Naplex Prep: RxPrep/UWorld - Diabetes

Which of the following statements about glucagon is correct?

Is produced by the alpha cells in the pancreas and work when BG is low

Hyperglycemia is due to:

decreased insulin secretion

decreased insulin sensitivity

or both

Types of Diabetes:

Type 1

It must be treated with insulin

Absolute insulin deficiency

It is diagnosed with very low or absent C-peptide levels

It is caused by an autoimmune destruction of beta cells in the pancreas

c peptide

produced when insulin is released. t1d have low or none since no insulin is being produced

Type 1 diabetes

Diagnosis (what tests can be done?) + why

Islet antibodies (autoimmune)

C peptide - only produced when insulin is released. So no insulin releasing = low/no c peptide

Types of Diabetes:

Type 2

It is due to insulin deficiency and insulin resistance

Strongly associated with obesity, physical activity, family history and presence of other comorbid conditions

Sarah has been diagnosed with GDM. She has implemented lifestyle modifications but is unable to reach blood glucose goals. what is the preferred treatment in GDM? (after lifestyle)

Insulin is preferred treatment to control blood glucose in a pregnant patient if lifestyle modification are not adequate

Types of Diabetes:

Gestational Diabetes - Management (4)

lifestyle first

insulin is DOC, used if needed

Metformin and glyburide (not preferred, but may be considered)

Types of Diabetes:

Gestational Diabetes - Risks to baby

macrosomia (larger baby)

hypoglycemia at birth

obesity and type 2

Types of Diabetes:

Prediabetes - Treatment Options (broad)

Diet & Exercise

Metformin

Annual Monitoring for Dm and CVD

Types of Diabetes:

Prediabetes - Treatment Options

Who is eligible for Metformin?

BMI > 35

25-59 yrs old

gestational DM Hx

what are the risk factors for type 2 diabetes? 11

age (older)

Physical Inactivity

Overweight (BMI >25 kg/m2 or > 23 kg/m2 in Asian Americans)

High-risk race/ethnicity:

(African American, Latino/Hispanic American, Native American, Asian American or Pacific Islander)

History of gestational diabetes mellitus

A1C > 5.7%

First-degree relative with diabetes

HDL < 35 mg/dL and/or TG > 250 mg/dL

Hypertension(> 140/90 mmHg or taking medication

CVD history or smoking history

Conditions that cause insulin resistance (e.g., acanthosis nigricans, polycystic ovary syndrome)

what are the symptoms of high blood glucose? 7

Polyuria (excessive urination)

Polydipsia (excessive thirst)

Polyphagia (excessive hunger)

Fatigue

Blurry Vision

Erectile Dysfunction

Vaginal Fungal Infection

There are three types of tests used to identify if prediabetes or diabetes is present:

Hemoglobin A1C (or simply A1C) indicates the average BG over approximately the past 3 months

Fasting plasma glucose (FPG) gives the BG at that moment, and is taken after fasting for > 8 hours

The OGTT determines how well glucose is tolerated by measuring the BG level 2 hours after drinking a liquid that is high in sugar

Screening & Testing:

Who should be Tested

everyone with a BMI >/= 25 kg/m2 in (>/= 23 kg/m2 in Asian Americans) + one other risk factor

>/= 35yrs old

symptoms

Diagnostic criteria for diabetes:

A1C: > 6.5%

FPG (mg/dL): > 126

OGTT 2 hr BG (mg/dL): > 200

Diagnostic criteria for pre-diabetes:

alc, fpg, ogtt levels

A1C: 5.7 - 6.4%

FPG (mg/dL): 100 - 125

OGTT 2 hr BG (mg/dL): 140 - 199

Glycemic targets in diabetes - not pregnant

a1c, pre and post prand

A1C: < 7%

Preprandial (mg/dL): 80 - 130

2 - hr PPG (mg/dL): < 180

Glycemic targets in diabetes - pregnant

a1c, pre and post prand

dont use a1c in preg!!

Preprandial (mg/dL): < 95

1 - hr PPG (mg/dL): < 140

2 - hr PPG (mg/dL): < 120

Glycemic control (A1C or another test) should be measured:

Quarterly (every 3 months) if not yet at goal

Biannually (every 6 months or twice per year) if at goal

An A1c of 6% is equivalent to an eAG of _____, with each additional 1% increases the eAG by about ____-

126 mg/dL, 28 mg/dL

HINT: an A1C of 7% is 126 + 28 = 154 eAG

Microvascular diabetes complications includes:

Retinopathy

Diabetic kidney disease (i.e., nephropathy)

Peripheral neuropathy (i.e., loss of sensation, often in the feet), INCREASE risk for foot infections and amputations

Autonomic neuropathy (gastroparesis, loss of bladder control/UTIs, erectile dysfunction)

Macrovascular diabetes complications includes:

Coronary artery disease (CAD), including MI

Cerebrovascular disease including stroke (CVA)

Peripheral artery disease (PAD)

DM Anti-platelet Therapy (Aspirin)

Aspirin 75 - 162 mg/day (usually given as 81 mg/day) is recommended for ASCVD secondary prevention (e.g., post MI)

Not recommended for primary prevention

CAD/PAD: aspirin + low dose rivaroxaban can be added

Used in pregnancy to decrease risk of preeclampsia

DM Diabetic Retinopathy monitoring

T2D: eye exam with dilation in diagnosis

If retinopathy repeat annually

Diabetic Neuropathy Treatment

timeline and types of tests that must be done

treatment (3)

Annually: a 10 g monofilament test and 1 other test to assess sensation

Comprehensive foot exam at least annually

Treatment option: Pregabalin (Lyrica), Duloxetine (Cymbalta), Gabapentin (Gralise, Neurontin)

Vaccines required, in addition to all childhood vaccines:

Hepatitis B virus (HBV)

Influenza

Pneumovax

age 2-64years: PPSV23 x 1

-- when 65+ years, give another (if 5+ years since previous)

Diabetic Foot Care Counseling

Every day: wash dry and examine feet. Moisturize the top and bottom of feet, but not between the toes

Each office visit: take off shoes to have feet checked

Annual foot exam by a podiatrist

Trim toenails with file; do not leave sharp edges from the clippers

Wear socks and shoes. Elevate feet when sitting

According to the ADA,what is the recommended treatment for cholesterol control?

( who should be treated with high vs mod intensity; add on? how often monitoring?)

High Intensity Statin (Atorvastatin 40 -80 mg or Rosuvastatin 20 - 40 mg daily) for:

Diabetes + ASCVD

Age 50 - 75 years with multiple ASCVD risk factors

Moderate Intensity Statin for:

Diabetes + Age 40 -75 years (no ASCVD)

Diabetes + Age < 40 years + ASCVD risk factors

Add on Treatment (to Maximally Tolerated Statin)

Ezetimibe if ASCVD 10 yr risk > 20%

Icosapent ethyl (Vascepa) if LDL is controlled but TGs are 135 - 499 mg/dL

Monitoring lipid panel annually and 4 -12 weeks after starting a statin or increasing the dose

Comprehensive Care:

weight loss

goal weight loss of ___% of body weight

waist circumference

goal of >/= 5% body weight

waist circumference < 35 inches for females and < 40 inches for males

1 carbohydrate serving = ____ grams

15 grams (1 small fruit, 1 slice of bread, 1/3 cup cooked rice/pasta)

DM Non-Drug Treatment:

Physical activity

150 min/week (over 3 days), with resistance training 2x week

stand q30min

Comprehensive Care:

Cholesterol Control what's high and mod intensity?

high intensity:

- rosuvastatin 20-40 mg

- atorvastatin 40-80 mg

moderate intensity:

- rosuvastatin 5-10 mg

- atorvastatin 10-20 mg

- simvastatin 20-40 mg

Comprehensive Care:

Blood Pressure Control

goal

treatment if albuminuria

no albuminuria

ADA guidelines

- < 130/80 mmHg if higher risk of CVD

- <140/90 mmHg for most

albuminuria

- acei or arb

diabetes and HTN, no albuminuria

- thiazide, CCB, ACEI or ARB

Diabetic Kidney Disease

what and when to check

Check Urine Albumin and eGFR:

Annually if normal kidney function

Twice yearly if reduced kidney function (eGFR 30 - 60 mL/min/1.73 m2 or urine albumin > 300)

Which of the following products are likely to be found in over the counter decrease BG products? 3 (are they rec'd?)

Cinnamon

Alpha Lipoic Acid

Chromium

Magnesium

Panax/American Ginseng

NOT rec'd per guidelines

Comprehensive Care:

Bone Health

bone mineral density (DXA scan) q2-3 yrs if >65 or risks

treat if t = <2 or fracture

Treatment algorithm for t2dm

a1c <8.5

8.5-10

>10 (also bg>300, weight loss, sx of hyperglycemia)

dual, mono, etc.

monotx (oral or non insulin injectable)

2 drugs (oral or non insulin injectable)

insulin (regimen can be changed once controlled)

Drug Treatment Options for T2DM:

ASCVD or High risk

1st line

if a1c not at goal

1st line: SGLT2i (dapa, cana, empagliflozin only, if egfr >20) or GLP1 agonist (dulaglutide, lira, SC semaglutide; preferred if egfr <30)

add sglt2i or glp-1 (if not yet started), TZD (NO HF)

Drug Treatment Options for T2DM:

HF

1st line

if cant use

SGLT2i (cana, empag, dapa only, egfr >20)

if eGFR adequate <20

use GLP-1RA with CVD benefit (dula, lira, SC semaglutide)

Drug Treatment Options for T2DM: CKD

1st line

a1c not at goal

1st line: SGLT2i (preferred) (dapa, cana, empagliflozin only, if egfr >20) or GLP1 agonist (dulaglutide, lira, SC semaglutide; preferred if egfr <30)

add glp-1 (if not yet started)

Drug Treatment Options for T2DM:

efficacy for glucose reduction

very high or high efficacy

Drug Treatment Options for T2DM:

efficacy for weight loss

very high or high efficacy

intermediate

neutral

Drug Treatment Options for T2DM:

Minimize hypoglycemia

use: dpp4-i, glp1-ra, SGLT2i, TZD

A1C > 6.5%: add different class from above; keep adding

Drug treatment options for T2DM:

combos to avoid + why

DPP4i + glp1 (both increase glp1 hormones)

SU + insulin ( high risk of hypoglycemia)

What is the mechanism of action of Metformin

(Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet)?

DECREASING hepatic glucose production, DECREASING intestinal absorption of glucose and INCREASING insulin sensitivity

meftformin effect on alc

1-2%, weight neutral, no hypoglycemia

Metformin has many boxed warnings, including which of the following?

Lactic Acidosis - risk INCREASE with renal impairment , Contrast dye, Excessive alcohol

Metformin has many contraindications, including which of the following? (2)

eGFR < 30

Acute or Chronic Metabolic Acidosis

Metformin is not recommended to start if eGFR is _____

30 -45

Side effects of Metformin includes:

GI Effect: Diarrhea, Nausea, Flatulence, and Cramping, Vitamin B12 deficiency (cobalamin)

what lab should be monitored (deficiency) when metformin is used long term?

Can cause vitamin b12 deficiency when used long term

monitor q1-2 years

Metformin levels may increase with _____

kidney impairment

decreased fxn = increased metformin (primarily eliminated through kidney)

Which of the formulations of metformin should patients be informed about a ghost capsule in the stool?

er formulations ->

Glumetza

Fortamet

Glucophage XR,

True or False: Intravacular iodinated contrast media can INCREASE risk of lactic acidosis. Discontinue Metformin before the imaging procedure. Metformin can be restarted 48 hours after procedure if eGFR is stable.

True

True or False: The combination of Metformin and Topiramate can INCREASE the risk of metabolic acidosis

True

Metformin (Fortamet

Glumetza)

initial dosing

titrating

max

1000mg BID = 2000mg/day

KH has just been started on Metformin. How should she be counseled to take it?

with a meal to decrease GI side effects

What are the SGLT2i drugs?

the flozins

canagliflozins (invokana)

dapagliflozin (farxiga)

empagliflozin (Jardiance)

ertugliflozin

bexagliflozin

SGLT2I:

effect on a1c

decrease by 0.7-1% with minimal hypoglycemia, unless w insulin

What is the mechanism of action of the Sodium Glucose Co - Transporter 2 Inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro)]?

Expressed in the proximal renal tubules, is responsible for the reabsorption of filtered glucose

Reduce reabsorption of glucose and INCREASE urinary glucose excretion and thereby DECREASING blood glucose concentrations

Sodium Glucose Co - Transporter 2 Inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro)]

when to avoid in kidney dx? (egfr)

<20

Sodium Glucose Co - Transporter 2 Inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro)] has many warnings, including which of the following? (7)

Ketoacidosis

Gential Mycotic Infections

Urosepsis

Pyelonephritis

Necrotizing Fasciitis of the Perineum

Hypotension

Acute Kidney Injury

Side effects of Sodium Glucose Co - Transporter 2 Inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro)] includes:

Weight Loss

INCREASE Urination

INCREASE Thirst

Hypoglycemia (low risk)

INCREASE Mg/PO4

Canaglifozin (Invokana) has additional safety concerns compared to other agents in its class. Which of the following safety concerns are specific for Canaglifozin (Invokana)?

Increased risk of leg and foot amputations, hyperkalemia risk, and risk of fractures

True or False: Dapagliflozin (Farxiga), Empagliflozin (Jardiance), and Ertugliflozin (Steglatro)] are contraindicated in patients with a eGFR < 30

True

True or False: Canaglifozin (Invokana), Dapagliflozin (Farxiga), and Empagliflozin (Jardiance) have shown reductions in HF and CKD progression

True

SGLT2i - drug interactions

which drugs should be used with caution/monitored?

diuretics

raas inhibitors

NSAIDs

increase volume depletion -> aki, hypotn

What is the mechanism of action of the Glucagon-like peptide 1 (GLP-l) agonists [Liraglutide (Victoza), Dulaglutide (Trulicity), Exenatide (Byetta), Semaglutide (Ozempic), Exenatide extended release (Bydureon, Bydureon BCise, Lixisenatide (Adlyxin)]?

INCREASE glucose-dependent insulin secretion, DECREASE glucagon secretion, slows gastric emptying, improves satiety and can result in weight loss

Which GLP1/glp-gip are for T2Dm and which are for weight loss only?

Liraglutide

- Victoza DM

-Saxenda - Weight Loss (WL)

Semaglutide

-Ozempic Rybelsus (oral version) DM

- Wegovy WL

gip/glp: Tirzepatide

-Mounjaro DM

-Zepbound WL

DM ONLY

Dulaglutide (Trulicity)

Exenatide (Byetta)

Exenatide extended release (Bydureon, Bydureon BCise)

Lixisenatide (Adlyxin)

Which of the following GLP-1 agonist have a boxed warning risk of thyroid C- cell carcinomas?

All except Exenatide (Byetta) and Lixisenatide (Adlyxin)

Glucagon-like peptide 1 (GLP-l) agonists [Liraglutide (Victoza), Dulaglutide (Trulicity), Exenatide (Byetta), Semaglutide (Ozempic), Exenatide extended release (Bydureon, Bydureon BCise, Lixisenatide (Adlyxin)] has many warnings, including which of the following?

Pancreatitis

Not recommended in patients with severe GI disease, including Gastroparesis

Patients using Liraglutide (Victoza) should be counseled regarding the rare, but possible risk of:

Pancreatitis

A patient has a new prescription for Exenatide ER (Bydureon). The pharmacist should counsel that the drug can cause which adverse effect:

Serious injection site reaction (e.g., abscess, cellulitis, necrosis) with or without SC nodules

Which of the following statements are true concerning [Liraglutide (Victoza), Dulaglutide (Trulicity), Exenatide (Byetta), Semaglutide (Ozempic), Exenatide extended release (Bydureon, Bydureon BCise, Lixisenatide (Adlyxin)]?

do not use with ____

which have ascvd benefit

Do not use with DPP-4 inhibitors

Liraglutide (Victoza), Dulaglutide (Trulicity), Exenatide (Byetta), Semaglutide (Ozempic) have demonstrated ASCVD benefit

Sam has a new prescription for Exenatide (Byetta). How should she be counseled to take this medication?

Take twice daily, within 60 minutes of your meals

Which GLP -1 agonists requires a separate purchase of pen needles? (HINT: ELL)

Exenatide (Byetta)

Liraglutide (Victoza)

Lixisenatide (Adlyxin)

Sulfonylureas (SUs) and meglitinides are known as ____________; they work by :____

what must be present for these drugs to work?

insulin secretagogues

stimulating insulin secretion from the pancreatic beta cells to decrease postprandial blood glucose

Pancreas MUST still be able to make insulin for drugs to work!!

Insulin secretagogues:

SUs and meglitinifes are most helpful on what type of glucose levels (pre/post prandial, long ating, etc)

POST prandial

bc the body needs help to produce enough insulin to handle the influx of glucose

Insulin Secretagogues: Sulfonylureas

Glipizide (Glucotrol, Glucotrol XL, Glipizide XL)

Glimerpiride (Amaryl)

Glyburide

micronized glyburide (glynase)

Insulin Secretagogues:

meglitinides

repaglinide

nateglinide

Insulin secretagogues:

differences b/t SUs and meglitiniddes

onset/duration of action; how to remember generic names , a1c decrease

SUs

longer acting

start with g, end with ide

a1c: decrease 1-2%

meglitinides

shorter

end in glinide

a1c: decrease 0.5-1.5

What is the mechanism of action of Glimepiride (Amaryl)?

Stimulates insulin secretion from the pancreatic beta cells to decrease postprandial BG

Patients should avoid Sulfonylureas (SUs) [Glipizide (Glucotrol, Glucotrol XL), Glimepiride (Amaryl), Glyburide, Micronized Glyburide (Glynase)] if they have:

sulfa allergy

Insulin Secretagogues:

What are possible side effects from these medication?

Hypoglycemia (glucose independent!!)

Weight gain

Nausea

Which of the following statements are true concerning Sulfonylureas [Glipizide (Glucotrol, Glucotrol XL), Glimepiride (Amaryl), Glyburide, Micronized Glyburide (Glynase)]?

which SUs have longer acting and increase risk of hypoglycemia? (hint: beers criteria)

which formulation may have a ghost tablet?

Glimepiride (Amaryl) and Glyburide is not preferred in elderly due to hypoglycemia risk

Glipizide (Glucotrol XL) îs an OROS formulation and can leave a ghost tablet in the stool

Insulin Secretagogues:

SUs;meglitinides

how are they taken? any exceptions?

SUs:

with 1ST meal of day, HOLD IF NPO (HYPOGLYCEMIA!!)

Glipizide IR should be taken 30 mins before a meal

meglitinides:

short acting - take 30 min before EVERY MEAL (up to tid)

can skip if skip a meal

Side effects of Meglitinides [Repaglinide

(Prandin) and Nateglinide (Starlix)] includes:

Hypoglycemia

Weight gain

Headache

URTIs

Sam has a new prescription for Repaglinide

(Prandin) 1 mg TID #30. How should the pharmacist counsel the patient to take the medications?

If you plan to skip a meal, skip the dose for that meal

Take your dose 15 - 30 minutes prior to a meal

SUs and meglitinides should NOT be taken with :

INSULIN!

meglitinides:

Repaglinide (Prandin) is contraindicated with

Gemfibrozil and Clopidogrel

DPP4i:

which ones? 4

sitagliptin (januvia)

Linaglitpin (tradjenta)

saxagliptin (onglyza)

Alogliptin (nesina)

What is the mechanism of action of the Dipeptidyl peptidase 4 (DPP-4) inhibitors [Sitagliptin (Januvia), Linagliptin (Tradjenta), Saxagliptin (Onglyza), Alogliptin (Nesina)]

Prevent the enzyme DPP-4 from breaking down incretin hormones, glucagon-like peptide 1 (GLP-l) and glucose-dependent insulinotropic polypeptide (GIP)

Help to regulate blood glucose levels by INCREASING insulin release from the pancreatic beta cells and DECREASING glucagon secretion from pancreatic alpha cells

Dipeptidyl peptidase 4 (DPP-4) inhibitors [Sitagliptin (Januvia), Linagliptin (Tradjenta), Saxagliptin (Onglyza), Alogliptin (Nesina)] has many warnings, including which of the following?

Pancreatitis (if have hx of alcoholism or hypertriglyceridemia use w caution)

Severe Arthralgia (joint pain)

Acute Renal Failure (rare)

which dpp4i is NOT renally cleared (doesn't need renal adjustments)?

linagliptin (tradjenta)

what are specific risks/warnings for saxagliptin and alogliptin (dpp4is)?

risk of HF for both, but warning added to whole class

risk of hepatotoxicity for alogliptin only

DPP4i have a (low/high) risk for hypoglycemia

low risk. increase insulin secretion. glucose dependent so if no glucose (food) present, then no insulin there.

What is the mechanism of action of the Thiazolidinediones [Pioglitazone, (Actos) Rosiglitazone (Avandia)]?

Peroxisome proliferator-activated receptor gamma (PPARy) agonists that cause INCREASE peripheral insulin sensitivity (INCREASE uptake and utilization of glucose by the peripheral tissues, also known as insulin sensitizers)

what are the TZDs?

Pioglitazone (Actos)

TZDs effect on a1c

decrease 0.5-1.4%