Webinar - Diabetes

Maximizing the Role of GLP-1 Agonists in Our Patients with Type 2 Diabetes 

Physiology

Consumption of food leads to a rise in a glucose levels. This rise in glucose leads to release of incretins from the intestines, specifically the duodenum to stimulate a decrease in blood glucose levels.  The two types of incretin are glucagon-like peptide (GLP) and glucose dependent insulinotropic polypeptide or gastric inhibitor polypeptide (GIP).  GLP1 acts on the brain to promote satiety and reduce appetite, acts on the pancreas alpha cells to decrease postprandial glucagon secretion, acts on the pancreas beta cells to increase glucose dependent insulin secretion, acts on the liver to decrease glycogenolycis (due to decrease glucagon secretion), acts on the gastro intestinal tract to slow gastric emptying. 

GLP1 agonists drugs

·         Short acting à lower postprandial glucose

Exenatide short acting BID

·         Long acting à lower postprandial glucose and fasting

Exentaide long acting weekly

Liraglutide

Albiglutide

Dulaglutide

Side effects of GLP1 agonists

Weight loss

Stomach upset – patients should eat smaller/frequents meals

Caution with pancreatitis

Storage of GLP1 pens

Refrigerate unopened pens

Room temperate pens sting less

GLP1 pens vs insulin pens

GLP1 pens should be primed initially

Insulin pens should be primed each time

GLP1 agonists vs DPP4 inhibitors

DPP4 inhibitors raise GLP1 to endogenous levels

GLP1 agonists raise GLP1 much higher

Pharmacotherapy options for diabetes treatment

·         Bolus insulin

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

Inhaled (Afrezza)

Regular (Humulin R, Novolin R)

·         Basal insulin

NPH (Humulin N, Novolin N)

Detemir (Levemir)

Glargine U100;U300 (Lantus, Toujeo)

·         Non-insulin injectables

Glucagon like peptide 1 agonists – exenatide, liraglutide, albaglutide, dulaglutide

Amylinomimetic – pramlintide

·         Oral

Alpha glucosidase inhibitors – acarbose, miglitol

Biguanides – metformin

Bile acid sequestrants – cholestyramine, colestipol, colesevelam

Dipeptidyl peptidase 4 inhibitors – sitagliptin, saxagliptin

Dopamine agonists – bromocriptine

Glinides – nateglinide, repaglinide

Sulfonylureas – glipizide, glimepiride

Sodium glucose co-transporter 2 inhibitors – canagliflozin, dapagliflozin

Thiazolidinediones – rosiglitazone, pioglitazone

Weight changes with antihyperglycemic agents added to metformin

Drugs causing weight gain Insulin* (most gain) Thiazolidinediones* Sulfonylureas* Glinides* Dipeptidyl peptidase 4 inhibitors (least gain)

Drugs causing weight loss Alpha glucosidase inhibitor (least loss) Glucagon like peptide 1 agonists Sodium glucose co-transporter 2 inhibitors (most loss)

*hypoglycemic risk