Diabetes

Question 1

Drugs used to treat diabetes

Answer 1

○ Biguanides/Metformin
○ Sulfonylureas
○ Thiazolidinediones (TZDs)
○ Dipeptidyl peptidase-4 (DDP-4) inhibitors
○ Glucagon-like peptide-1 (GLP-1) agonist
○ Sodium-glucose cotransporter-2 (SLGT-2) inhibitors
○ Insulin

Question 2

Biguanides example

Answer 2

Agents: Metformin (Glucophage™)
○ Immediate Release Formulation
○ Extended Release Formulation

Question 3

Biguanides MOA

Answer 3

Decreases hepatic glucose production, decreased intestinal
glucose absorption, and increases insulin sensitivity and peripheral glucose uptake and
utilization

Question 4

Biguanides preferred

Answer 4

Preferred initial agent for type 2 diabetes

Question 5

Biguanides efficacy

Answer 5

Efficacy: Decreases A1C approximately 1-1.5%

Question 6

Biguanides SE

Answer 6

○ GI Upset (diarrhea, nausea, upset stomach, flatulence)

○ B12 and other vitamin deficiencies

Question 7

Biguanides do what to avoid SE

Answer 7

take with food

Question 8

Biguanides Serious side effects

Answer 8

○ Lactic Acidosis

Question 9

Biguanides Monitoring

Answer 9

○ Side effects (mainly GI)
○ Renal Function
○ Lactic Acidosis
○ A1C, Fasting and 2-hour PP Blood glucose

Question 10

Biguanides Contraindications

Answer 10

○ eGFR <30mL/min

Question 11

Sulfonylureas - agents

Answer 11

glipizide (Glucotrol™), glimepiride (Amaryl™), and glyburide (Glynase™)

Question 12

Sulfonylureas - MOA

Answer 12

: Stimulates insulin secretion from functioning beta cells in the
pancreas, especially in response to a meal; may also increase insulin sensitivity and lower
hepatic glucose production

Question 13

Sulfonylureas - Efficacy

Answer 13

○ Hypoglycemia

○ Weight gain

Question 14

Sulfonylureas - Common side effects

Answer 14

○ Hypoglycemia - Avoid in elderly patients for fall risk

Question 15

Sulfonylureas - Serious side effects

Answer 15

○ Hypoglycemia!

○ A1C, blood glucose

Question 16

Sulfonylureas monitoring

Answer 16

○ Avoid in patients with G6PD deficiency

○ Glimepiride - Avoid in the elderly

Question 17

Sulfonylureas - place in therapy

Answer 17

○ Really fallen out of favor given newer agents with better benefits
○ Used when cost is a major issue (uninsured/underinsured)

Question 18

Sulfonylureas administration

Answer 18

○ Take with food for ER products and just before (30ish minutes) before a meal for IR products
○ ER tablets should not be crushed/chewed

Question 19

Sulfonylureas - Pearls

Answer 19

Inexpensive and generally well covered

Question 20

Biguanides - place in therapy

Answer 20

○ First line for management of Type 2 Diabetes

○ Should be continued for as long as possible

Question 21

Biguanides administartion

Answer 21

○ Take with food to reduce GI upset

Question 22

Biguanides - pearls

Answer 22

○ ER formulation less likely to cause GI upset
○ Osmotic ER formulation is rarely covered by insurance
○ Take with food

Question 23

Thiazolidinediones (TZDs) - Agents

Answer 23

pioglitazone (Actos™) and rosiglitazone (Avandia™)

Question 24

Thiazolidinediones (TZDs)

- MOA

Answer 24

: increases insulin-dependent glucose disposal and decreases

hepatic glucose output by decreasing insulin resistance in the periphery and in the liver

Question 25

Thiazolidinediones (TZDs)

Efficacay

Answer 25

Decreases A1C approximately 1-1.5%

Question 26

Thiazolidinediones (TZDs)

SE

Answer 26

○ Edema
○ Weight Gain
○ Headache

Question 27

Thiazolidinediones (TZDs)

- Seriously SE

Answer 27

Heart Failure

○ LFT elevations

Question 28

Thiazolidinediones (TZDs)

Monitoring

Answer 28

○ LFTs prior to therapy
○ Signs/symptoms of heart failure
○ A1C, blood glucose

Question 29

Thiazolidinediones (TZDs)

- Precautions

Answer 29

History of heart failure
○ Severe edema
○ Generally not recommended with renal impairment - fluid retention

Question 30

Thiazolidinediones (TZDs)

Place in Therapy

Answer 30

Used less often, generally third line agent after metformin and another agent
○ Generally used when cost is a concern

Question 31

Thiazolidinediones (TZDs)

Administration

Answer 31

Can take with or without food

Question 32

Thiazolidinediones (TZDs)

Pearles

Answer 32

Avoid with patients with history of heart failure

Question 33

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Agents

Answer 33

Agents: sitagliptin (Januvia™), linagliptin (Tradjenta™), alogliptin (Nesina™), saxagliptin
(Onglyza™)
○ The “gliptins”

Question 34

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- MOA

Answer 34

protects glucose-dependent insulinotropic polypeptide (GIP) and
glucagon-like peptide (GLP-1) from inactivation by DPP-4, thereby enhancing their
actions; Increases insulin release and decreases glucagon levels in the circulation in a
glucose-dependent manner

Question 35

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Efficacy

Answer 35

Decreases A1C approximately 0.5-1%

Question 36

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Common Side Effects

Answer 36

○ Headache

○ Nasopharyngitis

Question 37

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Serious Side Effects

Answer 37

Pancreatitis

Question 38

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Monitoring

Answer 38

○ Renal Function
■ Dosing Adjustments: sitagliptin, saxagliptin, alogliptin
○ A1C, Blood glucose

Question 39

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Contraindications

Answer 39

○ Concomitant use of sulfonylurea

○ Heart Failure

Question 40

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Place in Therpay

Answer 40

○ More rarely used but sometimes used as a 3rd line option
○ Similar mechanism of action to GLP-1 agonists, so generally not used in combination with these
agents

Question 41

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Administration

Answer 41

○ Take with or without food

Question 42

Dipeptidyl Peptidase-4 Inhibitors (DPP-4
Inhibitors)
- Pearls

Answer 42

Becoming increasingly well covered