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Hyperglycemic hyperosmolar state r39
Hypoglycemia with neuroglycopenia r37
Uncontrolled diabetes r37
Comprehensive diabetes management encompasses several components, including:
All patients should engage in lifestyle modifications directed at weight loss and increased physical activity r41
General guidance on pharmacologic therapy
Antihyperglycemic medications
Self-monitoring of blood glucose level r62r63
Bariatric surgery
Management of comorbidities
Drug class | Hemoglobin A1C–lowering effect | Hypoglycemia risk | Cardiovascular effects | Effect on body weight | Comments |
---|---|---|---|---|---|
GLP-1 receptor agonist | 1%-1.5% | Neutral | Liraglutide associated with reduction in major adverse cardiovascular events,* myocardial infarction, and reductions in cardiovascular and all-cause mortality; semaglutide associated with reduction in MACE (but not mortality)* | Loss | Contraindicated in patients with personal or family history of medullary thyroid carcinoma or MEN-2; check renal function at baseline and periodically throughout therapy |
Combined insulin- GLP-1 receptor agonist | More than 1.5% | Moderate, due to insulin component | Allows less weight gain (or even promotes minor weight loss) that otherwise occurs with insulin | Same contraindications as with GLP-1 receptor agonist; check renal function at baseline and periodically throughout therapy | |
Amylin Mimetic | 0.5% | Neutral alone, but increased risk of hypoglycemia when used with insulin (as indicated) | Slight loss; may limit weight gain that occurs with use of insulin | Indicated for use in conjunction with basal-bolus insulin regimens | |
Dual GIP and GLP-1 agonist | 1.8 - 2.07% | Neutral | SURPASS-CVOT trial underway to asses long-term cardiovascular outcomes | Loss | Same contraindications as with GLP-1 receptor agonists |
Type of insulin | Names | Time of action: onset, peak, and duration of effects | Comments |
---|---|---|---|
Basal | NPH | Onset: 2-4 hours Peak: 4-10 hours Duration: 10-18 hours | Variable action profile; can mix with rapid-acting insulins. NPH available as 100 unit/mL |
Basal analog | Glargine | Onset: 1.5 hours Peak: none Duration: 24 hours | Glargine available as 100 unit/mL as well as concentrated 300 unit/mL |
Detemir | Onset: 1-3 hours Peak: 6-8 hours Duration: 18-20 hours | Basal analog insulins provide similar hemoglobin A1C levels, better evening glucose levels, and less hypoglycemia compared to NPH. Determir available as 100 unit/mL | |
Degludec | Onset: 1 hour Peak: 12 hours Duration: more than 42 hours | Ultra-long-acting, once-daily basal analog with peakless activity. Degludec available as 100 unit/mL and 200 unit/mL | |
Bolus regular | Humulin R | Onset: 30 minutes Peak: 1.5-3.5 hours Duration: 5-7 hours | Longer duration compared to rapid-acting analogs makes regular insulin useful in gastroparesis. Available as 100 unit/mL |
Bolus regular U-500 insulin | Humulin R U500 | Onset: 30 minutes Peak: 1.5-3.5 hours Duration: 5-7 hours | Use for insulin-resistant patients who need more than 200 total units per day, given 3 times per day. Available as 500 unit/mL |
Bolus rapid-acting analog | Lispro, aspart, glulisine | Onset: 5-15 minutes Peak: 0.5-2 hours Duration: 3-5 hours | Rapid-acting analog insulin provides better control of postprandial glucose levels and less hypoglycemia compared with regular insulin; may be taken during or after meals. Lispro available as 100 unit/mL and 200 unit/mL. Aspart and glulisine available as 100 unit/mL |
Premixed insulin (50/50, 70/30, 75/25, 80/20) | Humalog 75/25 or 50/50 mix, Novolog 70/30 mix, Novolin 70/30, Humulin 70/30 | Onset: 5-15 minutes Peak: 0.5-2 hours Duration: 3-5 hours | Titration of both basal and prandial must occur simultaneously; compared with use of basal insulin or basal bolus insulin regimens, there is an increased rate of hypoglycemia with inferior achievement of glycemic goals |
Drug class | Hemoglobin A1C–lowering effect | Hypoglycemia risk | Micro- or macrovascular benefit | Weight change | Use in renal disease | Warnings | Comments |
---|---|---|---|---|---|---|---|
Biguanide | 1%-1.5% | Neutral | Reduction in cardiovascular events noted in UKPDS | Mostly neutral, but potential for slight loss | eGFR should be more than 45 mL/minute/1.73 m² at the time drug is started; thereafter, contraindicated if eGFR falls below 30 mL/minute/1.73 m² | Lactic acidosis risk | Vitamin B₁₂ deficiency can occur, and levels should be checked annually; drug should be discontinued on hospital admission, before administration of radiocontrast agents or in the setting of hypoxia or volume disturbance |
SGLT2 inhibitors | 0.5%-1% | Neutral | Empagliflozin has been shown to reduce cardiovascular and all-cause mortality and to slow progression of renal disease in nephropathy; canagliflozin has been shown to slow nephropathy | Loss | Requires renal dosing adjustments at chronic kidney disease stage 3 or greater; contraindicated if eGFR is less than 45 mL/minute/1.73 m² | Increased risk of bone fractures and increased risk of lower extremity amputations for canagliflozin; increased potential for DKA with all SGLT2 inhibitors | Reductions in blood pressure; risk for volume contraction; check renal function at baseline and periodically throughout therapy |
Sulfonylureas | 1%-1.5% | Moderate to severe | Reduction in microvascular complications noted in UKPDS | Gain | Hypoglycemia risk increases with declining renal function; contraindicated in chronic kidney disease stage 4 | Glyburide not recommended with renal failure | Retrospective data suggest a possible cardiovascular risk with use of this class of drugs, as compared with metformin |
Meglitinides | 1% | Moderate | Gain | Hypoglycemia risk increases with declining renal function; may be used in chronic kidney disease stages 3-5 with dosing adjustments | Dosed multiple times per day at meals | ||
DPP4 inhibitors | 0.6%-0.8% | Neutral | Microvascular benefit of reducing albuminuria; potential risk for heart failure hospitalizations with saxagliptin | Neutral | Requires renal dosing adjustments, except linagliptin | Check renal function at baseline and periodically throughout therapy; only linagliptin does not require adjustments for renal insufficiency | |
Thiazolidinediones | 1% | Neutral | Reduction in cardiovascular events noted in PROactive trial with pioglitazone, but drugs of this class increase incidence of heart failure | Gain | Risk of congestive heart failure (contraindicated in class III and IV heart failure), fracture risk, and possible risk of bladder cancer with pioglitazone | Possible benefit in nonalcoholic steatohepatitis; elevated risk of bone fractures; slight elevation in LDL-C | |
α-glucosidase inhibitors | 0.5% | Neutral | Neutral | Nonsystemic absorption | |||
Dopamine-2 agonists | 0.5% | Neutral | Neutral |
Therapeutic lifestyle modifications r27r97c149
Diabetes self-management education and support r97c153
Blood glucose monitoring
Immunizations r11