| What is the 1st line of agent monotherapy in addition to lifestyle? | Metformine + lifestyle |
| What are some combination regimens that are not recommended? | - Metformine + DPP-4 inhibitor + GLP-1 agonist - Metformine + basal insulin + SU |
| When to consider change in therapy? | if A1c is not controlled after adding 3 drugs; then consider: 1- oral--> inject 2- add basal insulin to GLP-1 agonist 3- max basal insulin-- add meal time |
| Which class(s) of drug (s) is secretagogues? | SU + meglitinides ( aglinide) |
| Which class of drug(s) is sensitizers? | Thiazolidinedione ( zone drug) |
| which class increases the glucose excretion? | SGLT-2 inhibitor ( flozin) |
| Which class reduces the hepatic glucoses output? | metformine |
| When metformin is considered C/I in DM patient? | - eGFR< 30 - Acidosis ( DKA or metabolic acidosis) with/without coma |
| Which DM drugs is associated with lactic acidosis and considered BBW? | - metformin |
| What are some of the risk factors increases the risk of lactic acidosis in pt receiving metformin? | - Hypoxic states ( HF, sepsis( - dehydration, -renal/hepatic impairment, ->65, -etOH, alcohol - IV I2 contrast,) |
| Which vitamin should be monitored for pt on metformin? | - Vitamin B12 |
| what are the most common side effects of metformin? | GI (n/v/d) flatulence abd cramp |
| What are monitor parameters for metformin in DM pt? | - renal as C/I if eGFR< 30 - Vit B12 --? Vit B12 deficiency - DM: A1c/BG |
| what are the available dosage forms of metformin? | - glucophage IR - glucophage xr |
| what are the recommended dose of metformin? | - glucophage IR 500mg BID or 850 mg/day --> increases by 500mg/ week for max of 2000 mg/day - glucophage ER: 500-1000mg/day ** with food 2/2 to GI side effect ** ER formula: ghost shell in the stool |
| what is the primary MOA of metformin? | - reduces hepatic glucose production*** - increases insulin sensitivity |
| What is the protocol of using IV iodinated contrast media in DM pt who receives metformin? | - hold metformin at the time of the procedure - Hold metformin 48 hrs after the procedure as this can increase the risk of iodine induced acute kidney injury |
| Which seizure medication can increases the risk of lactic acidosis in DM pt who takes metformin? | - topiramate |
| when pt with anemia or peripheral neuropathy who takes metformin should get VitB 12 checked? | periodically |
| In which case meglitinides is preferred over SU ? | - they both secretagogues Meglitinides: fast onset/ shorter duration preferred in 1- pt has late hypoglycemia while taking SU 2- pt with irregular meal schedule |
| What is the suffix for meglitinides? | glinide |
| When Meglitinides are C/I? | type 1 DM DKA |
| Which antihyperlipidemic drug is C/I in pt takes Repaglinide ( prandin)? | Gemfibrozil --( rape in gem) as gemfibrozil increases conc of rapaglinide |
| What is the max dose of Repaglinide? | max dose of preandin is 16 mg/day |
| what is the recommended dose of repaglinide ( preandin) ? | A1c< 8 --> 0.5 mg 3X/day A1c> 8 --> 1-2 mg 3X/day taken 30 min prior to meal |
| What is the recommended dose nateglinide ( starlix) ? | 60-120 mg 3X/day 30 min prior to meal |
| What the most common side effects of nateglinide and repaglinide? | - hypoglycemia - Weight GAIN - headache, URTI |
| when SU are C/I ? | - - *** SULFA ALLERGY *** - DKA - type 1 |
| Which pulmonary artery antihypertensive drug ( dual endothelin receptor blocker) is C/I in pt takes GLYburide? | bosentan ( bos-fly) |
| Which SU drug is known to cause Hypersensitivity** reactions such as anaphylaxis, SJS and angioedema? | GLImepiride ( gum) |
| What are some of SU warnings? | - hypoglycemia - G6PD deficiency ** note the effect of these drugs decline as Beta cell function declines over time |
| What is the most common side effects of SU? | - Weight GAIN - N |
| What is the max dose of glipizide IR ( glucotrol IR) and glipizide XL ( glucotrol XL? | - IR: 40 mg/day -- if dose > 15mg divide into BID ( should be taken 30 min prior to meal) - XL : 20 mg/day ( ghost tablet) |
| What is the max dose of glimepiride ( amaryl)? | Max 8mg/day |
| what is the max dose of GLYburide and GLynase? | - GLyburide: 20mg/day - Glynase: 12mg/day |
| Which SU should be avoided in pt with renal inefficiency? | GLYburide 2/2 weak metabolite |
| What is the recommended timing for SU admin? | take with breakfast or the first meal of the day except GLIPIZIDE IR 30 min prior |
| which Anti DM drugs increases the risk of hypoglycemia as a combination therapy? | - SU + insulin + meglitinides |
| what are the common sxs of hypoglycemia? and severe hypoglycemia? | - shakiness, irritability, hunger, headache, confusion, weak, sleepy, dizziness, sweating, fast heartbeat, - severe hypoglycemia: seizure, fainting or coma |
| What is the main MOA Of thiazolidinediones ( zone)? | - classified as insulin sensitizing agent. - activate the PPAR GAMMA --> increases the peripheral sensitivity |
| Which Thiazolidinediones drug has been associated with increased risk of MI? | - Rosiglitazone -BBW |
| When is thiazolidinediones C/I? | - pt with CLASS III and IV HF as it exacerbate HF and causes fluid build up and water retention |
| Which thiazolidinedions increases the risk of urinary bladder tumor and should be avoided in pt with active or h/o of bladder cancer? | - pioglitazone ( actos) |
| What is some of the consideration in premenopausal anovulatory women starting thiazolidinediones? | - Thiazolidinediones --> ovulation --> unintended pregnancy -- use contraceptive |
| What BBW has been associated with Thiazolidinediones? | - MAY CAUSE HF Or exacerbate HF |
| What are sone of Thiazolidinediones side effects/ warnings? | - Warnings: Edema, macular edema, Hepatic failure, fractuers - side effects: peripheral edema, wt gain, URTI, malgia |
| What to monitor pt starting thiazolidinediones? | - LFT - Wt gain - S/sx of HF |
| What is the max dose of pioglitazone? | - 45mg/day |
| what is the max dose of rosiglitazone? | 8mg/day |
| What are some of s/sx thiazolidinediones induced liver failure? | - can causes liver damage --> hepatic failure - s/sx of live damage: 1- dark colored urine 2- reduced appetite 3- stomach pain 4- N/V 5- jaundice |
| What is the MOA of SGLT-2 inhibitor? | - inhibits the Na/Water transporter in the proximal tubule - reduction in the absorption of Na/water - increases glucoses excretion in the urine |
| What is the suffix for SGLT-2 inhibitors? | FLOZIN |
| Which SGLT-2 inhibitor can increases the risk of leg and foot amputation? | - canagliflozin -BBW - risk increases with ( PAD and peripheral neuropathy or diabetic foot ulcer) |
| When is SGLT-2 inhibitor is C/I? ( renally dosed) | eGFR <30, dialysis, and ESRD ** remember metformin is C/I eGFR < 30 |
| Which SGLT-2 inhibitors can indue hyper KALEMIA K? | canagliflozin ( the coke cane has a lot of potassium) |
| Which SGLT2- inhibitors increases the risk of bladder cancer? | Dapagliflozin ( dapa - bladder) |
| what are some of the FDA warnings of SGLT-2 inhibitors uses? and what is the proposed MOA? | 1-volume depletion 2/2 to Na/water inhibitor --? 1- hypotension 2- AKI 3- renal impairment 2-sugar excretion in the urine --> increases risk of infection 1- genital mycotic infection 2- urosepsis 3- pyelonephritis 3- others: ketoacidosis/ incre LDL |
| what are the common side effects of SGLT-2 inhibitors? | 1- WT LOSS 2- hypoglycemia 3- increases urine --> thirst 4- increases mg/po4 |
| what is some monitoring parameters? | - renal function - LDL 2/2 increase of it - BP/ volume status 2/2 volume depletion |
| what is the max dose of SGLT-2 inhibitors? | 1- canagliflozin: 100mg/day for max of 300 mg/day 2- dapagliflozin: 5mg/day for max of 10 mg/day 3- empagliflozin: 10mg/day for max of 25 mg/day |
| which classes of drug increases the risk of volume depletion/ hypotension/ AKI while pt takes SGLT-2? | - NSAIDs - RAAS - diuretics |
| what are some considerations when pt taking rifampin, phenytoin, phenobarbitol while taking Canagliflozin? | - DDI between UGT inducers and canagliflozin - UGT inducers --> reduce the conc of canagliflozin - so consider increasing the dose from 100mg/day to 300 mg/day |
| Which drug Canagliflozin increases its AUC? | digoxin |
| Which drug(s) increases the risk of hyper-kalemia in pt taking canagliflozin? | - ACEI - ARBS - Aldosterone blocker |
| What is the best admin timing for SGLT-2 inibitor | - morning except canagliflozin before breakfast |
| What is the main MOA of DDP-4 inhibitors? | - inhibits DDP-4 enzymes - prevents the break down GLP-1 and GIP -results in increase insulin secretion from beta cells - results in reduction of glucagon secretion from alpha cells |
| what is the DDP-4 inhibitors suffix? | LIPTIN |
| Which drugs of DPP-4 inhibitors increase the risk of HF? | - Saxagliptin - alogliptin |
| Which drug of DPP-4 inhibitor can cause hepatotoxicity? | - Alogliptin |
| what are common warning to watch for while using DPP-4 inhibitors in DM pt? | - ACUTE Pancreatitis**** |
| what are some other warning to watch for while using DPP-4 inhibitors? | - arthralgia ( joint pain) - hypersensitivity rxn - pemphigoid ( blister and erosions) |
| Which DPP-4 inhibitors dose NOT REQUIRED renal adjustment? | LINAgliptin |
| what are some common side effects of DPP-4 inhibitors? | - Nasopharyngitits - URTI - UTRI - peripheral edema - rash |
| What are common monitoring parameters for DPP-4inhibitors ? | renal function as renal adjustment is needed |
| what is the dosing of DPP-4 inhibitors? and whats the adjusted dose if CrCl is < 30? | - sitagliptin: 100mg/day -- > reduce to 25mg/day - saxagliptin: 5mg/day--> 2,5 mg/day - linagliptin: no adjustment is needed - Alogliptin: 25mg/day --> 6.25 mg/day |
| Which of the DPP-4 inhibitors are CYP 3A4 substrate and P=gp? | - saxagliptin - linagliptin |
| What is the best timing to take DPP-4 inhibitor? | morning |
| What is the main MOA OF alpha glucosidase inhibitors? | inhibits breakdown of SUCROSE delay glucose absorption |
| What is the recommended tx of hypoglycemia in pt taking Acarbose or Miglitol? | - both of these drugs are alph glucosidase inhibitors - pt can NOT be treated with SUCROSE FOUND in candy or fruits - GIVE PT GLUCOSE TABLET or GEL |
| What is the best timing to take alpha glucosidase inhibitors ( acarbose and miglitol)? | WITH the first meal |
| what are the common side effects of Acarbose and miglitol? | - GI 2/2 to delaying glucose absorption - flatulence /D/ abd pain |
| What are the most common side effects of Colesevelam? | - constipation - this is a bile acid binding resins --> binds to ADEK ( fat soluble vit) - |
| what is the compelling effect of colesevelam? | - dyslipidemia |
| When is the use of BROMOCRIPTINE ( dopamine agonist) is C/I in DM pt? | syncopal migraines 2/2 risk of hypoftesion and orthostasis lactation: 2/2 inhibits lactation |
| What are DM guidelines available? | - ADA - AACE/ACE |
Created by:
Smoham38
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