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Biguanide - metformin
- DI: ETOH = INC lactic acidosis (renal impairment and advanced heart dx)
- - Iodinated contrast dye = INC lactic acidosis (hold 48 hours and check renal prior to restart)
- - DEC vit B-12 absorption and folic acid (supplement)
- Counseling: 1. take BID with morning and evening meals, daily with evening ER
- 2. upset stomach - food will help
- 3. rare - life-threatening condition called lactic acidosis (weakness, SOB, stomach pain, slow heart rate, sleepy)
- 4. Glumetza, Fortamet, Glucophage XR - ghost shell
- 5. X-ray or CT scan with dye injection - temporarily stop metformin and let doctor know
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Sulfonyureas - glipizide, glimepiride, glyburide
- DI: insulin - stop SU = hypoglycemia
- - reduce dose SU with TZD, GLP-1 agonist, DDP-4 inhibitors, canagliflozin
- - caution 2C9 ind/inh
- - Glyburide avoid CRCL < 50 ml/min
- Counseling: 1. Glipizide XR with first meal, IR 30 mins before breakfast and dinner, Glimepiride QD with first meal
- 2. watch for sx of hypoglycemia (shaky, hungry, confused, dizzy, sweat, fast heartbeat)
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Meglitinides - repaglinide, nateglinide
- DI: insulin = hypoglycemia
- - reduce dose of meg with TZD, GLP-1 agonist, DDP-4 inhibitors, canagliflozin
- - Gemfibrozil INC Prandin (repa) and DEC BG = choose fenofibrate instead
- - caution with drugs cause hypoglycemia (IQ FLOP)
- Counseling: 1. 30 mins prior to meals (skip if forget)
- 2. skip meal = skip dose
- 3. watch for sx of hypoglycemia (shaky, hungry, confused, dizzy, sweat, fast heartbeat)
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TZD - pioglitazone, rosiglitazone
- DI: can reduce amount of insulin or SU/meg required
- - CYP2C8 - caution with rifampin and gemfibrozil
- Counseling: 1. QD w/wo food
- 2. takes several weeks to work = monitor
- 3. check up to rule out CHF, heart issues, fluid retention, bladder cancer, hx of MI, stroke, liver dx
- 4. Contact doctor - a) liver damage (dark colored urine, pale stools, skin or eyes are yellow), b) water retention (ankles swell, trouble breathing), c) women = bone fractures
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Alpha- glucosidase inhibitors - acarbose, miglitol
- Counseling: 1) take with full glass of water with first bite of food (no food, no drug)
- 2) gas, diarrhea, abdominal pain that goes away with time
- 3) hypoglyemic - use glucose tabs ONLY (sugars won't work)
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DPP-4 inhibitors - sitagliptin, saxagliptin, linagliptin, alogliptin
- DI: reduce insulin or SU/megs required
- - saxagliptin (Onglyza) - major 3A4 substrate = lower dose 2.5 mg with strong inhibitors
- - linagliptin (Tradjenta) - major 3A4 and P-gp substrate = DEC levels cause by strong inducers
- Counseling: 1) QD in AM w/wo food
- 2) Contact doctor - trouble breathing, sx of pancreatitis (severe stomach pain, radiate from abdomen to back)
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Sodium glucose co-transporter-2 inhibitor (SGLT2) - canagliflozin
- DI: reduce insulin or SU/megs required
- - UGT inducers (rifampin) reduce level of SGLT2 = dose increase SGLT2 to 300 mg
- - INC digoxin AUC
- - contraindicated in renal CRCL <30 ml/min, ESRD, dialysis
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Glucagon-like peptide-1 (GLP-1) agonists - exenatide, liraglutide
- DI: reduce insulin or SU/megs required
- - can slow gastric emptying and reduce absorption of PO drugs
- - Byetta (exenatide) - OC DEC = take OC 1 hour prior
- Counseling: 1) Administer with fresh needle by SC injection in stomach area, thigh, back of upper arm (count to 5)
- 2) store in fridge or RT (30 days), not freeze
- 3. nausea decreases over time (drink fluids)
- 4. Contact doctor - sx of pancreatitis (severe stomach pain, radiate from abdomen to back), dec ETOH use
- Byetta: 1) inject BID within 60 mins before morning and evening meals (meals 6 hours apart) - after meals = hypoglycemia
- 2) expect in 1 month - no nausea = INC dose
- 3) toss after 30 days
- Bydureon: 1) once every 7 days (weekly), missed dose - at least 3 days from next dose
- 2) inject immediately after mixing
- Victoza: 1) inject QD
- 2) expect dose inc after 1 week
- Note: not with thyroid cancer, contact doctor - swelling in neck, trouble swallowing, SOB
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Pramlintide
DI: slows gastric emptying which can reduce absorption of PO drugs
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Bile acid binding resins - colesevelam
- DI: Separate 4 hours AFTER with certain drugs
- - monitor INR with warfarin
- - 4-6 hours BEFORE Niaspan
- Counseling: 1) constipation = laxatives (senna), stool softener (docusate), fluid intake
- 2) DEC ADEK vitamins = take multivitamin at other time
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Bromocriptine
- DI: CYP 3A4 - watch inducers and inhibitors
- - do NOT use other ergot medications
- - adjust with SU
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Insulin
- Counseling: 1) store unused in fridge and used in RT
- 2) wash hands and prepare
- 3) check insulin - color, crystals, lumps
- 4) roll bottle gently in hand (don't shake) or invert pen 4-5 times
- 5) clean injection site and insulin top with alcohol swab (let dry)
- 6) abdomen is preferred injection site
- 7) alter sites (avoid inflammation and atrophy) and make sure 1 inch from navel and last site
- 8) pinch skin, insert 90 degree , and count to 5-10 seconds
- 9) proper disposal
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hypoglycemia
- sx: dizziness, h/a, anxiety, shakiness, diaphoresis (sweating), excessive hunger, confusion, clumsy or jerky movements, tremors, palpitations, fast hear rate, blurred vision
- Treatment: conscious - 15-20 grams of glucose, 1/2 cup (4 oz) of any juice or regular (non-diet) soda, 1 cup (8 oz) milk, 1 tablespoon of sugar or honey, 2 tablespoons of raisins, 4-5 saltine crackers, 3 or 4 glucose tabs, 1 servicing of glucose gel
- then - retest in 15 minutes, repeat if necessary and eat a meal when BG back to normal
- - unconscious = glucagon 1 mg SC/IM/IV
- - alternative: Dextrose 25%, 50%
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