Drug Interactions between Anurx-HC and Xultophy

MONITOR: The efficacy of insulin and other antidiabetic agents may be diminished by topical corticosteroids in situations where they are absorbed systemically. Corticosteroids can raise blood glucose levels by antagonizing the action and suppressing the secretion of insulin, which results in inhibition of peripheral glucose uptake and increased gluconeogenesis. Factors that can affect the likelihood of systemic absorption include the steroid's potency and formulation, duration of exposure, application surface area, use on occluded areas of skin, and thickness and/or integrity of skin in the applied areas. Infants and small children also have an increased risk of systemic absorption due to their larger skin surface to body mass ratios. The interaction was suspected in a case report of a 71-year-old patient with type 1 diabetes mellitus that had been well controlled on an insulin pump. The patient developed acute hyperglycemia after using fluocinonide 0.1% cream for 2 days due to a psoriasis flare. He was applying the cream twice daily to a large area of his body (including his abdomen) and using occlusive techniques to increase its effectiveness. His insulin requirements increased from 73 units per day to 326 units in a 24-hour period. The patient's hyperglycemia resolved with discontinuation of the fluocinonide cream, allowing him to resume his previous insulin dosage.

MANAGEMENT: Close clinical monitoring of glycemic control is recommended when systemic absorption of topical corticosteroids is considered probable or likely (e.g., more potent agents, larger areas of application, longer duration of treatment, application on thinner skin like the face, occlusion of the application area, use on infants or young children), with adjustment of the patient's antidiabetic regimen as needed. The package labeling of the corticosteroid involved should be consulted to assess the risk.

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MONITOR: The efficacy of insulin and other antidiabetic agents may be diminished by topical corticosteroids in situations where they are absorbed systemically. Corticosteroids can raise blood glucose levels by antagonizing the action and suppressing the secretion of insulin, which results in inhibition of peripheral glucose uptake and increased gluconeogenesis. Factors that can affect the likelihood of systemic absorption include the steroid's potency and formulation, duration of exposure, application surface area, use on occluded areas of skin, and thickness and/or integrity of skin in the applied areas. Infants and small children also have an increased risk of systemic absorption due to their larger skin surface to body mass ratios. The interaction was suspected in a case report of a 71-year-old patient with type 1 diabetes mellitus that had been well controlled on an insulin pump. The patient developed acute hyperglycemia after using fluocinonide 0.1% cream for 2 days due to a psoriasis flare. He was applying the cream twice daily to a large area of his body (including his abdomen) and using occlusive techniques to increase its effectiveness. His insulin requirements increased from 73 units per day to 326 units in a 24-hour period. The patient's hyperglycemia resolved with discontinuation of the fluocinonide cream, allowing him to resume his previous insulin dosage.

MANAGEMENT: Close clinical monitoring of glycemic control is recommended when systemic absorption of topical corticosteroids is considered probable or likely (e.g., more potent agents, larger areas of application, longer duration of treatment, application on thinner skin like the face, occlusion of the application area, use on infants or young children), with adjustment of the patient's antidiabetic regimen as needed. The package labeling of the corticosteroid involved should be consulted to assess the risk.

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ADJUST DOSE: Coadministration of a glucagon-like peptide-1 (GLP-1) receptor agonist or dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist with insulin may potentiate the risk of hypoglycemia. GLP-1 receptor agonists and dual GLP-1 and GIP receptor agonists lower blood glucose by stimulating insulin secretion and lowering glucagon secretion. An increased incidence of hypoglycemia has been observed in patients treated with a combination of basal insulin and GLP-1 or dual GLP-1 and GIP receptor agonists. Additionally, patients with diabetic retinopathy who received treatment with basal insulin and subcutaneous semaglutide in one clinical trial had an increased risk of developing diabetic retinopathy complications. Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy, but other mechanisms cannot be excluded. The safety and efficacy of GLP-1 or dual GLP-1 and GIP receptor agonists in combination with non-basal insulin have not been established.

MANAGEMENT: When a GLP-1 receptor agonist or dual GLP-1 and GIP receptor agonist is used as add-on therapy to basal insulin, a lower dosage of insulin may be required. Some clinical trials have reduced the basal insulin dose by 20% in patients with a baseline hemoglobin A1c <= 8% when a GLP-1 or dual GLP-1 and GIP receptor agonist was initiated. Because diabetic ketoacidosis has been reported in insulin-dependent patients after rapid discontinuation or dose reduction of insulin, a stepwise approach to insulin dose reduction is recommended and blood glucose levels should be closely monitored. Patients should receive guidance on the recognition and management of hypoglycemia as well as precautions to take to avoid hypoglycemia, particularly while driving or operating hazardous machinery. Those with diabetic retinopathy should also be monitored for progression of the condition or complications. A rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy.

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