Diabetes Medications

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anhpham
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Diabetes Medications
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2014-06-24 14:00:32
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Diabetes Medications
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Generic, brand names, and drug class
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  1. Glucophage, Glucophage XR
    • Metformin
    • Biguanide

    MOA: Decreases hepatic glucose production, decreasing intestinal absorption of glucose and improves insulin sensitivity (increases peripheral glucose uptake and utilization)

    Medications that Target Fasting or Preprandial Blood Glucose.
  2. Glumetza
    Metformin

    Biguanide

    MOA: Decreases hepatic glucose production, decreasing intestinal absorption of glucose and improves insulin sensitivity (increases peripheral glucose uptake and utilization)

    Medications that Target Fasting or Preprandial Blood Glucose
  3. Fortamet
    Metformin

    Biguanide

    MOA: Decreases hepatic glucose production, decreasing intestinal absorption of glucose and improves insulin sensitivity (increases peripheral glucose uptake and utilization)

    Medications that Target Fasting or Preprandial Blood Glucose
  4. Rosiglitazone
    Avandia (REMS)

    Thiazolidinedione

    MOA:  improving target cell response to insulin, without increasing pancreatic insulin secretion. It has a mechanism of action that is dependent on the presence of insulin for activity

    Mediactions that tartget fasting or preprandial blood glucose.
  5. Pioglitazone
    Actos

    Thiazolidinedione (TZD)

    MOA:  improving target cell response to insulin, without increasing pancreatic insulin secretion. It has a mechanism of action that is dependent on the presence of insulin for activity

    Medications that Target Fasting or Preprandial Blood Glucose
  6. Glimepiride
    Amaryl

    Sulfonylurea

    MOA: Stimulates insulin release from the pancreatic beta cells; reduces glucose output from the liver; insulin sensitivity is increased at peripheral target sites

    Medications that Target Fasting or Preprandial Blood Glucose
  7. Glipizide
    Glucotrol XL

    Sulfonylurea

    MOA: Stimulates insulin release from the pancreatic beta cells; reduces glucose output from the liver; insulin sensitivity is increased at peripheral target sites

    Medications that Target Fasting or Preprandial Blood Glucose
  8. Glyburide
    Diabeta

    Sulfonylurea

    MOA: Stimulates insulin release from the pancreatic beta cells; reduces glucose output from the liver; insulin sensitivity is increased at peripheral target sites

    Medications that Target Fasting or Preprandial Blood Glucose
  9. Insulin Glargine
    Lantus

    Basal insulin

    Medications that Target Fasting or Preprandial Blood Glucose
  10. Insulin Detemir
    Levemir

    Basal insulin

    Medications that Target Fasting or Preprandial Blood Glucose
  11. NPH
    Humulin N, Novolin N

    Basal insulin

    Medications that Target Fasting or Preprandial Blood Glucose
  12. Repaglinide
    Prandin

    Meglitinide

    MOA: Nonsulfonylurea hypoglycemic agent which blocks ATP-dependent potassium channels, depolarizing the membrane and facilitating calcium entry through calcium channels. Increased intracellular calcium stimulates insulin release from the pancreatic beta cells. Repaglinide-induced insulin release is glucose-dependent.

    Medications that Target  Postprandial Blood Glucose
  13. Nateglinide
    Starlix

    Meglitinide

    MOA: Nonsulfonylurea hypoglycemic agent which blocks ATP-dependent potassium channels, depolarizing the membrane and facilitating calcium entry through calcium channels. Increased intracellular calcium stimulates insulin release from the pancreatic beta cells. Nateglinide-induced insulin release is glucose-dependent.

    Medications that Target  Postprandial Blood Glucose
  14. Exenatide
    Byetta

    GLP-1 agonist

    MOA: Exenatide is an analog of the hormone incretin (glucagon-like peptide 1 or GLP-1) which increases glucose-dependent insulin secretion, decreases inappropriate glucagon secretion, increases B-cell growth/replication, slows gastric emptying, and decreases food intake. Exenatide administration results in decreases in hemoglobin A1c by approximately 0.5% to 1% (immediate release) or 1.5% to 1.9% (extended release)

    Medications that Target  Postprandial Blood Glucose
  15. Liraglutide
    Victoza

    GLP-1 agonist

    MOA: Exenatide is an analog of the hormone incretin (glucagon-like peptide 1 or GLP-1) which increases glucose-dependent insulin secretion, decreases inappropriate glucagon secretion, increases B-cell growth/replication, slows gastric emptying, and decreases food intake. Exenatide administration results in decreases in hemoglobin A1c by approximately 0.5% to 1% (immediate release) or 1.5% to 1.9% (extended release)

    Medications that Target  Postprandial Blood Glucose
  16. Lispro
    Humalog

    Rapid Prandial Insulin

    Medications that Target  Postprandial Blood Glucose
  17. Aspart
    Novolog

    Rapid Prandial Insulin

    Medications that Target  Postprandial Blood Glucose
  18. Glulisine
    Apidra

    Rapid Prandial Insulin

    Medications that Target  Postprandial Blood Glucose
  19. Regular Insulin
    Humulin R, Novolin R

    Rapid Prandial Insulin

    Medications that Target  Postprandial Blood Glucose
  20. Sitagliptin
    Januvia

    DPP4 Inhibitors

    MOA: inhibits dipeptidyl peptidase IV (DPP-IV) enzyme resulting in prolonged active incretin levels. Incretin hormones (eg, glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic polypeptide [GIP]) regulate glucose homeostasis by increasing insulin synthesis and release from pancreatic beta cells and decreasing glucagon secretion from pancreatic alpha cells. Decreased glucagon secretion results in decreased hepatic glucose production

    Medications that Target  Postprandial Blood Glucose
  21. Saxagliptin
    Onglyza

    DPP4 Inhibitors

    MOA:  inhibits dipeptidyl peptidase IV (DPP-IV) enzyme resulting in prolonged active incretin levels. Incretin hormones (eg, glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic polypeptide [GIP]) regulate glucose homeostasis by increasing insulin synthesis and release from pancreatic beta cells and decreasing glucagon secretion from pancreatic alpha cells. Decreased glucagon secretion results in decreased hepatic glucose production

    Medications that Target  Postprandial Blood Glucose
  22. Linagliptin
    Tradjenta

    DPP4 Inhibitors

    MOA:  inhibits dipeptidyl peptidase IV (DPP-IV) enzyme resulting in prolonged active incretin levels. Incretin hormones (eg, glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic polypeptide [GIP]) regulate glucose homeostasis by increasing insulin synthesis and release from pancreatic beta cells and decreasing glucagon secretion from pancreatic alpha cells. Decreased glucagon secretion results in decreased hepatic glucose production

    Medications that Target  Postprandial Blood Glucose
  23. Acarbose
    Precose

    Alpha Glucosidase Inhibitors

    MOA: Competitive inhibitor of pancreatic α-amylase and intestinal brush border α-glucosidases, resulting in delayed hydrolysis of ingested complex carbohydrates and disaccharides and absorption of glucose; dose-dependent reduction in postprandial serum insulin and glucose peaks; inhibits the metabolism of sucrose to glucose and fructose

    Medications that Target  Postprandial Blood Glucose
  24. Miglitol
    Glyset

    Alpha Glucosidase Inhibitors

    MOA: Competitive inhibitor of pancreatic α-amylase and intestinal brush border α-glucosidases, resulting in delayed hydrolysis of ingested complex carbohydrates and disaccharides and absorption of glucose; dose-dependent reduction in postprandial serum insulin and glucose peaks; inhibits the metabolism of sucrose to glucose and fructose

    Medications that Target  Postprandial Blood Glucose
  25. Pramlinitide
    SymlinPen

    Neuro Endocrine Hormone Amylin

    MOA: Synthetic analog of human amylin cosecreted with insulin by pancreatic beta cells; reduces postprandial glucose increases via the following mechanisms:

    • 1) prolongation of gastric emptying time,
    • 2) reduction of postprandial glucagon secretion, and
    • 3) reduction of caloric intake through centrally-mediated appetite suppression

    Medications that Target  Postprandial Blood Glucose
  26. Canagliflozin
    Invokana

    Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor

    MOA:  inhibiting sodium-glucose cotransporter 2 (SGLT2) in the proximal renal tubules, canagliflozin reduces reabsorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose (RTG). SGLT2 is the main site of filtered glucose reabsorption; reduction of filtered glucose reabsorption and lowering of RTGresult in increased urinary excretion of glucose, thereby reducing plasma glucose concentrations.
  27. Dapagliflozin
    Farxiga

    Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor

    MOA:  inhibiting sodium-glucose cotransporter 2 (SGLT2) in the proximal renal tubules, canagliflozin reduces reabsorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose (RTG). SGLT2 is the main site of filtered glucose reabsorption; reduction of filtered glucose reabsorption and lowering of RTGresult in increased urinary excretion of glucose, thereby reducing plasma glucose concentrations.
  28. Oral diabetes combination drugs
    • Actoplus Met: Combines Actos and metformin
    • Avandamet: Combines Avandia and metformin
    • Avandaryl: Combines Avandia and glimepiride
    • Duetact: Combines Actos and glimepiride
    • Glucovance: Combines glyburide and metformin
    • Janumet: Combines Januvia and metformin
    • Metaglip: Combines glipizide and metformin
    • PrandiMet: Combines Prandin and metformin
  29. Actos and metformin
    Actoplus Met
  30. Avandia and metformin
    Avandamet
  31. Avandia and glimepiride
    Avandaryl
  32. Actos and glimpepiride
    Duetact
  33. Glyburide and metformin
    Glucovance
  34. Januvia and metformin
    Janumet
  35. Glipizide and metformin
    Metaglip
  36. Prandin and metformin
    PrandiMet
  37. Pioglitazone (Actos) and rosiglitazone (Avandia) shouldn't be used in what patients?
    Congestive heart failure (CHF)
  38. What diabetes agents that shouldn't be used if patients have hypoglycemia?
    • Sulfonylurea
    • Insulin
  39. What diabetes agents that patients should use if they don't want to gain weight?
    • DPP-4 inhibitor
    • GLP-1 receptor agonist
  40. What diabetes patients should use to minimize the cost?
    • Sulfonylurea
    • Metformin
    • Insulin
  41. Where does thiazolidinedione (Actos, Avandia) work on?
    Muscle
  42. Where do alpha-glucosidase inhibitors work on?
    Gut
  43. Where does sulfonylureas work on?
    Pancreas
  44. Where does Biguanides work on?
    Liver
  45. Where do DPP-4 inhibitors work on?
    • Liver
    • Pancreas
  46. Where does meglitinide work on?
    Pancreas
  47. What diabetes agents work on pancreas?
    • Sulfonylureas
    • Meglitinides
    • Exenatide
    • DPP-4 Inhibitors
    • Exogenous Insulin
  48. What agent works on muscle?
    Thiazolidinediones
  49. What agent work on gut?
    Alpha-glucosidase inhibitors
  50. What agents on work liver?
    • Biguanides
    • DPP-4 Inhibitors
  51. Biguanide agents
    Metformin (Glucophage, Glumetza, Fortamet)
  52. Thiazolidinedione agents
    • Pioglitazone (Actos)
    • Rosiglitazone (Avandia)
  53. Sulfonylurea agents
    • Glimepiride (Amaryl)
    • Glipizide (Glucotrol XL)
    • glyburide (Diabeta)
  54. Basal insulin agents
    • Insulin glargine (Lantus)
    • Insulin Detemir (Levemir)
    • NPH (Humulin N, Novolin N)
  55. Meglitinide agents
    • Repaglinide (Prandin)
    • Nateglinide (Starlix)
  56. GLP-1 agonist agents
    • Exenatide (Byetta)
    • Exenatide extended release (Bydureon)
    • Liraglutide (victoza)
  57. Rapid prandial insulin
    • Lispro (Humalog)
    • Aspart (Novolog)
    • Glulisine (Apidra)
    • Regular (Humulin R, Novolin R)
  58. DPP4 inhibitors
    • Sitagliptin (Januvia)
    • Saxagliptin (Onglyza)
    • Linagliptin (Tradjenta)
  59. Alpha glucosidase inhibitors
    • Acarbose (Precose)
    • Miglitol (Glyset)
  60. Neuro endocrine hormone amylin
    Pramlinitide
  61. What serum creatinine level is contraindicated in male and female in using metformin?
    • Metformin is contraindicated if serum creatinine level:
    • Male: >= 1.4 mg/dL
    • Female: >= 1.5 mg/dL
  62. Metformin therapy should be withheld if patients undergoing what procedure and why it has to be withhold?
    Metformin therapy should be withheld in patients undergoing radiographic procedures in which a nephrotoxic dye is used and not reinstated until 48 hours after the procedure and renal function has returned to normal.
  63. Main side effects of metformin
    • Diarrhea
    • Nausea
  64. What diabetes agent is recommended as first line agent to treat T2DM?
    Metformin
  65. Primary MOA of metformin
    Decrease hepatic glucose production
  66. How long metformin should be discontinue after contrast dye procedure?
    48 hours (2 days)
  67. Which the drug classes used
    to lower blood glucose can cause edema, weight gain, and exacerbate Congestive
    Heart Failure?
    TZDs (Actos and Avandia)
  68. Side effects of TZDs (Pioglitazone and Rosiglitazone)?
    • Edema
    • Weight gain
    • Anemia
  69. Side effects of alpha-glucosidase inhibitors (Acarbose and Miglitol)
    • Flatulence
    • Diarrhea
  70. What medications have modest glycemic effects and side effect profiles that make them less desirable for use?
    • Colesevelam
    • Bromocriptine
  71. What medications that have modest glycemic lowering effects and dosage adjustment/ frequency more than once daily considerations make them less desirable for use?
    • Acarbose
    • Miglitol
    • Symlin
  72. Which agent in DPP-IV inhibitor class doesn't need to have renal and hepatic dosing adjustment ?
    Linagliptin (Tradjenta)
  73. Side effects of sulfonylureas?
    • Hypoglycemia
    • weight gain
  74. Side effects of Metformin?
    • Gastrointestinal
    • Lactic acidosis
  75. Side effects of Thiazolidinediones?
    • Fluid retention
    • CHF
    • Weight gain
    • Bone fractures
  76. Side effects of DPP-4 inhibitors
    No major SEs
  77. MOA of Pramlintide (Symlin)
    • 1) Prolongation of gastric emptying time,
    • 2) Reduction of postprandial glucagon secretion, and
    • 3) Reduction of caloric intake through centrally-mediated appetite suppression
  78. Contraindications of Pramlintide (Symlin)
    ›Gastroparesis

    ›Hypoglycemia unawareness

    ›Hemoglobin A1C >9%

    Patients unwilling to Self-monitor blood glucose
  79. Advantages of Pramlintide (Symlin)
    Weight loss
  80. Adjust dose of Basal Insulin according to Fasting Blood Glucose (FBG)
    • ›Increase the insulin dose every 3-4 days as needed with below scale
    • ›FBG 100-140mg/dL  Increase 2 units
    • ›FBG 141-180mg/dL  Increase 4 units
    • FBG 181-220mg/dL  Increase 6 units
    • ›FBG >220mg/dL  Increase 8 units
    • ›If FBG drops below 80mg/dL, cut dose back to previous dose immediately

    ›Can Increase by 1 unit every 1 day until FBG at 100mg/dL

    Can Increase Levemir by 3 units every 3 days until FBG goal; Decrease by 3 units if FBG below goal 
  81. How to calculate insulin dose for type 1DM ?
    ›Calculate daily dose (0.5units of insulin per kg per day)

    Give 50% as bolus insulin (Split into 3 mealtime doses)
  82. We have to rotate insulin injection sites to prevent what?
    Lipohypertrophy which is a lump under the skin caused by accumulation of extra fat at the site of many subcutaneous injections of insulin.
  83. What type of insulin can't be mixed and why?
    • Long acting insulin (Glargine-Lantus, Detemir-Levimir)
    • Because  this could change how the insulin work.
  84. How long should we inject rapid acting insulin before meal? 
    Insulin aspart (Novolog)
    Insulin lispro (Humalog)
    Insulin glulisine (Apidra)
    5-10 minutes before meal
  85. what is the form of rapid acting insulin?
    Monomer
  86. What is the peak of rapid acting insulin?
    1-2 hours
  87. What insulin will form clusters when it's injected under the skin and ?
    Insulin glargine (Lantus)
  88. What insulin will absorb into blood stream and attach to albumin and detach from albumin within 12-24 hours?
    Insulin detemir (Levimir)
  89. What insulin doesn't require prescription?
    Novolin N
  90. What are acute complications with DM?
    Hypoglycemia

    Diabetic Ketoacidosis

    Hyperosmolar Hyperglycemic State (HHS)
  91. What are long-term complications with DM?
    • Cardiovascular disease
    • Peripheral vascular disease
    • CVA
    • Neuropathy
    • Diabetic foot disease
    • Nephropathy
    • Retinopathy
    • Periodontitis
    • ED
  92. What are some symptoms of hypoglycemia?
    • Shakiness
    • Sweating
    • Fatigue
    • Hunger
    • Headaches
    • Confusion
    • Irritable
    • Dizziness
    • Fast heartbeat
    • Impaired vision
  93. What level of blood glucose is clinically defined as hypoglycemic?
    • < 50 mg/dL
    • However, many symptoms may occur when levels fall below 70 mg/dL
  94. Causes of hypoglycemia
    Excessive doses of medications (Sulfonylureas, Glinides, Insulin)

    • Delayed Food or Meal
    • Ex: Ate Breakfast at 9am and next meal was at 7pm

    Inadequate Amounts of Food (especially carbohydrates)

    Exercising when insulin doses are reaching peak effect

    Not adjusting drug dosing for renal or hepatic impairment
  95. Treatment of hypoglycemia
    • Rule 15
    • Check BG level
    • If low, consume 15g Carbohydrate (CHO)
    • Wait 15 minutes for symptom improvement then recheck BG

    • Treatment options:
    • 15 gram of Carbohydrate
    • 4 oz Orange juice
    • Small box of raisins
    • If on alpha glucosidase inhibitor
    •     3-6 Glucose Tablets
    •     8 oz Skim Milk

    • Note: reatment options for BG< 50mg/dL
    • May need 30g CHO

    • Loss of consciousness with Hypoglycemia
    • Glucagon
  96. What is the rule of 15 for hypoglycemia treatment?
    Give 15 gm CHO- recheck BG in 15 min- repeat if not better or repeat it until symptoms get resolve.
  97. What are some example of 15gm of CHO?
    • 4 oz orange juice
    • 8 oz milk
    • 3-6 glucose tabs
    • 6-7 lifesavers
  98. What do we do if patients are unconscious because of hypoglycemia?
    • Glucagon Emergency Kit
    • Requires reconstitution
    • Administer 1 mg by IM or SQ (may repeat in 20 minutes)
  99. Vomiting frequently occurs after administering glucagon in the case of unconsciousness due to hypoglycemia. What should we do in that case?
    Roll patients to their side to prevent aspiration.
  100. What is BP goal for diabetic patients?
    130/80
  101. Hypertension pharmacologic therapy for diabitics?
    ACE Inhibitor or Angiotensin Receptor Blocker ARB

    Next, thiazide recommended
  102. What complication is the most commonly reported in T2DM?
    Peripheral Neuropathy
  103. Diabetic peripheral neurophathy treatment recommended as improves quality of life?
    Pregabalin, Gabapentin, low dose TCA, duloxetine, venlafaxine, topiramate, NSAIDs, topical capsaicin
  104. Besides lowering BP, ACE inhibitors can also do what in diabetic patients?
    Microalbuminuria
  105. Immunization recommendations in diabetics
    DM patients need annual influenza vaccine ≥6months of age

    Pneumoccocal polysaccharide vaccine to all DM patients ≥ 2 years of age

    One time revaccination for >64 year old previously immunized when <65 years old and vaccine administered >5 years ago.

    • Nephrotic Syndrome, Chronic renal disease, transplantation, and other immunocompromised states require repeat
    • vaccination

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