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DIABETES MEDS - Coggle Diagram

- - - - CONS
        
        CI
        
        pedal edema 🦵
        
        bladder cancer :toilet: :crab:
        
        macular edema :eyes:
        
        CHF stage III and IV :balloon:
        
        liver disease LFT >2.5 ULN
        
        osteoporosis :skull_and_crossbones:
        
        weight gain
        
        increase pregnancy chance
        
        DDI
        
        pio decrease effect of these meds
        
        cyclosporin
        
        tacrolimus
        
        statin
        
        contraceptives # #
        
        ethinyl estradiol
        
        norethidrone
        
        ketonazole
        
        inhibit pio metabolism
        
        use different -azole
        
        SMBG
      - dosing
        
        15 mg :arrow_right: 30 mg :arrow_right: 45 mg q8 weeks
        
        no food :forbidden: :rice:
      - tell patient watch for
        
        yellow skin - hepatic
        
        edema - fat leg
        
        CHF sx
        
        check eyes qyear
      - PRO
        
        TREAT PCOS
        
        decrease A1C 0.5% - 1.5%
        
        cheap
    - - cons
        
        raise LDL
        
        weight gain 5-20lbs
        
        macular edema
        
        osteoporosis
        
        LFT elevation
        
        increase pregnancy chance
      - dosing
        
        2 - 4mg Qday
        
        2mg BID
        
        :forbidden: :rice_ball:
        
        1, 2, 4mg
    - - PPAR-gamma agonist
      - insulin sensitizer
      - decrease insulin resistance
        
        muscle
        
        liver
      - there must be insulin for this drug to work
  - - - CONS
        
        sunburn :sunny:
        
        hypogly :dizzy_face:
        
        weight gain :meat_on_bone:
        
        DDI
        
        pls decrease S/U dose
        
        ASA
        
        antacids
        
        gemfibrozil
        
        fluconazole
        
        pls increase s/u dose
        
        cyclosporin
      - pro
        
        decrease A1C 1-2 %
        
        cheap
        
        decrease microvascular risk
      - dosing
        
        IR
        
        5mg :arrow_right: 10mg q1-2 weeks
        
        max 20mg
        
        elderly 2.5mg
        
        30 min ac
        
        XL
        
        2.5 :arrow_right: 5mg :arrow_right: 10gm
        
        max 20mg
        
        30 min AC
        
        DNC
    - - pro
        
        decrease A1C 1-2%
        
        decrease microvascular risk
        
        cheap
      - CONS
        
        sunburn :sunny:
        
        weight gain :meat_on_bone:
        
        hypoglycemia
        
        DDI: pls decrease S/U dose
        d/t increase hypoglycemia risk
        
        antacids
        
        fluconazole
        
        gemfibrozil
        
        ASA
      - dosing
        
        1 mg :arrow_right: 2mg :arrow_right: 4 mg q2w
        
        max 8 mg
        
        elderly 1mg Qday
    - - increase pancreatic insulin secretion
  - - - SEMAGLUTIDE/RYBELSUS
        
        PRO
        
        FBG 29
        
        8 lbs weight loss
        
        improve CVD :<3:
        
        CONS
        
        CI
        
        retinopathy :eye:
        
        thyroid cancer 🎀 :crab:
        
        pregnant
        
        pancreatitis 🧽
        dull pain, abdominal pain radiating to the back
        
        N/V/D/ constipation 🤮
        
        AKI
        
        hypogly if on insulin
        
        STOP 2 MONTHS PRIOR PREGNANT :forbidden: :pregnant_woman:
        
        dosing
        
        3 mg :arrow_right: 7 mg :arrow_right: 14mg q30 days
        
        take 30 min before meals/beverage :rice:
        
        take with 4 oz H20
        
        DNC
        
        ORAL 14MG QDAY :arrow_right_hook: INJECTABLE 0.5MG QWEEK
        start a day after
        
        INJECTABLE 0.5 MG QWEEK :arrow_right_hook: ORAL 7//14MG QDAY
        start a week after last injection
      - high efficacy decrease A1C 1.2-1.5% :+1:
      - MOA
        
        GUT HORMONE
        
        increase incretin level
        
        glucose-dependent manner
      - weight loss
    - - medications
        
        SAXAGLIPTIN/onglyza
        
        CI
        
        CHF :balloon:
        
        adjust dose in renal
        
        5mg if GFR>50
        
        2.5mg
        
        if GFR<50
        
        on ketonazole
        
        immune response: URTI, UTI, nasopharyngitis
        
        DDI
        
        ketonazole
        pls reduce saxa dose
        
        LINAGLIPTIN/tradjenta
        
        CONS
        
        urticaria
        
        dermatitis
        
        bronchospasm
        
        DDI
        
        rifampin
        pls increase lina dose
        
        hypoglycemia :dizzy_face:
        
        PRO
        
        NO DOSE ADJUSTMENT NECESSARY
        
        ALOGLIPTIN/nesina
        
        CI
        
        CHF
        
        hepatic failure: LFT monitoring
        
        adjust dose
        
        renal
        
        6.25mg if GFR<30
        
        12.5mg if GFR betweeen 30-60
        
        25mg if GFR>60
        
        hepatic
        
        SITAGLIPTIN/januvia
        
        adjust dose in renal
        
        25mg if GFR<30
        
        50mg if GFR between 30-50
        
        100mg if GFR>50
        
        dosing: 25-100-200mg qday :forbidden: :rice:
      - MOA
        
        prolongs incretin effects
        
        increase insulin
        
        decrease glucagon
      - PRO
        
        A1C 0.5-0.8%
        
        no hypoglyc unless on insulin/SU // EXCEPT LINAGLIPTIN
        
        QDay take without meal :forbidden: :rice:
        
        glucose dependent manner
      - CONS
        
        IMMUNE RESPONSE
        
        severe joint pain
        
        URTI
        
        nasopharyngitis
        
        UTI
        
        multifocal skin lesions in monkey
        
        CI: pregnant :forbidden: :pregnant_woman:
      - intermediate efficacy
  - - - CONS
        
        CI
        
        osteopororis
        
        renal GFR<45
        
        amputation
        
        lose bone density :skull_and_crossbones:
        
        mycotic yeast infection, UTI, necrotizing fasciitis of perineum :snowflake:
        
        DKA
        
        orthostatic hypotension: dizziness :star2: dehydration :potable_water:
        
        DDI :pill:
        
        digoxin - cana increase lvl
        
        decrease cana lvl
        fix by increasing cana dose
        
        ritonavir
        
        rifampin
        
        phenytoin
        
        phenobarb
        
        AMPUTATION RISK :👩🏼‍🦽
        
        prior amputation
        
        PVD
        
        neuropathy
        
        diabetic foot ulcer :footprints:
        
        tell pt to monitor
        
        new pain
        
        tingling
        
        numbness
        
        new infection
        
        hypogly if on insulin/SU
      - PRO
        
        improved CVD :<3: in T2D only
        
        improved CKD 🚽
        
        decrease blood pressure
      - dosing:
        
        100 :arrow_right: 300mg qday
        
        before 1st mea :red_cross:l :rice:
    - - dosing 10mg :arrow_right: if GFR>65 25mg qday
      - pro: improve CVD :<3:
      - cons
        
        yeast infection, uti
        
        hypotension
        
        necrotizing fasciitis perineum
        
        DKA
    - - indication: T2D with CVD
      - dosing: 5 :arrow_right: 10mg qday
      - pro
        
        improve CVD :<3:
        
        moderately improve CKD 🚽
      - cons
        
        yeast infection, UTI, necrotizing fasciitis of perineum :snowflake:
        
        DKA
        
        hypotension
        
        CI: renal GFR<45
    - - dosing: 10 :arrow_right: 15mg qday
      - cons
        
        yeast infection
        
        hypotension, dehydration
        
        necrotizing fasciitis perineum
        
        DKA
    - - proximal tubule kidney
      - prevent reabsorption of glucose
      - increase urine glucose output # #
    - - pause SGLT2 for 24h , but don't pause insulin
      - monitor blood ketone if DKA
      - tell pt
        
        no alcohol
        
        no low carb/keto diet
  - - - decrease LDL 8%, TG 16%
      - increase HDL 2%
      - weight neutral/ weight loss
      - no hypoglycemia
      - adjunct therapY: PCOS to restore ovulation
      - reduce A1C 1.5-2%
    - - active in hepatocyte
      - decrease hepatic glucose production #
      - insulin sensitizer
      - cleared by renal #
    - - N/V
      - decrease vit B12 absorption #
      - CI
        
        pregnancy :
        
        GFR<30 #
        
        CHF :forbidden: :balloon:
        
        alcohol abuse
        
        hx metabolic acidosis
        
        hepatic disease
      - lactic acidosis #
    - - A1C
      - hypoglycemia
      - anemia
      - renal function
      - lactic acidosis.i.e labored breathing
      - SMBG
      - unexplained weight loss
    - - INITIATE: 500MG BID
      - titrate q2weeks
      - max 2000mg/day
      - with meals :rice:
    - - CONTRAST STUDIES
        
        stop drugs 48 hours
        
        lactic acidosis
        
        renal failure
      - on cimetidine
        
        tell pt to use famotidine instead
  - - - minimal GI absorption
      - 50% excreted in feces
      - AE
        
        flatulence
        
        cramping
        
        ab distention
      - CI
        
        renal Scr >2
      - dosing
        
        Wt <60kg: 50mg TID
        
        Wt> 60 : 100mg TID
        
        25mg TID
        
        with meal :rice:
      - tell pt
        
        SMBG
        
        skip meal, skip dose
        
        avoid Beano
        
        hypoglycemia
    - - systemic absorption
      - 100% urnine excretion
      - AE
        
        flatulence
        
        dirrhea
        
        cramping
        
        CI
        
        renal Scr >2
      - dosing
        
        25mg QAM :arrow_right: 25mg every meal q4-6 weeks
        
        25, 50, 100mg
        
        with meal :rice:
      - tell pt
        
        skip meal, skip dose
        
        SMBG
        
        avoid Beano
        
        hypoglycemia
    - - inhibit glucosidase
      - brush border
      - prevent breakdown of poly- and di-saccharides into glucose
  - - - pro
        
        less hypo glys
      - dosing 0.5-16 mg qday
      - take 30 min with meals :rice:
    - - pro
        
        less hypo gly
      - dosing 120mg tid
      - take 30 min with meals :rice:
    - - stimulate pancreatic insulin
      - glucose dependent manner
- - - - Affreza monotherapy
      - or + oral agents + long acting insulin
  - - - exhale
      - tilt inhaler 45 degrees
      - inhale deeply
      - hold breath as long as comfy
      - exhale after removing and breathe normally
    - - 4 units
      - 8 units
      - 12 units
      - 1 : 1 mealtime insulin dose
      - round down if not multiple of 4
  - - - acute bronchospasm
      - COPD
      - asthma
      - smokers
    - - albuterol: increase AUC of insulin
        pls decrease affrezza dose
      - inhaled steroid: no effect
- - - - synthetic amylin analog
      - T1D: mealtime insulin users
      - T2D mealtime insulin users : SFU and / or MET
      - amylin is coscreted with insulin
    - - PRO
        
        weight loss
        
        intermediate A1C efficacy
        
        reduction mealtime insulin dose
      - CON
        
        N/V anorexia
        
        severe insulin induced hypogly, 3 hours after dose
        
        expensive
      - dosing
        
        separate from insulin injection by 2 in
        
        skip meal- skip dose
        
        T1D
        
        reduce mealtime insulin 50%
        
        start 15mcg/meal same time as insulin but separate site
        
        increase 15mcg qweek
        
        max 60mcg/meal
        
        T2D
        
        reduce meal time insulin by 50%
        
        start 60mcg/meal same time as insulin
        
        prn: increase to 120mcg/meal
  - - - RAPID ACTING
        
        ASPART/novolog
        
        onset 15 min
        
        peak 2 hours
        
        DOA 4 hours
        
        GLULYSINE/apidra
        
        onset 15 minutes
        
        peak 2 hours
        
        DOA 4 hours
        
        LISPRO/humalog
        
        peak 2 hours
        
        peak 2 hours
        
        onset 15 minutes
        
        PRO
        
        1:1 conversion between rapid acting
        
        pen and vials
        
        flexibility
        
        better match with glucose peak
        
        less hypoglycemia
        
        CONS
        
        match carb with insulin
        
        expensive
      - SHORT ACTING: REGULAR INSULIN U-100
        
        onset 1 hour
        
        peak 4 hours
        
        DOA 10 hours
        
        dosing
        
        BID- QID
        
        30 min before meal
        
        PRO - CHEAP
        
        CONS - HYPOGLY
      - very fast acting: fiasp (faster aspart)
        
        onset 0-6 minutes
        
        peak 1 - 1.5 h
        
        DOA 3-4h
    - - LONG ACTING
        
        LANTUS/GLARGINE
        
        onset 2 h
        
        no peak
        
        DOA 24 h
        
        PRO
        
        lantus U-100
        
        comes in pen and vial
        
        less weight gain
        
        dosed Qday (BID in 10% T1D pt)
        
        stable 28 days room temp
        
        Touejo U-300
        
        pen does conversion
        
        more concentrated than lantus, 450 U/pen
        
        dosed Qday (BID in 10% T1D patient)
        
        stable 28 days room temp
        
        more predictable PK/PD compared to NPH and levelmir
        
        CONS
        
        lantus U-100
        
        expensive
        
        cannot be mixed
        
        Touejo U-300
        
        expensive
        
        clear and colorless
        
        BIOSIMILAR/basaglar/semglee
        
        same protein sequence
        
        similar glucose-lowering effect
        
        cheaper
        
        CONVERSION
        
        glargine to detemir #
        
        glargine is 20% stronger than levelmir
        
        once a day glargine --> increase 10% dose when converted to levemir
        
        levemir divided into BID
        
        glargine U100- 300
        
        converting from lantus to toujeo, increase daily dose of Toujeo
        
        DETEMIR/LEVEMIR
        
        onset 4 hours
        
        peak 6 hours
        
        DOA 30 hours
        
        PRO
        
        dose QD-BID
        
        longer acting with higher dose
        
        can be converted to glargine
        
        comes in pen
        
        CONS
        
        cannot be mixed
        
        expensive
        
        DEGLUDEC/TRESIBA
        
        no peak
        
        onset 2 hours
        
        DOA 42 hours
        
        pro
        
        more predictable PK/PD compared to NPH and levelmir
        
        half life is twice as long than glargine
        
        available formulation
        
        rezodeg 70/30 (degludec/aspart)
        
        xyltophy 100/3.6 (degludec/liraglutide)
        
        start 16 units
        
        max: 50 units/day
        
        1 dose has 1 unit insulin and 0.036mg of liraglutide
      - INTERMEDIATE
        
        NPH
        
        onset 2 hours
        
        peak 6-10 hours
        
        DOA 10-20 hours
        
        PRO
        
        dose QD - BID, or more frequently
        
        cheap
        
        can be mixed
        
        conversion NPH to glargine #
        
        BID NPH to Glargine U-100 or U-300
        
        start dose 80% of NPH
        
        once a day
        
        REGULAR U-500
        
        onset 0.5 hours
        
        peak 4 hours
        
        DOA 24 hours
  - - - LIRAGLUTIDE/victoza
        
        PRO
        
        weight loss
        
        FDA improve CVD:<3:
        
        treat children T2D 10-17 years old
        
        dosing
        
        0.6 mg QD SQ x 1 week :arrow_right: 1.2mg QDay x 1 week :arrow_right: 1.8 mg Qday
        
        :forbidden: :rice:
        
        if on SU, decrease 50% SU dose
        
        CI
        
        thyroid cancer
        
        MENS2
        
        renal GFR<30
        
        pancreastitis
        
        gallstone
        
        Saxenda
        
        BMI >30
        
        comorbidities
        
        HTN
        
        T2D
        
        dyslipidemia
        
        liraglutide for weight loss
        
        0.6mg SQ Qday x1 week :arrow_right: 1.2 mg x 1week, keep going till 3mg max
      - LISIZENATIDE/ADLYXIN
        
        20mcg QD SQ
        
        CONS
        
        CI
        
        pancreastitis
        
        MENS2
        
        renal GFR<30
        
        gallstrone
        
        thyroid
        
        severe anaphylaxis reaction
        
        longer delay in gastric emptying than liraglutide
        
        pro
        
        slight better PPG AUC reduction than liraglutide
      - EXENATIDE/byetta
        
        dosing
        
        5 mcg BID SQ :arrow_right: 10mcg bid q1month
        
        1 hour before meal :rice:
        
        keep pen pressed 10 seconds
        
        missed dose, skip. don't double
        
        prime 1st time use only
        
        unused pen in fridge
        
        used pen at room temp
        
        CI
        
        thyroid cancer
        
        pancreastitis
        
        MENS2
        
        gallstone
        
        renal EGF<30
    - - EXENATIDE ER/bydureon
        
        dosing
        
        2mg QWeek SQ
        
        remove from fridge 15 minutes before use
        
        shake 15 times
        
        inspect cloudy, no particle
        
        inject
        
        abdomen
        
        arm
        
        upper thigh
        
        rotate site
        
        CI
        
        thyroid cancer
        
        pancreastitis
        
        gallstone
        
        renal GFR<30
        
        alcoholic TG>500
        
        MENS 2
      - DULAGLUTIDE/trulicity
        
        CONS
        
        CI
        
        :eye: retinopathy
        
        pancreatitis
        
        renal GFR<30
        
        thyroid cancer
        
        alcohol TG>500
        
        gallstone
        
        MENS2
        
        PRO
        
        improve CVD MACE PREVENTION :<3:
        
        dosing
        
        0.75mg sq qweek :arrow_right: 1.5mg
        
        missed dose, administer 3 days within missed dose then back to regular schedule
        
        administration
        
        lock pen
        
        remove cap
        
        press against belly
        
        hear 2 clicks
        
        remove
        
        unlock pen
        
        push green button
      - SEMAGLUTIDE/ozempic
        
        CONS
        
        CI
        
        :eye: retinopathy
        
        thyroid cancer
        
        pancreastitis
        
        renal GFR<30
        
        alcoholic TG>500
        
        gallstone
        
        MENS2
        
        PRO
        
        improve CVD :<3:
        
        weight loss
        
        high efficacy
        
        dosing
        
        titration: 0.25mg Qweek x 4w :arrow_right: 0.5mg Qweek x 4w :arrow_right: 1mg qweek if needed
        
        to reduce GI ADR, titrate dose gradually 16 to 20 weeks
      - common education
        
        pick one day of the week
        
        no meal :forbidden: :rice:
        
        avoid injecting near belly button
        
        inject in separate location from insulin injections
        
        hold 10s
    - - release from L cells in gut
      - glucose-dependent manner
        inhibit glucagon from alpha cell
      - 1st and 2nd phase insulin response restored
      - inhibit gastric emptying
      - glucose-depend manner
      - effect on body
        
        CNS: reduce appetite
        
        liver
        
        : decrease glucagon
        
        enhance glucose-dependent insulin
        
        stomach: slow gastric emptying
    - - N/V/D #
      - dehydration from n/v/d
      - dizziness, HA
      - acute renal failure #
      - pancreatitis
        
        abdominal pain radiating to back
        
        n/v/f
        
        chills