NR 508 Study guide week 5
DM:
1. Preferred oral agent for DM Type 2, (Ch. 53- pg. 590-597) slides
Metformin is used now as the first-line choice.
2. Vitamin deficiency associated with metformin use; (Ch. 53, pg. 599) an slides
A decrease to subnormal levels of vitamin B12 was observed in about 7% of patient
3. Managing glucose in the ICU setting with insulin goal of 140-180 rather than oral agents and lower therapy goals;
(Ch. 53, pg. 590-598) Epocreates
In 2008, the American Heart Association recommended a target blood glucose of 90 to 140 mg/dL. However, a
large RCT subsequently raised concerns about current intensive blood glucose targets for inpatient glycemic
control and found a higher 90-day mortality for ICU patients with a blood glucose target of 81 to 108 mg/dL
than for ICU patients with a blood glucose target of 180 mg/dL.
This raised concern that there may not be any additional benefit to lowering blood glucose levels below 140 to
180 mg/dL in the ICU setting and for all hospitalized patients
Insulin is considered the preferred form of treatment for inpatients. Intravenous insulin infusion is the
preferred method of delivering insulin in these situations and is highly recommended in critically ill patients.
4. Adverse effects of Oral agents (see lecture),
Biguanides Metformin (Glucophage), Metformin liquid ( Riomet),Metformin extended release (Glucophage
XR, Fortamet, Glumetza)
o Bloating, gas, diarrhea, upset stomach, loss of appetite (usually within the first few weeks of starting).
Take with food to minimize symptoms. Metformin is not likely to cause low blood glucose. In rare cases,
lactic acidosis may occur in people with abnormal kidney or liver function.
Sulfonylureas -Glimepiride (Amaryl) , Glyburide (Diabeta, Micronase), Glipizide (Glucotrol, Glucotrol XL),
Micronized glyburide (Glynase)
o Low blood glucose, occasional skin rash, irritability, upset stomach
Meglitinides- Repaglinide (Prandin); D-Phenylalanine Derivatives- Nateglinide (Starlix)
o Effects diminish quickly and they must be taken with each meal; may cause low blood glucose.
Thiazolidinediones- Pioglitazone (TZDs)- Pioglitazon (Actos)
o May cause side effects such as swelling (edema) or fluid retention.
o Do not cause low blood sugar when used alone.
o Increased risk of congestive heart failure in those at risk.
DPP-4 Inhibitors- Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin ( Tradjenta)
o Stomach discomfort, diarrhea, sore throat, stuffy nose, upper respiratory infection.
o Do not cause low blood glucose.
Alpha-glucosidase Inhibitors- Acarbose (Precose), Miglitol (Glyset)
o Gas, diarrhea, upset stomach, abdominal pain
Bile Acid Sequestrants- Colesevelam (Welchol)
o Constipation, nausea, diarrhea, gas, heartburn, headache (may interact with glyburide, levothyroxine
and contraceptives)
Combination Pills- Pioglitazone & metformin) (Actoplus Met), Glyburide & metformin (Glucovance) , Glipizide
& metformin (Metaglip), Sitagliptin & metformin (Janumet), Saxagliptin & metformin (kombiglyze ) ,
Repaglinide & metformin (Prandimet), Pioglitazone & glimepiride (Duetact)
o Side effects are the same as those of each pill used in the combination.
o Some combination pills may lead to low blood glucose levels if one of the medications contained in the
combination has this effect.
5. Risks associated with SGLT2 inhibitors (amputations, acidosis, yeast/mycotic infections, some cases of renal
injury and hyperkalemia)
Canagliflozin (Invokana)- leg amputation
1
, NR 508 Study guide week 5
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
DKA, Hyperkalemia,
Transient increase Cr
Increased falls/fractures
Volume depletion
Hypotension/dizziness
Glycosuria/polyuria
Female yeast infections
Increased LDL
CV:
6. preferred antihypertensives in African American patients; p 229p 232
Calcium Channel Blocker (CCB) + Thiazides (if no disease specific contraindications)
7. preferred antihypertensives in those with chronic kidney disease (regardless of race); ( ppt, p 231)
ACEI- captopril ( capoten), Lisinopril ( prinivil), Ramipril ( altace)
ARB- candesartan ( atacand), losartan( cozaar), eprosartan ( teveten), olmesartan ( Benicar), valsartan( diovan)
o Side note do not use ARB in sexually active females
8. Types of antihypertensives and their uses; know the agents by name and class, review the diuretic classes
including specific names in each class, uses of the various types and side effects of acetazolamide, ethacrynic
acid, spironolactone, triameterene (this was part of previous reading but is again covered this week since many
are used as adjuncts or primary tx if thiazides for HTN);
Chapter 17 Hypersension and misc antihypertensive medications
Class Generic Name Trade Name
Peripheral α1-receptor blockers (adrenergic agonists) doxazosin
Cardura
prazosin Minipress
terazosin Hytrin
Centrally acting α2-agonists (antiadrenergics) clonidine
Catapres
methyldopa Aldomet
Peripheral vasodilators hydralazine Apresoline
minoxidil Loniten
Renin inhibitors aliskiren Tekturna
Thiazides- .- hydrochlorthiazide chlorthiazize, chlorthalidone, indapamide, metolazone- increase excretion of
sodium and chloride and thus water, decrease circulating plasma volume
BB (CARDIOSELECTIVE)- acebutolol, atenolol, bisoprolol, metoprolol – blocks stimulation of the beta1
receptors in the heart causing decrease in heart rate, blood pressure, and cardiac output
2
DM:
1. Preferred oral agent for DM Type 2, (Ch. 53- pg. 590-597) slides
Metformin is used now as the first-line choice.
2. Vitamin deficiency associated with metformin use; (Ch. 53, pg. 599) an slides
A decrease to subnormal levels of vitamin B12 was observed in about 7% of patient
3. Managing glucose in the ICU setting with insulin goal of 140-180 rather than oral agents and lower therapy goals;
(Ch. 53, pg. 590-598) Epocreates
In 2008, the American Heart Association recommended a target blood glucose of 90 to 140 mg/dL. However, a
large RCT subsequently raised concerns about current intensive blood glucose targets for inpatient glycemic
control and found a higher 90-day mortality for ICU patients with a blood glucose target of 81 to 108 mg/dL
than for ICU patients with a blood glucose target of 180 mg/dL.
This raised concern that there may not be any additional benefit to lowering blood glucose levels below 140 to
180 mg/dL in the ICU setting and for all hospitalized patients
Insulin is considered the preferred form of treatment for inpatients. Intravenous insulin infusion is the
preferred method of delivering insulin in these situations and is highly recommended in critically ill patients.
4. Adverse effects of Oral agents (see lecture),
Biguanides Metformin (Glucophage), Metformin liquid ( Riomet),Metformin extended release (Glucophage
XR, Fortamet, Glumetza)
o Bloating, gas, diarrhea, upset stomach, loss of appetite (usually within the first few weeks of starting).
Take with food to minimize symptoms. Metformin is not likely to cause low blood glucose. In rare cases,
lactic acidosis may occur in people with abnormal kidney or liver function.
Sulfonylureas -Glimepiride (Amaryl) , Glyburide (Diabeta, Micronase), Glipizide (Glucotrol, Glucotrol XL),
Micronized glyburide (Glynase)
o Low blood glucose, occasional skin rash, irritability, upset stomach
Meglitinides- Repaglinide (Prandin); D-Phenylalanine Derivatives- Nateglinide (Starlix)
o Effects diminish quickly and they must be taken with each meal; may cause low blood glucose.
Thiazolidinediones- Pioglitazone (TZDs)- Pioglitazon (Actos)
o May cause side effects such as swelling (edema) or fluid retention.
o Do not cause low blood sugar when used alone.
o Increased risk of congestive heart failure in those at risk.
DPP-4 Inhibitors- Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin ( Tradjenta)
o Stomach discomfort, diarrhea, sore throat, stuffy nose, upper respiratory infection.
o Do not cause low blood glucose.
Alpha-glucosidase Inhibitors- Acarbose (Precose), Miglitol (Glyset)
o Gas, diarrhea, upset stomach, abdominal pain
Bile Acid Sequestrants- Colesevelam (Welchol)
o Constipation, nausea, diarrhea, gas, heartburn, headache (may interact with glyburide, levothyroxine
and contraceptives)
Combination Pills- Pioglitazone & metformin) (Actoplus Met), Glyburide & metformin (Glucovance) , Glipizide
& metformin (Metaglip), Sitagliptin & metformin (Janumet), Saxagliptin & metformin (kombiglyze ) ,
Repaglinide & metformin (Prandimet), Pioglitazone & glimepiride (Duetact)
o Side effects are the same as those of each pill used in the combination.
o Some combination pills may lead to low blood glucose levels if one of the medications contained in the
combination has this effect.
5. Risks associated with SGLT2 inhibitors (amputations, acidosis, yeast/mycotic infections, some cases of renal
injury and hyperkalemia)
Canagliflozin (Invokana)- leg amputation
1
, NR 508 Study guide week 5
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
DKA, Hyperkalemia,
Transient increase Cr
Increased falls/fractures
Volume depletion
Hypotension/dizziness
Glycosuria/polyuria
Female yeast infections
Increased LDL
CV:
6. preferred antihypertensives in African American patients; p 229p 232
Calcium Channel Blocker (CCB) + Thiazides (if no disease specific contraindications)
7. preferred antihypertensives in those with chronic kidney disease (regardless of race); ( ppt, p 231)
ACEI- captopril ( capoten), Lisinopril ( prinivil), Ramipril ( altace)
ARB- candesartan ( atacand), losartan( cozaar), eprosartan ( teveten), olmesartan ( Benicar), valsartan( diovan)
o Side note do not use ARB in sexually active females
8. Types of antihypertensives and their uses; know the agents by name and class, review the diuretic classes
including specific names in each class, uses of the various types and side effects of acetazolamide, ethacrynic
acid, spironolactone, triameterene (this was part of previous reading but is again covered this week since many
are used as adjuncts or primary tx if thiazides for HTN);
Chapter 17 Hypersension and misc antihypertensive medications
Class Generic Name Trade Name
Peripheral α1-receptor blockers (adrenergic agonists) doxazosin
Cardura
prazosin Minipress
terazosin Hytrin
Centrally acting α2-agonists (antiadrenergics) clonidine
Catapres
methyldopa Aldomet
Peripheral vasodilators hydralazine Apresoline
minoxidil Loniten
Renin inhibitors aliskiren Tekturna
Thiazides- .- hydrochlorthiazide chlorthiazize, chlorthalidone, indapamide, metolazone- increase excretion of
sodium and chloride and thus water, decrease circulating plasma volume
BB (CARDIOSELECTIVE)- acebutolol, atenolol, bisoprolol, metoprolol – blocks stimulation of the beta1
receptors in the heart causing decrease in heart rate, blood pressure, and cardiac output
2
