Oral agents are FDA approved for ___ diabetes
Type2
What are the 5 types of oral agents?
Metformin Sulfonylureas TZDs DPP-4 Inhibitors SGLT-2 Inhibitors
What is the cornerstone of T2DM management?
Metformin
When do you start metformin?
Immediately after diagnosis of type 2 diabetes
How does metformin lower blood glucose and improve glucose tolerance?
- Decrease glucose production of the liver
- Decrease glucose absorption of the gut
- Increase sensitivity of insulin receptors
Does metformin stimulate insulin release from the pancreas? What does this mean?
No, it does not “hit” the pancreas to release glucose so it does NOT pose much threat to developing hypogycemia when used alone
What are the 5 most common adverse effects of metformin?
- Diarrhea and flatulence (very common and goes away with time)
- Decreased vitamin b12 (can contribute to peripheral neuropathy)
- Decreased folic acid (deficiency in pregnancy can impair development of CNS of fetus)
- Lactic acidosis (RARE)
- Weight neutral (does not cause weight gain or loss)
What must we teach patients who are taking metformin in regards to lactic acidosis?
Teach them the early signs of it (hyperventilation, myalgia, malaise, and unusual somnolence)
Who is metformin contraindicated in?
Patients with HF
Is it okay to drink alcohol when taking metformin?
No, avoid consuming alcohol in excess, discontinuing would be even safer because alcohol can inhibit the breakdown of LA and therefore, can intensify LA
What is the second most common T2DM?
Sulfonylureas
What is the MOA of sulfonylureas?
“Hits” pancreas over and over to secrete more insulin, so it makes blood sugar go down
If you are taking a sulfonylurea, is there a risk of hypoglycemia?
YES
What are the 3 examples of sulfonylureas?
Glipizide
Glyburide
Glimepiride
What sulfonylurea is the most kidney friendly aka the “least renally excreted”?
Glipizide
What are the 3 adverse effects of the sulfonylureas? (glipizide, glyburide, glimepiride)
- HYPOGLYCEMIA!!!
- Weight gain
- “Burn out”
How much weight gain may be seen with the sulfonylureas?
5-10 lbs
How long can you take a sulfonylureas before “burnout”?
5-10 years
Is it okay to take a sulfonylureas during pregnancy?
No!! ONLY oral drug that is okay in pregnancy is metformin!
Can you take alcohol with sulfonylureas?
NO! There is a disulfiram-like reaction because alcohol POTENTIATES the hypoglycemic effects of this drug!!!
TZDs are normally taking as an add on with what other oral anti-diabetic?
Metformin
What is the MOA of TZDs?
Reduce glucose levels primary by decreasing insulin resistance by activation of the PPAR gamma receptor
Does TZDs work on DNA?
Yes
Since TZDs work on DNA, what does that mean?
It will take 3-4 MONTHS before they start working!
What are the two main drugs for TZD?
Rosiglitazone
Pioglitazone
Which TZD has possible CV issues like sudden death?
Rosiglitazone
Which TZD has mixed effects on lipids..and what does that mean?
Pioglitazone
Increases HDL and LDL
Decreases TG
What are the 5 adverse effects of TZDs?
- Sodium retention (water follows sodium, so excess fluid) –> edema
- Weight gain (because the excess fluid and edema)
- Bone fractures
- Hepatotoxicity (RARE)
- Bladder cancer (RARE)
What is the MOA of the DPP-4 Inhibitors?
Blocks the incretic hormones and keeps blood glucose from rising too high
What drug is a DPP-4 inhibitor?
Sitagliptan
What are the adverse effects of DPP-4 inhibitor (sitagliptan)?
- Well tolerated
- Upper respiratory issues (runny nose)
- Pancreatitis (RARE)
What is the MOA of SGLT-2 Inhibitors?
Reduce the reabsorption of glucose in the kidneys
Explain how SLGT-2 inhibitor work?
Normally if blood glucose is less than 180, then it is reabsorbed back into the blood. If blood glucose is greater than 180, then it gets peed out. SGLT-2 Inhibitors will block the reabsorption if the blood glucose is only greater than 80
What is the example of the SGLT-2 Inhibitor?
Canagliflozin
What are the adverse effects of canagliflozin (SGLT-2 Inhibitor)?
- Weight loss
- Dehydration
- Hyperkalemia
- Genital infections
How much weight is loss with SGLT-2 Inhibitors?
5-7 lbs
What kind of genital infections are seen when taking canagliflozin (SGLT-2 Inhibitor)?
Fungal
10% of women
3-4% of men
Glipizide
Sulfonylureas
Canagliflozin
SGLT-2 Inhibitors
Rosiglitazone
TZD
Sitagliptin
DPP-4 Inhibitor
Glyburide
Sulfonylureas
Piolitazone
TZD
Glimepiride
Sulfonylureas
Metformin
No class
What oral causes hypoglycemia?
Sulfonylureas (glipizide, glyburide, glimepiride)
What oral causes genital infections?
Canagliflozin (SGLT-2 Inhibitors)
What drug is well tolerated but has the rare effect of pancreatitis?
Sitagliptin (DPP-4 Inhibitors)
What drug has the rare effect of causing cancer?
Pioglitazone (TZD)
What drug causes weight gain, how much?
Sulgonylureas (glipizide, glyburide glimepiride); 5-10lbs
What drug causes weight loss? how much?
SGLT-2 Inhibitor (Canagliflozin)
5-7 lbs
What drug is weight neutral?
Metformin
What drug has diarrhea and gas for adverse effects?
Metformin
What drug must be taken before breakfast?
SGLT-2 Inhibitors (canagliflozin)