When do we treat prediabetes with pharm therapy and what do we use? How often do we monitor?
When BMI is greater than 35, age < 60, or women with history of gestational diabetes
Use metformin
Monitor annually
Gestational diabetes - goals? Treatment?
Fasting < 95, 1-hour post meal < 140, 2-hours post meal < 120
Insulin is preferred treatment
When should we test someone for T2DM? How often should we repeat if tests are normal?
Screen adults who are overweight or obese (BMI > 25 or > 23 in Asian Americans) and who have one or more additional risk factor
Test after age 45 regardless of risk factors
Normal test results should be repeated every 3 years
Waist circumference goals
< 35 in for females, < 40 in for male
Nutritional supplements recommended
Omega-3 fatty acids (EPA and DHA) and omega-3 linolenic acid (ALA)
Carbohydrate serving is how many grams?
15
Which diabetic agents have been shown to decrease cardiovascular and all-cause mortality when added to standard treatment?
Empagliflozin (Jardiance)
Liraglutide (Victoza)
When should aspirin be added to diabetes therapy?
Primary prevention: age > 50 years who have diabetes and at least one additional ASCVD risk factor
Secondary prevention: everyone
When are statins recommended with diabetes therapy?
In most patients with diabetes, intensity of dosing is based on ASCVD risk
ACC/AHA: Recommend high intensity in patients age 40-75 who have diabetes plus ASCVD risk
ADA recommends:
Age < 40 years, only if they have ascvd risk factors
Age > 75 years, mod intensity of they have no risk factors or mod/high if they have risk factors
Preferred anti-htn in diabetes?
ACEi or ARB preferred in patients with albuminuria (urine albumin > 30 mg/24 hours or UACR > 30 mg/g)
Otherwise any agent from the preferred classes are fine
How to monitor for renal disease progression in diabetes?
Annual urine albumin excretion
How to monitor for retinopathy in diabetes?
Eye exams every 2 years
Women with preexisting diabetes who become pregnant: higher risk, check each trimester and up to 1 year postpartum
How to monitor for neuropathy?
Assess annually using 10-g monofilament and at least one additional test (pinprick, temperature, or vibration sensation)
Preferred agents for neuropathy per the ADA?
Duloxetine, pregabalin
How to monitor for foot ulcers etc?
Comprehensive foot exams once per year
All patients with diabetes should inspect their feet daily
Foot care counseling
Underlined:
Check feet every day
Avoid walking barefoot
Protect feet from hot and cold
Vaccinations for patients w diabetes
Annual flu
Pneumococcal (23 x 1 between age 2-64
13 then 23 after age 65, spaced at least 1 year apart and 23 separated by 5 years after previous admin)
Hepatitis B vaccine? approved ages 19-59, per ACIP can be used in age > 60
How often should A1C be measured?
Quarterly
Drugs that can cause hyperglycemia
Beta blockers (or hypo) Diuretics (thiazides/loop) Immunosuppressants (cyclosporine, tacrolimus) Niacin Protease inhibitors Quinolones (or hypo) Second-gen antipsychotics Statins Steroids
Janumet
Metformin and sitagliptin
Qtern
Saxagliptin and dapagliflozin
DPP-4 inhibitor and SGLT2 inhibitor
Xultophy
Liraglutide and insulin degludec
GLP-1 agonist + long acting insulin
Soliqua
Lixisenatide and insulin glargine
GLP-1 agonist + long acting insulin
Metformin boxed warnings
Lactic acidosis, increased risk with intravascular iodinated contrast, age > 65, hypoxic states, dehydration, alcohol
Underlined: contrast, alcohol, eGFR stuff
Renal dosing metformin
based on eGFR
Contraindicated in eGFR < 30
Not recommended to initiate if between 30-45, assess benefit if already taking if eGFR < 45 and already taking
Side effects metformin
N/V/D
Flatulence
Abdominal cramping (give w/ meal)
Vitamin B12 deficiency
Sulfonylureas and meglitinides MOA
Insuline secretagogues; work by stimulating insulin secretion from the pancreatic cells to decrease postprandial blood glucose
Sulfonylureas and meglitinides side effects, counseling
Meglitinides (nateglinide, repaglinide): Take 15-30 mins before meals
Sulfonylureas: once or twice daily
Can cause weight gain, hypoglycemia
Take before meals (sulfonylureas take 30 min before breakfast, except glipizide IR take 30 mins before any meal
Hold doses if NPO!
True or false: It’s ok to use sulfonylureas and insulin together
False - high risk of hypoglycemia
Thiazolidinediones MOA
Increase peripheral insulin sensitivity by agonizing PPAR-gamma receptors
Actos dosing, generic, drug class, contraindications/warnings, side effects
Pioglitazone
Thiazolidinediones
15-30 mg daily
Contraindicated in Class III/IV heart failure
Can cause hepatic failure, edema (including macular edema)
Increased risk of bladder tumors, do not use in patients with active bladder cancer
Can cause peripheral edema, weight gain
Monitor for s/sx of HF
SGLT-2 inhibitors MOA
Increases reabsorption of filtered glucose in the proximal renal tubule (underlined)
Increases urinary glucose excretion
Invokana generic, MOA, dose
Canagliflozin
100 mg daily but can inc to 300 mg daily
Decrease based on eGFR - if 45-59, dec to 100 mg daily max
Not recommended in 30-44, contraindicated < 30
SGLT-2 inhibitor
SGLT2 inhibitor boxed warnings, warnings, side effects, monitoring
Canagliflozin has a boxed warning for increased risk of leg and foot amputations
Contraindicated in eGFR < 30
Warnings of ketoacidosis, genital mycotic infections, urosepsis, and pyelonephritis
Also can cause intravascular volume depletion (hypotension, dehydration) when used with diuretics, RAAS inhibitors, or NSAIDs
Canagliflozin can cause hyperkalemia
Side effects: wt loss, hypoglycemia
Monitor: renal fx
Jardiance generic, MOA, dose
Empagliflozin SGLT-2 inhibitor 10 mg daily, up to 25 mg daily Not recommended in eGFR 30-44 Contraindicated eGFR < 30
DPP-4 inhibitor MOA
Increases insulin release from pancreatic beta cells and decreases glucagon excretion from pancreatic alpha cells
Januvia generic, MOA, dose
Sitagliptin DPP-4 100 mg daily CrCL 30-49: 50 mg daly CrCL < 30: 25 mg daily
Warnings w DPP-4, side effects, counseling
DPP-4
Acute pancreatitis
Saxagliptin (Onglyza) and alogliptin (Nesina) can inc risk of heart failure
SIde effects: nasopharyngitis, URTI’s, UTI’s
Onglyza generic, MOA, dose
Saxagliptin
DPP-4 inhibitor
2.5-5 mg daily
eGFR < 45: 2.5 mg daily
Tradjenta generic, MOA, dose
Linagliptin
DPP-4
5 mg daily
No renal dose adjustment!
Nesina generic, MOA, dose
Alogliptin DPP-4 25 mg daily eGFR 30-59: 12.5 mg daily < 30: 6.25 mg daily
Which drugs require glucose (not sucrose) for tx of hypoglycemia if caused by another drug?
Acarbose (Precose) or miglitol Glyset)
These block metabolism of intestinal sucrose, which delays glucose absorption to reduce BG
Need glucose gel or tablets if pt is on these