DMNote Nov 6, 2023_21-22.pdf

Rx PRE P 2022 COURSE BOOK I Rx PREP © 2 02 1 , ©202 2 SELECTING DRUG TREATMENT The Study Tip Gal below summarizes some of the key safety issues seen with medications for diabetes, and the following Case Scenario highlights how these safety issues could appear in exam questions. More examples can...

Rx PRE P 2022 COURSE BOOK I Rx PREP © 2 02 1 , ©202 2 SELECTING DRUG TREATMENT The Study Tip Gal below summarizes some of the key safety issues seen with medications for diabetes, and the following Case Scenario highlights how these safety issues could appear in exam questions. More examples can be found in the Test Banks. IF PRESENT Cancer AVOID -------------- Gastroparesis, GI disorders Genital infection/UT! Heart failure Hepatotoxicity : Pioglitazone (bladder), GLP-1 agonists (thyroid, including medullary thyroid carcinoma) GLP -1 agonists, pramlintide I SGLT2 inhibitors ---------------~------------, TZDs, alogliptin, saxagliptin · TZDs, alogliptin Hypoglyce_m _i_a- - - - - - - - - - - ,-,n-s_u_U_ n,- s-u-lf_o_n_y -lu-re_a_s_, -meglitinides and pramlintid~ Hypotension/dehydration Hypokalemia SGLT2 inhibitors Insulin Ketoacidosis • SGLT2 inhibitors (can occur when BG< 250 mg/dl); i risk with acute illness, dehydration, renal impairment. Discontinue SGLT2 inhibitors prior to surgery to reduce risk. Lactic acidosis • Metformin ; i risk with renal impairment, alcoholism, hypoxia Osteopenia/osteoporosis Canagliflozin (1. BMD, fractures), TZDs (fractures) Pancreatitis DPP-4 inhibitors, GLP-1 agonists Peripheral neuropathy, PAD, foot ulcers Canagliflozin Sulfa allergy, severe Consider avoiding sulfonylureas, or use cautiously Renal insufficiency (eGFR or CrCI < 30) Weight gain/obesity --------------- ; Metformin, SGLT2 inhibitors, exenatide, glyburide; may need to start insulin at a lower dose Sulfonylureas, meglitinides, TZDs, insulin CASE SCENARIO CS is a 56-year-old female with hypertension, diabetes and a past Ml. At her last clinic visit 3 months ago, her AlC was 8.6% despite treatment with metformin ER 2,000 mg PO daily and Januvia 100 mg PO daily. At that time, lnvokana 100 mg PO daily was added to her regimen. CS also takes aspirin, rosuvastatin, lisinopril, Careg CR and hydrochlorothiazide for her hypertension and ASCVD. At the current visit, CS complains of dry mouth, weakness, dizziness and lightheadedness. On a couple of occasions she has nearly fainted. These symptoms began approximately 2 months ago. What do CS's symptoms likely describe? CS has symptoms of dehydration and hypotension. Which medications could be associated with these symptoms? The addition of lnvokana (canagliflozin) to her medication regimen put CS at risk for these adverse effects. lnvokana decreases blood glucose by excreting it in the urine; water is also excreted with glucose. The use of diuretics and antihypertensive medications could be contributing to the problem due to additive effects. What laboratory abnormalities could occur with this combination of medications? CS is at risk for acute kidney injury. Evaluate for elevated BUN, SCr and eGFR. Check an anion gap and ketones; if they are elevated, this is a sign of ketoacidosis, which can occur with lnvokana. If asked to select an alternative diabetes medication, what should be selected? There are a number of treatment options for diabetes management. CS 's history of ASCVD will dictate the next treatment option. An SGLT2 inhibitor was appropriate, but due to side effects , she should be switched to a GLP1 agonist with benefit (e.g .. dulaglutide, liraglutide or semaglutide). 633 44 I DIABETES KEY COUNSELING POINTS See the Drug Formulations and Patient Counseling chapter for counseling language/layman's terminology. Metformin Cancause: Cancause: o Lactic acidosis. o Pancreatitis. o Diarrhea, nausea; usually goes away. Taking with food and using long-acting metformin will help. o Renal impairment. With long-term metformin, take a vitamin B12 supplement. Long-acting formulations of metformin can leave a ghost tablet in the stool. SGLT2 Inhibitors Cancause: o Hypotension. o Severe arthralgia. o Saxagliptin and alogliptin: heart failure. Sulfonylureas/Meglitinides Take sulfonylureas with breakfast, except glipizide IR: take 30 minutes before breakfast. Take meglitinides 15 - 30 minutes before meals. Do not take if skipping the meal. Cancause: o Ketoacidosis. Stop prior to surgery to reduce risk. o Hypoglycemia. o Severe UTis and genital fungal infections. o Weight gain. o Canagliflozin: amputation risk (avoid if foot problems, neuropathy), fractures. GLP-1 Receptor Agonists Byetta, Adlyxin: give within 60 minutes of meals; others can be taken anytime. Insulins Subcutaneous injection (exceptAfre22a). Rotate injections sites. See Insulin Injection Counseling section for details. • Can cause: o Hypoglycemia. Trulicity, Bydureon, Bydureon BCise, Ozempic: inject once a week. The needles are inside the box. o Hypokalemia. Byetta, Victoza, Adlyxin: needles need to be purchased. o Weight gain. If injection has been in the refrigerator, leave at room temperature 15 minutes before using. Bydureon BCise: shake the injection well to mix the medication. Look in the window to check for drug particles; if present, shake again. Can cause: Store unopened insulin pens/vials in the refrigerator. Once opened, store at room temperature and discard after the designated number of days (for that type of insulin). Pramlintide When starting, reduce dose of mealtime insulin by 50%. Inject before meals. Do not mix with insulin. o Nausea, diarrhea, decrease in appetite, weight loss. • Can cause nausea. o Pancreatitis and gallbladder disease. Alpha Glucosidase Inhibitors o Kidney damage, especially from dehydration due to severe vomiting or diarrhea. o Bydureon: injection-site reactions (abscesses, nodules). o Ozempic: diabetic retinopathy. Thiazolidinediones Cancause: o Heart failure (cause or worsen). o Weight gain. o Bone fractures. o Pioglitazone: bladder cancer (avoid if history). 634 DPP-4 Inhibitors Can cause flatulence and diarrhea. • Do not cause hypoglycemia. If you get hypoglycemia (from another medication) treat with glucose tablets or gel. Select Guidelines/References American Diabetes Association (ADA). Standards of Medical Care in Diabetes. Diabetes Care. 2021;44 (suppl 1):51-5232. AACE Consensus Statement on the Comprehensive Type 2 Diabetes Management Algorithm - Executive Summary. Endocr Pract. 2020 Jan;26(1):107-139.