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Tx DM Part I
Pharm-II
| Question | Answer |
|---|---|
| What is DM associated w/ | abnl carb, fat, and protein metabolism |
| What are post effects of DM | blindness, end stage renal dz, HD, and stroke |
| Why are new cases of DM2 increasing | d/t lifestyle, ethnicity, and age |
| What ↓ complications in DM pts | strict glucose control |
| Tx goals for DM | reduce LT micro/macrovascular complications, prevent acute complications of ↑BG: DKA, HHS, minimize hypoglycemic episodes, maintain QOL, educate pt on DM |
| Glycemic goals for DM | A1C <7%, FPG: 70-130, 2 hr PP: < 180 |
| What do we check if the pt’s report and A1C doesn’t match up | meter, additional tx, (Don’t assume they r lying) |
| Non-pharm management of DM | Pt ed, lifestyle changes: |
| All the levels of DM tx | pt ed on dz process and PA, nutritional management, medications, monitoring BG, preventing acute/chronic complications |
| Lifestyle changes necessary for DM control | nutrition, self monitoring, PA, adherence to medications |
| Why does physical activity help? | improves insulin sensitivity, may improve glucose tolerance |
| What four biological components lead to DM | ↓ insulin secretion, ↓ glucose use in peripheral tissues, ↑ glucose made in liver, sugar absorption in the gut |
| What drugs stimulate insulin secretion | sulfonylureas, and meglitinides |
| What drugs ↑ glucose uptake | thiazolidendione |
| What drugs ↓ gluconeogenesis in the liver | Biguanides |
| What drugs block sugar absorption in the gut | a-Glucosidase inhibitor |
| What is the initial therapy for BM | a Biguanide: metformin |
| When is metformin CI | Cr >1.5 or 1.4 in F, also HOLD with contrast |
| What will ↑ peak of metformin by 60% | cimetidine |
| Trade name for metformin | Glucophage |
| Two other additional therapy after the metformin | insulin and sulfonylurea |
| MOA of sulfonylurea and names | Enhance insulin secretion Glipizide Glyburide, Glimepiride |
| AE’s of sulfonylureas | hypoglycemia, wt gain, nausea |
| AE’s of metofrmine | GI disturbances, rare but can occur: lactic acidosis |
| AE’s of insulin | hypoglycemia, pain at injection site, atrophy/hypertrophy of sq fat tissues, wt gain |
| How are SUs eliminated | liver CYP substrate but metabolites are renally eliminated |
| What are the “tier 2” drugs | Thiazolidinedione and Glucagon-like peptide-1 agonists (GLP-1) |
| MOA of thiaxolidinedione and name | reduce insulin resistance, Pioglitazone: Trade: actos |
| AE’s of TZD | wt gain, fluid retention, hepatotoxicity |
| What will ↓ BG w/ TZD | the administration of insulin and SU |
| Monitoring of TZD | ALT d/t hepatotox |
| MOA of GLP-1 | potentiates glucose-stimulated insulin secretion, slow stomach emptying, ↓ hunger |
| Two names of GLP-1 | Exenatide, Liraglutide |
| Black box warning on GLP-1 | thyroid tumor in RODENTS, also pancreatitis |
| Why would we add GLP-1 | used in pts taking metformin and/or SU to improve glucose control |
| What drugs delay glucose absorption | Alpha-glucosidase inhibitors (never monotherapy) |
| What drugs are similar to sulfaureas and y | Glitinides, stimulates insulin release from B-cells |
| Diff b/w Sulfonyureas and GLitinides | Glitinides: Faster onset, shorter duration, covers CHO meals |
| SE’sof Glitinides | Wt gain, Hypoglycemia, Nausea, HA |
| Fxn of amylin | ↓ BG after eating, secreated by the pancreas |
| Repaglinide | Prandin: a glitinide |
| Pramlintide | symlin: amylin agonist |
| What must we adjust w/ the start of pramlintide | ↓ insulin dose d/t ↓ Glucose absorbtion |
| What are DPP-4 inhibitors | they enhance endog incretin activity by inhibiting breakdown of DPP-4, ↑ glu-med insulin secretion, ↓ glucagon secretion |
| Names for DPP-4 inhibitors | “gliptins” Sitagliptin, Saxagliptin, Linagliptin |
| AE’s for gliptins | generally well tolerated, may interfere w/ immune fxn? URI? |
| When do we adjust the gliptin dose | in pts w/ moderat-severe renal insufficiency (also note w/ Digoxin, may ↑ dose) |
| MOA for dopamine receptor agonist | ↑ insulin sensitivity (Bromocriptine: cycloset) |
| AE’s of Bromocriptine | Dizziness/syncope, N, fatigue, HOTN, rhinitis (LT safety unknown) |
| Do we start w/ combo products?? NO:D | |
| Commone combinations | Glyburide/metformin, Pioglitazone/Metformin, Rosiglitzone/glimepiride, Sitagliptin/metformin |
| When do we dose (time of day) oral agents | 30 min before meals, (qday? Then before 1st meal of the day) |
| Two initial steps in tx DM | ↓wt, ↑ activity, metformin |
| What is the best at lowering A1C | insulin |
| Initial dose of metformin | 500mg qday, after 5-7 days, ↑ to 850mg qday or 500mg bid |
| Maximum effective dose of metformin | 1000mg bid (but often 850mg bid is used) |
| What may limit the dose of metformin that will be used | GI side effects |
| What is the 1st choice of pharm therapy | metformin (generic) |
| Fxns of insulin | stimulates glucose uptake, inhibits HGPm inhibits lipolysis, proteolysis, and ↑ protein synthesis |
| Usual sorce of insulin | human MC, some use animal: beef or pork |
| Where do we store the insulin | in the refrigerator (kept at RT if used w/I 30 days) |
| When should pt’s not use their insulin | discolored, particles clumped in the bottle, past expiration date or not refridgerated >1m |
| How and where is insulin administered | SQ, 90 degree angle, in the abd, arm, thigh, buttocks |
| What is the ONLY IV form of insulin | regular |
| Why can’t we give insulin PO | stomach acids will disenegrate prior to action |
| AE’s of insulin | hypoglycemia, pain at site, atrophy or hypertrophy of SQ fat |
| Starting dose for DM1 and DM2 pts for insulin | 1: .5-.6U/kg/day, 2: .2U/kg/day |
| Usual maintnence dose for insulin | .5-2U/kg/day in divided doses (50% basal 50% prandial insulin) |
| F/U while starting insulin | at least weekly until dose is established |
| Three types of dosing regimens | Minimal, Conventional, Intensive |
| What type is inappropriate for type 1 DM | minimal (only dosed 1-2 times/day of NPH) |
| Conventinal insulin dosing | NPH 2 times daily (morning, supper) and Regular breakfast and supper (can mix) |
| Intensive dosing for insulin | 3-4 injections w/ 50% basal and 50% short acting |
| What is the % of short acting for each meal | 20% B, 15%l, 15%S |
| What is CSII | continuous subcutaneous insulin infusion (basal insulin 24/7 w/ bolus prior to meals and snacks) |
| Temporary remission of hyperglycemia in some newly diagnosed pts w/ T1 or transient ↓ need for exogenous insulin | honeymoon phase |
| Relative resistance to insulin during morning hours | dawn phenomenon |
| Rebound hyperglycemia following an episode of hypoglycemia | somogyi effect |
| Effects of decongestants on BG | can raise BG, (pseudophedrine_ use nasal sprays short term |
| What simple analgesics can be used in DM | APAP and IBU fine, use aspirin in low doses (<8/day) |
| What should we remember on cough preperations w/ DM | syrup? Sugar?. Decongestants? Cough drops; sugar? |
Created by:
becker15
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