NAPLEX Question of the Week: Actos or Fiction: A Diabetes Dilemma

This week's question focuses on a common diabetes medication. Are you up for the challenge?
NAPLEX Question of the Week: Actos or Fiction: A Diabetes Dilemma
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JL is a 65 year old female (5’4” and 165 lbs) that presents to her pharmacotherapy appointment at your ambulatory care clinic. You review her medications and get updated labs.

PMH:

Hypertension

Type 2 Diabetes Mellitus

Ischemic Stroke (2 years ago)

Dyslipidemia

HFrEF (NYHA class III)

Major Depressive Disorder

Current Medication List:

Entresto 97/103mg BID

Coreg 25 mg BID

Spironolactone 25 mg QD

Lasix 20 mg QD

Glucophage 1000 mg BID

Farxiga 10 mg QD

Crestor 40 mg QD

Aspirin 81 mg QD

Wellbutrin XL 150 mg QD

Labs:

HR: 80

RR: 19

BP: 132/81

A1c: 9.6%

You wish to initiate a new agent to address her uncontrolled DM, and since JL has experienced episodes of hypoglycemia in the past you consider recommending Actos. Which is true regarding potential use of Actos in our patient?

A. There is a pharmacologic duplication with Farxiga

B. Actos is contraindicated in JL due to her past history of stroke

C. Actos is contraindicated in JL due to her heart failure diagnosis

D. There is a significant drug interaction with Wellbutrin

Rationale:

Type 2 Diabetes Mellitus is a chronic metabolic disease characterized by elevated levels of blood glucose which can lead to damage of several organs within the body over time. Around 11% of the United States’ population has either type one or two diabetes, with Americans spending billions of dollars each year for treatment. Actos (Pioglitazone) is an agonist for peroxisome proliferator-activated receptor-gamma (PPARγ) which results in an increase of transcription for insulin receptors leading to decreased insulin resistance. Actos is primarily used in patients with type II diabetes who have a risk of hypoglycemia; it is a relatively low cost option compared to other diabetes medications. However, it is not recommended first-line by most due to its side effect profile. It may also increase the risk of bladder cancer. 

Answer A is incorrect: Farxiga (dapagliflozin) is an SGLT2 inhibitor and Actos (pioglitazone) is a PPARγ agonist. There is not a pharmacologic duplication with these medications as they address diabetes with two separate mechanisms of action.

Answer B is incorrect: Pioglitazone is NOT contraindicated in patients with a history of stroke. Effient (prasugrel) is an antiplatelet agent that is contraindicated in patients with previous TIA or stroke. 

Answer C is correct: There is a Boxed Warning regarding heart failure with Actos (pioglitazone). Actos can cause fluid retention which can worsen a patient's heart failure. Actos is contraindicated in New York Heart Association (NYHA) Class III or IV heart failure. 

Answer D is incorrect: There is not a significant interaction between Actos (pioglitazone) and Wellbutrin (bupropion).

Brand/Generics Covered: Entresto (sacubitril/valsartan), Coreg (carvedilol), Aldactone (spironolactone), Lasix (furosemide), Glucophage (metformin), Farxiga (dapagliflozin), Crestor (rosuvastatin), Aspirin, Wellbutrin (bupropion)

Naplex Competencies Covered:

Area 1 – Obtain, Interpret, or Assess Data, Medical, or Patient Information

  • 1 – From instruments, screening tools, laboratory, genomic or genetic information, or diagnostic findings
  • 2 – From patients: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
  • 4 – From medical records: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
  • 5 – Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiology

Area 2 – Identify Drug Characteristics

  • 1 – Pharmacology, mechanism of action, or therapeutic class
  • 2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied
  • 3 – Boxed warnings or REMS

Area 3 – Develop or Manage Treatment Plans

  • 2 – Therapeutic goals or outcomes and clinical endpoints
  • 3 – Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions
  • 4 – Drug dosing or dosing adjustments; duration of therapy
  • 6 – Drug contraindications, allergies, or precautions
  • 8 – Drug interactions

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