Type 2 Diabetes Flashcards
T2DM – General Treatment Main goals Treatment Lifestyle modifications Cardiovascular risk
- Main goals of treatment include education on nutritional and lifestyle modifications, prevention of potential future complications, regulation of hyperglycemia.
- Treatment should include a combination of lifestyle modifications (including nutrition) and pharmacologic therapies.
- Lifestyle modifications include assisting in weight loss, glycemic control through diet, exercise.
- Cardiovascular risk reduction should also be implemented in combination with diabetes education.
- It is recommended that pharmacologic therapy be initiated at the time that diabetes is diagnosed (HbA1c > 7.5%); some patients (HbA1c < 7.5%) can do a trial for lifestyle modifications for 3-6 months before initiating pharmacologic treatment.
Initial treatment usually begins with?
biguanide (Metformin)
Contraindications to Metformin use include:
Kidney insufficiency, don’t give/use!!!!!! (GFR has to be WNL** metabolized in the kidney, lactic acidosis)
- Men with serum creatinine > 1.5mg/dL; Women with serum creatinine > 1.4mg/dL
- Those with a GFR < 30mL/min
If there are contraindications to metformin, treatment is generally a sulfonylurea (Glipizide), or basal insulin.
Combination drug therapy considered if HbA1c > 9%
Insulin therapy should be strongly considered as a first line treatment if HbA1c > 10%
Intensive insulin therapy has no effect on cardiovascular outcomes and will increase the risk of hypoglycemic events.
Diabetes Medications:
1. – decreases hepatic glucose production, decreases intestinal absorption of glucose, improves insulin sensitivity.
- – increases insulin secretion from the pancreas, decreases hepatic glucose production, increases insulin sensitivity. Relatively inexpensive.
- – newer medications – increases incretin hormone levels which increase insulin synthesis and decrease glucagon secretion from the pancreas. These have a lower risk of hypoglycemia.
- – improves insulin sensitivity without increasing insulin secretion. Contraindicated in those with congestive heart failure; not commonly used anymore
Biguanides (Metformin) – decreases hepatic glucose production, decreases intestinal absorption of glucose, improves insulin sensitivity.
Sulfonylureas (Glipizide, Glyburide) – increases insulin secretion from the pancreas, decreases hepatic glucose production, increases insulin sensitivity. Relatively inexpensive.
Dipeptidyl-Peptidase-4 Inhibitors (Sitagliptin) – newer medications – increases incretin hormone levels which increase insulin synthesis and decrease glucagon secretion from the pancreas. These have a lower risk of hypoglycemia.
Thiazolidinediones (Rosiglitazone) – improves insulin sensitivity without increasing insulin secretion. Contraindicated in those with congestive heart failure; not commonly used anymore (Used to be the main line of use but increases CVD.)
Metformin side effects
GI issues (nausea, vomiting and diarrhea)
Metformin - Monitoring and Follow Up
- Initial therapy – Metformin with diet and lifestyle changes
- If HbA1c levels still above goal after 3 months – add in 1 of the following: sulfonylurea, basal insulin, thiazolidinedione, DPP-4 inhibitor.
- If HbA1c levels still above goal after 3 months of dual therapy, consider adding in 3rd medication.
- HbA1c levels should be done at least 2x a year.
- Self-monitoring of blood glucose is not necessary
Metformin (Fortamet):
Goal 1500mg/day
Dosing Adult:
Monitoring:
Dosing Adult: initially 500mg po qd cc pm; titrate up by 500mg q 1-2 weeks (BID – TID dose); goal is for 1500mg/day; max dose is 2,000mg/day
Monitoring: fasting plasma glucose, HbA1c, renal function (initially/yearly)
Metformin (Fortamet)
Main SE:
Avoid combination:
Warning:
Main SE: diarrhea, nausea, vomiting, weakness
Avoid combination with the following supplements/foods: berberine (dec. blood sugar), alcohol
Black box warning for lactic acidosis (potentially fatal).
Avoid use in patients with renal insufficiency.
Estimated to drop HbA1c levels by 1 – 2%
Glipizide (Glucotrol): "Causes Weight gain" Treatment Indication – T2DM management Dosing Adult: Monitoring:
Dosing Adult: initially 5mg qd 30 min before meals am; titrate in doses 2.5 – 5mg q 1-2 weeks; keep dosing < 15mg per dose or 40mg/day
Monitoring: fasting plasma glucose, HbA1c
Glipizide (Glucotrol):
Main SE:
Avoid combination:
Main SE: hypoglycemia, diarrhea, dizziness, weight gain
Avoid combination with the following supplements/foods: berberine (decreases blood sugar)
Shorter acting sulfonylurea;
Usually used in combination with Metformin if blood glucose unable to be regulated.
Estimated to drop HbA1c levels by 1 – 2%
Glyburide (Diabeta):
Treatment Indication – T2DM management
Dosing Adult:
Monitoring:
Dosing Adult: initially 2.5 - 5mg qd cc; titrate in doses 2.5mg q 1-2 weeks; keep dosing < 20mg/day
Monitoring: fasting plasma glucose, HbA1c
Glyburide (Diabeta):
Main SE:
Avoid combination:
Main SE: hypoglycemia, diarrhea, dizziness, weight gain
Avoid combination with the following supplements/foods: berberine
Shorter acting sulfonylurea
Usually used in combination with Metformin if blood glucose unable to be regulated.
Estimated to drop HbA1c levels by 1 – 2%
Rosiglitazone (Avandia) "Causes congestive heart failure" Treatment Indication – T2DM management Dosing Adult: Monitoring:
Treatment Indication – T2DM management
Dosing Adult: initially 4mg qd or 2mg BID; titrate dose up to 8mg qd or 4mg BID after 8-12 weeks of treatment.
Monitoring: fasting plasma glucose, HbA1c, signs of CHF, LFT
Rosiglitazone (Avandia):
Main SE:
Avoid combination
Black box warning
Main SE: hypercholesterolemia, HTN, edema, headache, hypoglycemia
Avoid combination with the following supplements/foods: berberine, alcohol
Black box warning for use in those with congestive heart failure or risk of MI.
Also increases the risk of fracture and edema
Usually used in combination with Metformin if blood glucose unable to be regulated.
Estimated to drop HbA1c levels by 0.5 – 1.4%
