Type 2 Diabetes Initial Oral Therapy Flashcards
(27 cards)
Metformin
Slight risk reduction
- Pretty safe
Acarbose
Slight risk reduction
- Causes serious GI side effects
Pioglitazone
Strongest risk reduction
- Causes heart failrues
Rosiglitazone
Strong risk reduction
- Causes CV side effects (No longer on market)
Ramipril
No significant difference
Muscle and Liver
- Diabetes Pathophysiology
- Drugs
Insulin Resistance
Decrease Insulin Resistance
- Thiazolidinediones
Pancreatic Beta Cells
- Diabetes Pathophysiology
- Drugs
Decreases Insulin Secretion
Increases Insulin Secretion
- Thiazolidinediones
- GLP1ra
- DPP4i
- Sulfonylureas
- Non-sulfonylurea Secretagogues
- Insulin
Liver
- Diabetes Pathophysiology
- Drugs
Increase Hepatic Glucose Production
Decreases Hepatic Glucose Production
- Metformin
- Thiazolidinediones
- GLP1ra
- DPP4i
Small Intestine
- Diabetes Pathophysiology
- Drugs
Decreases Incretin Hormone Secretion
Increases Incretin Hormone Secretion
- GLP1ra
- DPP4i
Alpha-glucosidase Inhibitors (Acarbose)
- Inhibits breakdown of complex carbohydrates
Adipose Tissue
- Diabetes Pathophysiology
- Drugs
Increases Release of Free Fatty Acids
Prevents release of free fatty acids
- Thiazolidinediones
Pancreatic alpha cell
Increases Glucagon Secretion
- GLP1ra
- DPP4i
Kidney
Increases Glucose Reabsorption by Sodium/Glucose Co-Transporter 2
Inhibits SGLT2
- SGLT2i
Brain
Neurotransmitter Dysfunction
- GLP1ra
What Type 2 Diabetes Drugs have been removed from practice
Thiazolidinediones (Heart Attack/Failure)
Alpha-glucosidase Inhibitors (Nasty GI AE)
- Acarbose
Sulfonylurea (High Hypoglycemia Risk)
Non-Sulfonylurea Secretagogues
Goals of Therapy
- Type 2 Diabetes
Treat Normally:
- Maintain Targets (A1c/FPG/2-Hour Post-Prandial Blood Glucose)
Treat Agressively
- Reduce Microvascular and Macrovascular complications
- Minimize risk of hypoglycemia
- Maintain targets for CV risk factors
Type 2 Diabetes Guidelines
- Initial Therapy
- Healthy Behaviour Interventions
- Can add Metformin if needed
- Can add drugs for CV and Kidney - Add Antihyperglycemic Therapy if targets not reached within 3 months
- Add Metformin before other therapies - A1c is above 1.5% target
- Combine Metformin with a second antihyperglycemic agent - If patient has metabolic decompensation
- Start Insulin with or without Metformin
How long to reach target for Type 2 Diabetes
3-6 months
How much can Metformin shift A1c
By 1.5%
Metabolic Decompensation
- Symptoms
Marked Hyperglycemia
Ketosis
Unintentional Weight Loss
Initial Choice of Therapy
- A1c is less than 1.5% over target
Initiate healthy behaviour interventions and start Metformin if not at target in 3 months
OR
Start Metformin with Initiate healthy behaviour interventions
Initial Choice of Therapy
- A1c is greater than 1.5% over target
Start metformin with Healthy Behaviour Interventions AND Consider second concurrent agent
Initial Choice of Therapy
- When to start Insulin
Signs of Hyperglycemia and/or Metabolic Decompensation:
- Polyuria
- Polydipsia
- Weight Loss
- Volume Depletion
Start Insulin +/- Metformin
Why is Metformin the Initial Agent
- Efficacy in Lowering A1c
- Favourable Side Effect Profile
- Low Risk of Hypoglycemia
- Weight Gain is minimal/neutral - Cost Effective
Metformin
- Clinical Evidence
Only lowers blood sugars
- Does not reduce CV events or reduce progression of diabetes
Trials that do show CV benefits did not have many participants
