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Oral Anti Diabetes Mellitus Drugs + DM background

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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