GLP1 Receptor Agonists & DPP4 Inhibitors

Thank you to our pharmacists for a very informative lecture!

Lecture Video: see Class Capture

Lecture Powerpoints: GLP1 Receptor Agonists & DPP4 Inhibitors

When Do I Start These Medications?

Check out: AACE Algorithm for Adding/Intensifying Diabetes Medications

GLP1 Receptor Agonists

Ex: Liraglutide (Victoza®), Exenatide, Dulaglutide (Trulicity®), Abliglutide

Pros

  • Target multiple organs, not just the pancreas.
  • Improve HTN, HLD and can lead to weight loss!
  • Low risk of hypoglycemia
  • LEADER trial: Liraglutide significantly reduces MACE
  • Decrease A1C by 0.5-1.8% on average.
  • Long-acting, once weekly versions available
    • These versions affect both prandial and basal glucose levels
  • Dulaglutide is covered by Health Partners!

Cons

  • Requires subcutaneous injection
  • Can cause mild-moderate nausea (main side effect and the reason you uptitrate the medication)
    • Ex: with Liraglutide, if patient misses 3 days, then must restart titration
  • Exenatide injector is extremely confusing to use (go for Liraglutide or Dulaglutide instead)
    • Contraindicated in patients with h/o pancreatitis, thyroid C cell tumors, significantly renal impairment (varies by drug), severe GI disease
  • Expensive if not covered by insurance

DPP4 Inhibitors (the “gliptins”)

Ex: Sitagliptin (Januvia®), Saxagliptin, Linagliptin, Alogliptin

Pros

  • Oral
  • Well tolerated, weight neutral, low risk of hypoglycemia

Cons

  • Daily administration
  • Lack the systemic effects seen by GLP1 RA
  • Only decrease A1C by 0.5-0.9% on average
  • Warning for patients with h/o CHF, pancreatitis. May also cause hepatotoxicity, joint pain, hypersensitivity
  • Expensive (even the generic alogliptan is $3/dose)

Thyroid Emergencies

Lecture Video: head to the Lecture Database and click ‘Class Capture’.

Thank you Ajay Rao for giving us an amazing lecture.  Here are the highlights:

Thyroid Storm

  • Incidence of thyroid storm is less than 10% of patients hospitalized for thyrotoxicosis. Mortality rate can be as high as 20-30%.
  • Scoring system- Wartosky/Burch can be used to determine possibility of thyroid storm. Signs/symptoms of weight loss, generalized weakness/fatigue, diarrhea, palpitations, psychosis/confusion. A wide pulse pressure
  • Most common cause of thyroid storm is underlying Graves’ Disease.
    • Precipitating event like surgery, trauma, MI, VTE, DKA, infection, discontinuation of anti-thyroid drugs can lead to thyroid storm.
  • Management in the ICU:
    • Halt synthesis: give anti-thyroid drugs, i.e. methimazole or PTU
    • Halt release: give iodine therapy no sooner than 30-60 minutes AFTER anti-thyroid therapy
    • Halt peripheral effects: beta- blockade
    • Give steroids: inhibits peripheral conversion of T4 to T3

Myxedema Coma

  • Most patients with severe hypothyroidism present neither with myxedema or coma. Can present with progressive dysfunction of cardiovascular, respiratory and CNS systems.
  • Common precipitants include, sepsis, trauma, and surgery.
  • Findings include hypothermia, AMS, bradycardia, hypotension, and hyponatremia. Myxedema include swelling of the soft tissue associated with periorbital edema, ptosis, macroglossia or cool, dry skin.
  • Management:
    • Careful IV volume repletion
    • Hydrocortisone (if pituitary disease or adrenal insufficiency)
    • Give a SINGLE high dose of T4 (300-600mcg IV)
    • Daily T4 dosing (50-100mcg IV or PO)

DKA/ HHS

Lecture audio: DKA-HHS – McNellis.mp3

Many thanks to Dr McNellis for another amazing lecture!

Key Points:

Definitions

  • DKA
  • BG >200
  • pH<7.3
  • Bicarb<15
  • Serum/urine ketones

Precipitating Causes

  • Noncompliance
  • Infection
  • Ischemia (cerebral, myocardial, etc)
  • Pregnancy
  • Catecholamine surge (trauma, surgery, medications: steroids, pseudoephedrine)
  • Thyrotoxicosis

Treatment

  1. Volume status
  2. Acidosis
  3. Electrolytes
  4. Precipitating causes