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Therapeutic Categories and Diabetes Management

  • Diabetes Overview

    • Definition: Hyperglycemia due to lack of insulin and/or insulin resistance.

    • Key Terms:

      • Insulin: Hormone essential for glucose utilization.

      • Hyperglycemia: Excess glucose in the blood.

  • Types of Diabetes Mellitus

    • Type 1 Diabetes: Insulin-dependent (insulin-DEP).

    • Type 2 Diabetes: Insulin-independent (insulin-IND).

  • Management Goals:

    • Maintain normal blood glucose levels (80 – 120 mg/dL).

    • Monitor A1C as an indicator of diabetes control over three months:

      • A1C Levels:

        • Non-diabetic: < 5.7%

        • Prediabetes: 5.7% - 6.4%

        • Diabetic: > 6.5%

Types of Insulin

  • Short-acting Insulin:

    • Example: Regular Insulin (Humulin R, Novolin R).

    • Onset: ~30 minutes.

    • Duration: 8 hours.

  • Intermediate-acting Insulin:

    • Example: NPH (Humulin N, Novolin N).

    • Onset: 1 hour.

    • Duration: 20 hours.

  • Combination Insulin:

    • Example: Humulin 70/30, Novolin 70/30 (70% NPH, 30% Regular).

  • Insulin Analogs: (prescription only)

    • Rapid-acting Insulin:

      • Examples: Insulin lispro (Humalog), insulin aspart (Novolog), insulin glulisine (Apidra).

      • Onset: 15 minutes.

      • Duration: 6 hours.

      • Administer 15 minutes before a meal.

    • Ultra-rapid acting: Insulin aspart (Fiasp) – immediate onset due to Vitamin B3.

Long-acting Insulin Analogues

  • Provide continuous insulin to manage blood glucose levels:

    • Examples: Insulin glargine (Lantus, Toujeo, Basaglar, Semglee) and insulin detemir (Levemir).

    • Onset: 1 hour.

    • Duration: 24 hours.

  • Ultra long-acting: Insulin degludec (Tresiba), with a duration of 40 hours.

Concentration of Insulin Products

  • General Concentration: Most insulin products are available at 100 units/mL.

  • Exceptions:

    • Humulin R U-500: 500 units/mL.

    • Toujeo: 300 units/mL.

    • Humalog: 100 and 200 units/mL.

    • Tresiba: 100 and 200 units/mL.

Antidiabetic Classes for Type 2 Diabetes

  • Sulfonylureas: Stimulate insulin secretion and increase tissue sensitivity.

    • Examples: Glipizide, Glimepiride, Glyburide.

  • Biguanides: Increase tissue sensitivity to insulin.

    • Example: Metformin.

    • Black Box Warning: Risk of lactic acidosis.

  • Thiazolidinediones: Enhance insulin sensitivity.

    • Examples: Pioglitazone (Actos), Rosiglitazone.

    • BBW: May exacerbate heart failure.

  • Dipeptidyl Peptidase-4 Inhibitors: Stimulate insulin secretion.

    • Examples: Sitagliptin (Januvia), Linagliptin (Tradjenta).

  • GLP-1 Receptor Agonists: Stimulate insulin secretion.

    • Examples: Exenatide (Bydureon BCise), Liraglutide (Victoza), Dulaglutide (Trulicity), Semaglutide (Ozempic, Rybelsus).

  • Combination of GLP-1 and GIP Receptor Agonists: Tirzepatide (Mounjaro).

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

  • Function: Inhibit glucose reabsorption in kidneys.

  • Examples: Canagliflozin (Invokana), Empagliflozin (Jardiance), Dapagliflozin (Farxiga), Ertugliflozin (Steglatro).

Antihyperlipidemic Therapy

  • Definition: Manage hyperlipidemia, characterized by elevated lipoprotein levels.

  • Goal of Therapy: Lower LDL and triglycerides, raise HDL.

  • Risk Categories for CVD:

    • Extreme risk: LDL < 55

    • Low risk: LDL < 130

    • Optimal HDL: > 40 mg/dL

    • Optimal triglycerides: < 150 mg/dL.

Antihyperlipidemic Classes

  • HMG-CoA Reductase Inhibitors (Statins): Decrease cholesterol formation.

    • Side Effects: Muscle pain, rhabdomyolysis risk.

    • Examples: Atorvastatin (Lipitor), Simvastatin (Zocor).

  • ACL Inhibitors: Bempedoic acid (Nexletol) - adjunctive therapy.

  • Fibric Acid Derivatives: For hypertriglyceridemia.

    • Examples: Gemfibrozil, Fenofibrate.

  • Cholesterol Absorption Inhibitor: Ezetimibe (Zetia).

  • Bile Acid Sequestrants: Bind bile acids in GI tract.

    • Example: Cholestyramine (Prevalite).

  • PCSK9 Inhibitors: Prevent LDL receptor degradation.

    • Examples: Evolocumab (Repatha), Alirocumab (Praluent).

Osteoporosis Management

  • Definition: Decrease in bone density due to resorption.

    • Bone remodeling involves osteoblasts (formation) and osteoclasts (resorption).

  • Prevention:

    • Lifestyle changes: weight-bearing exercises (not swimming).

    • Calcium intake: 1200 mg, with preferred forms being calcium citrate (Citracal) for better absorption.

    • Vitamin D: 800 units daily.

Treatment Options for Osteoporosis

  • Bisphosphonates: Prevent bone loss.

    • Examples: Alendronate (Fosamax), Risedronate (Actonel).

    • Counseling: Take on an empty stomach with water; remain upright for 30 minutes.

  • Parathyroid Hormone Analogs: Stimulate osteoblast activity.

    • Example: Teriparatide (Forteo).

  • Monoclonal Antibodies: Inhibit osteoclast activity.

    • Examples: Denosumab (Prolia), Romosozumab (Evenity).