Diabetes

Front 1

DM

Treatment Principles and Goals

Glycemic control
BP
Lipids

Back 1

-A1C < 7% (<6% may reduce complications at the cost of increased risk of hypoglycemia)
-Preprandial plasma glucose - 90-130
-peak postprandial plasma glu - < 180

-BP < 130/80

-LDL < 100
-Triglycerides < 150
-HDL > 40

Front 2

DM

Prevention of complications

Back 2

-smoking cessation
-ASA TX
-secondary prevention in all
-primary prevention if >40 or have RF
-immunizations
-influenze
-lifetime pneumococcal
-foot care - daily self annual MD
-skin inspection daily
-eye: annual dilated eye

Front 3

DM

Medication classes

Back 3

Secretagogues
- sulfonylureas
- meglitinides

Sensitizers
- biguanides
- thiazolidinediones

Alpha-glucosidase inhibitors

Peptide analogs
- incretin mimetics
- dpp-4 inhibitors
- amylin analogs

Front 4

DM

secratagogues - the drugs

Back 4

SULFONYLUREAS
First-generation agents
o tolbutamide (Orinase)
o acetohexamide (Dymelor)
o tolazamide (Tolinase)
o chlorpropamide (Diabinese)
Second-generation agents
o glipizide (Glucotrol)
o glyburide (Diabeta, Micronase,
Glynase)
o glimepiride (Amaryl)
o gliclazide (Diamicron)

MEGLITINIDES
- repaglinide (Prandin)
- nateglinide (Starlix)

Front 5

DM

secratagogues

MOA and Clinical consideration

Back 5

Both
- ↑ insulin secretion from pancreas
- cause wt gain
- s/e hypoglucemia (sul > meg)
- not in pregnancy or breastfeeding

sulfonylureas - "LA - secratagogue"
- 1-2% A1C ↓
- before meals QD/BID

meglitinides "SA - secratagogue"
- 0.5-2% A1C ↓
- before every meal

Front 6

DM

Secratagogues

Cautions/CIs

Back 6

- caution w/↓ renal/hep f(n) & elderly
- safe with metformin or glitazones
**disulfiram (Antabuse)-like reaction
with EtOH use**
- following ↑ risk for hypoglycemia:
- anticoagulants, tricyclics
- fluconazole, digoxin
- gemfibrozil, sulfonamides
- CId in pts with:
- severe infection
- DKA
- surgery or trauma

Front 7

DM

sensitizers - the drugs

Back 7

biguanides
metformin (Glucophage)

thiazoladinediones (glitazones/TZDs)
rosiglitazone (Avandia)
pioglitazone (Actos)

Front 8

DM

metformin - MOA / A1C

Back 8

1. ↓ hepatic gluconeogenesis
2. improves glucose utilization
3. ↓ intestinal absorption of glucos

A1C reduction 1-2%

Front 9

DM

metformin - clinical consideration

Back 9

1. first choice in new dx of DM
2. ↓ weight a tad
3. favorable on trigs, LDL, HDL
4. GI sx:
- take w/food
- dose low and increase slowly
5. may take 8 weeks to see effects
6. may be best choice for HF pts

Front 10

DM

metformin - cautions/CIs

Back 10

1. ↑risk of lactic acidosis (↑ risk for la)
- aMI, CHF exacerbation
- severe respiratory dz
2. CIs
- SCr>1.4 F, 1.5 M
- hepatic dysf(n)
- excessive EtOH use (>2/d or binge)

Front 11

DM

TZDs - MOA / A1C

Back 11

agonist of PPARγ (a nuclear regulatory protein) → production of insulin-depen
enzymes that ultimately leads to
1. ↑ insulin sensitivity and therefore better use of glucose by the cells
2. ↓ hepatic glucose output

A1C reduction of 1-2%

Front 12

DM

TZDs - clinical consideration

Back 12

1. low risk of hypoglycemia
2. 5kg wt gain
3. favorable for Trigs, HDL
4. unfavorable for LDL
5. may take 16 wks to see effects

Front 13

DM

TZDs - cautions/CIs

Back 13

**edema** - Black Box for CHF

hepatotoxicity: LFTs qom for 12m. d/c if ALT > 3x ULN

decrease OC effectiveness

Front 14

DM

alpha glucosidase inhibitors - the drugs

Back 14

miglitol (Glyset)
acarbose (Precose/Glucobay)

Front 15

DM

alpha glucosidase inhibitors

MOA, A1C

Back 15

delay digestion of carbs from a meal into simple sugars and their absorption in small Intestine

reduce A1C by 0.5 to 1%

Front 16

DM

alpha glucosidase inhibitors

clinical considerations/CIs

Back 16

main target tx on postprandial hyperglycemia

GI sx: flatulence and bloating limit use in united states but not Europe

counsel pt to ↓ intake of simple sugars

Avoid in pts w/GI disorders and SCr > 2

Front 17

DM

Peptide analogs - the theory/players

Back 17

Incretins are insulin secretagogues

Two incretins:
- Glucagon-like peptide-1 (GLP-1)
- Gastric inhibitory peptide (GIP)

Dipeptidyl peptidase-4 (DPP-4)
- rapidly inactivates GLP-1 and GIP

Front 18

DM

Peptide analogs - the drugs
- incretin mimetics
- dpp-4 inhibitors
- amylin analogs

Back 18

Incretin mimetics
- exenitide (Byetta) - GLP-1 agonist

DPP-4 inhibitors
- sitagliptin (Januvia)

Amylin analogs
- pramlintide (Symlin)

Front 19

DM

exenitide (Byetta) - MOA/A1C

Back 19

GLP-1 agonist binding →
1. ↑ insulin production
2. ↓ glucagon production
3. slowing gastric emptying
4. ↑ satiety and wt loss
5. improved beta cell f(n)

reduces A1C by 0.5 - 1%

Front 20

DM

exenitide - clinical considerations

Back 20

- dose limiting s/e = naseua (50%)
- pts must ↓ meals size and CHO intake
prior to use
- dose 10-15 min before 2 largest meals
- not indicated to combine w/insulin
- most effective for post-prandial glucos
elevations

Front 21

DM

exenitide - cautions/CI

Back 21

- NOT GFR < 30
- NOT servere GI dz
- NOT DKA or type 1 DM

Front 22

DM

sitagliptin (Januvia) - MOA/A1C

Back 22

Inhibits degradation of GPP-4 & GIP→
1. ↑ insulin production
2. ↓ glucagon production
3. improved beta cell f(n)

Front 23

DM

sitagliptin (Januvia) - clinical considerations

Back 23

- combine w/met, TZDs

- minimal risk of hypoglycemia

- no effect on wt

Front 24

DM

sitagliptin - cautions/CIs

Back 24

adjust dose for renal insufficiency

Not in DKA or Tpye 1 DM

Front 25

DM

- pramlintide (Symlin) - MOA/A1C

Back 25

analog of endogenous amylin →
1. ↓ production of glucagon
2. slowing of gastric emptying
3. ↑ satiety and wt loss

Front 26

DM

pramlinitde (Symlin) - clinical considerations

Back 26

can use in combo w/insulin in DM 1 & 2

due to sig risk of hypoglycemia, when used w/insulin, prandial insulin dose should be ↓d by 50%

DLs/e is naseua

Front 27

DM

pramlintide (Symlin) - cautions/CIs

Back 27

do NOT use in following:
1. severe GI dz
2. poor adherence w/current insulin
3. recurrent severe hypoglycemia
4. A1C<9%
5. hypoglycemia unawareness

Front 28

DM

inhaled insulin (Exubera) - clinical consideration

Back 28

provides prandia insulin coverage

pts need baseline spirometry, 6mo, then yearly

type 1 or 2

Front 29

DM

inhaled insuline (Exubera) - cautions/CIs

Back 29

Not inpts with lung dz (COPD, Asthma..)

Not in active smokers or quit < 6mo
- insulin exposure incs by 2-5 fold

Front 30

DM

Insulin - MOA/A1C

Back 30

low levels - suppresses hepatic glucose production

higher levels - promotes glucose uptake by muscle tissue

A1C 2.5% or more

Front 31

DM

Insulin - rapid-acting
- onset
- time of peak
- duration
- names

Back 31

-onset: 10-30 min
-peak: 30-90 min
-duration: 3-5 hours

Insulin lispro (Humalog®)
Insulin aspart (NovoLog®)
Insulin glulisine (Apidra®)

Front 32

Insulin - short-acting
- onset
- time of peak
- duration
- names

Back 32

-onset: 30 min
-peak: 2.5 -5 hours
-duration: 4 -12 hours

Insulin regular (Humulin® R, Novolin® R)

Front 33

Insulin - intermediate-acting
- onset
- time of peak
- duration
- names

Back 33

-onset: 1-2 hours
-peak: 4-12
-duration: 18-24

Insulin NPH (isophane suspension) (Humulin® N, Novolin® N)
Human Lente

Front 34

Insulin - intermediate- to LA (Basal)
- onset
- time of peak
- duration
- names

Back 34

-onset: 3-4
-peak: 3-14
-duration: 6-23

Insulin detemir (Levemir®)
Human Lente

Front 35

Insulin - long-acting (Basal)
- onset
- time of peak
- duration
- names

Back 35

-onset: 3-4
-peak: no pronounced peak (glargine)
-duration: > 24h

Insulin glargine (Lantus®)
human ultra lente (not basal-simply LA)

Front 36

Insulin - combinations
- onset
- time of peak
- duration
- names

Back 36

-onset: 10 - 30 min
-peak: 2 -12 h
-duration: 18 -24

Insulin aspart protamine suspension and insulin aspart (Novolog® Mix 70/30)

Insulin lispro protamine and insulin lispro (Humalog® Mix 75/25™)

Insulin NPH suspension and insulin regular solution (Novolin® 70/30)