Lecture II DM - Oral Drugs.pptx

LECTURE II: ORAL ANTIDIABETIC AGENTS AKA DRUGS FOR TYPE 2 DM DR. FRANCISCO AYALA DNP, MSN, APRN, FNP-C, CCRN DRUG CLASSES BIGUANIDES • METFORMIN (Glucophage) • The initial drug of choice for Type 2 Diabetes • Reduces production of glucose by the liver, decreases intestinal absorption of glu...

LECTURE II: ORAL ANTIDIABETIC AGENTS AKA DRUGS FOR TYPE 2 DM DR. FRANCISCO AYALA DNP, MSN, APRN, FNP-C, CCRN DRUG CLASSES BIGUANIDES • METFORMIN (Glucophage) • The initial drug of choice for Type 2 Diabetes • Reduces production of glucose by the liver, decreases intestinal absorption of glucose, increases insulin sensitivity • No risk of weight gain, may actually see some weight loss • Usually dosed at 500 mg BID up to 1000 mg BID • Alone does not cause HYPOGLYCEMIA • When used with other medications, it CAN increase risk of hypoglycemia • Black Box Warning – Risk of Lactic Acidosis (To prevent this you do the following) • Withheld the day of surgery • If a diagnostic test requires contrast media, d/c metformin 48 hours before the test and do not begin until 48 hours after the test. Hold if severe kidney compromise/dysfunction. SULFONYLUREAS (INSULIN RELEASERS) • Glyburide (Glynase); Glypizide (Glucotrol) • Oldest group of oral agents for T2DM • Not commonly used, not liked due to HYPOGLYCEMIA risk • These drugs stimulate the release of the body’s own insulin (endogenous). Therefore, the body needs to still be producing insulin for them to be effective • Useful for managing POSTPRANDIAL hyperglycemia • Take 30 min before meals (need to have meals to take this drug to prevent hypoglycemia) • Educate on symptoms of HYPOGLYCEMIA (carry a rapid acting carbohydrate) ALPHA GLUCOSIDASE INHIBITORS • Acarbose (Precose) • Not good alone but can augment antidiabetic effect when combined with other medications • Works by delaying digestion of carbohydrates during meals to prevent after meal spikes in blood glucose • Due to its effect, GI side effects are seen such as bloating, flatulence, diarrhea • Should not be used in pt’s with intestinal disorder (IBD, Celiac disease etc) THIAZOLIDINEDIONES • Rosiglitazone (Avandia) • Aka – “Glitazones”, insulin sensitizers • Decrease insulin resistance • Takes up to 12 weeks to work • Stimulates receptors on muscle, fat and liver cells thus restoring effectiveness of insulin • Hepatotoxic (requires LFT monitoring) • Black Box Warning – Risk of Congestive Heart Failure MEGLITINIDES • Repaglinide (Prandin) • Non-sulfonylureas, insulin secreatagogues (BUT similar MOA) • Depends on existence of functioning beta cells left in progress (pancreas has to work for this drug to work) • Risk of Hypoglycemia SODIUM GLUCOSE COTRANSPORTER 2 (SGLT2) INHIBITORS • Canagliflozin (Invokana); Jardiance (Empagliflozin) • Drugs contain “flooo” so they make you wanna goo (pee)  • Inhibits renal SGLT2 (blocks reabsorption of glucose in the kidney + promotes renal excretion of excess glucose in the urine. • Protect the kidneys by decreasing protein loss and reducing damage caused by hyperfiltration SGLT-2 • Jardiance (Empagliflozin); Invokana (canagliflozin) • Excellent cardiovascular outcomes • The higher the blood glucose the better they work • Blocks reabsorption of glucose in the kidney (gets excreted in the urine) – osmotic effect (diuresis) • Dehydration, hypotension, syncope, dehydration due to diuretic effect. • Adverse effects – Balanitis, candida, vulvovaginal candidiasis (why?) SGLT-2 SOAPBOX • Very interesting drug • Has many cardiovascular and renal protective properties • AHA – New guidelines recommend SGLT-2 for HFrEF/HFpEF (diuretic effect) SGLT-2 CONTINUED • Not recommended in patients with GFR < 45 mL/min Side Effects Think of diuretics - Dehydration - Hypotension - Syncope Increased UTI/Vulvovaginal candidiasis/balanitis/Fournier’s gangrene(Why is this a common side effect?) INCRETIN HORMONES • Stimulate release of insulin in response to a meal to normalize glucose levels • This action increases release of insulin and decreases hepatic glucose production • The DPP-4 enzyme inactivates incretins (this is a bad thing) • GLP-1 (a type of incretin) stimulates insulin release and inhibits glucagon release (this is a good thing DIPEPTIDYL PEPTIDASE 4 INHIBITORS • Sitagliptin (Januvia) • Minimizes the rate of inactivation of the incretin hormones (GLP1) to increase hormone levels and prolong their activity • Used in combination with other medications. Do not cause hypoglycemia alone. GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST • Dulaglutide (Trulicity), Wegovy (Semaglutide) • Incretin mimetic. • Acts as a natural hormone helper (GLP-1) stimulating the pancreas to secrete the right amount of insulin based on the food that was just eaten. < gluconeogenesis, slows gastric emptying, increases satiety (feeling fuller after a meal) = the patient will eat less and lose weight (some GLP’s are now FDA approved for weight loss • Black Box Warning – Increased risk of Thyroid Cancer, Contraindicated in family history of Endocrine Neoplasia Type 2 AMYLIN ANALOGS • Pramlintide (symlinPen 120) • A newer adjunctive treatment WITH mealtime insulin for Type 1 and 2 Diabetes • Slows gastric emptying, regulates post-prandial rise in blood glucose, < post prandial glucagon secretion, > sense of satiety • Black Box Warning – Severe Hypoglycemia (due to being combined with insulin) ADJUVANT DRUGS FOR DIABETES • Renal protection for Diabetes!!! VERY IMPORTANT • ACE or ARB for renal protection (dose usually lower than for BP management) • Lisinopril – ACE • Losartan – ARB • In patients who have proteinuria! • Lipid Management (for primary prevention of cardiac disease) < MI risk • Hmg-CoA – “-Statin” drugs – (Atorvastatin, Simvastatin) SUMMARY • Review Mechanism of Action and Name of Drugs • Recognize and remember all Black Box Warnings • Remember which drugs have a hypoglycemic effect • Remember “cutoffs” for each drug (a certain kidney function) SPECIAL POPULATIONS • Diabetic pregnant women should be on regular insulin for management of diabetes whether it is T2DM or Gestational Diabetes. • Most drugs are not approved for the use in children (probably type 1, require insulin) • Some drugs may need to be renally adjusted (dose reduction < based on kidney function.