1. SENSITIZERS
1.1. BIGUANINES
1.1.1. METFORMIN (Glucophage, Riomet, Glucophage XR)
1.1.1.1. CI: increased Cr, lactic acid increase, CHF, ETOH, contrast studies
1.1.1.2. 850mg PO qd OR 500mg BID
1.1.1.2.1. inc 500mg qwk or 850mg q2wk
1.1.1.2.2. MAX: 2550mg/day
1.1.1.3. FIRST LINE MONOTHERAPY
1.1.1.4. ADD ON FOR DUAL/TRIPLE THERAPY
1.1.1.5. AE: Slight weight loss, GI sx, decrease B12 absorption
1.1.1.6. CI: CKD stage 3B, 4 & 5
1.1.1.7. plain vs XR
1.1.1.7.1. 1000mg is name brand ($300/month)
1.1.1.7.2. ER = 500mg
1.2. THIAZOLIDINEDIONES
1.2.1. lowers A1C .5-1.4% in 12-15 weeks
1.2.2. increases sensitivity to insulin
1.2.3. slows disease progression
1.2.4. AE: worsens CHF, peripheral edema, weight gain, decreased bone density, bladder cancer
1.2.5. **PIOGLITAZONE (Actos)
1.2.5.1. START: 15-30mg PO qd
1.2.5.1.1. MAX: 45mg/day
1.2.5.2. BLACK BOX: CHF
1.2.5.3. CI: CHF, DMI, Bladder CA, estradiol,
1.2.5.4. AE: CHF, hepatotoxicity, HA, edema, fluid retention
1.2.6. ROSIGLITAZONE (Avandia)
1.2.6.1. START: 4mg PO qd OR 2mg PO BID
1.2.6.1.1. MAX: 8mg/day
1.2.6.1.2. with insulin MAX: 4mg/day
1.2.6.2. CI: CHF, DMI, ACS, sulfonylurea use, insulin, nitrates,
1.2.6.3. AE: CHF, MI, angina, angioedema, URI, HA, edema, wt gain, ovulation induction
2. INSULINS
2.1. sliding scale
2.1.1. Xu / BG increase of 50
2.1.2. UNITS = BS-120/20 + 1u/15g CHO eating
2.2. CI: hypoglycemia, hypokalemia, renal/hepatic dx, -olol, -glitide,
2.3. AE: hypoglycemia, hypokalemia, inj. rxn, myalgia, rash wt gain,
2.4. DRUG OF CHOICE FOR GESTATIONAL DIABETES
2.5. may need to adjust long acting when adding rapid actings
2.6. RAPID
2.6.1. INSULIN ASPART (Novolog)
2.6.1.1. .5-1 u/kg/day
2.6.1.1.1. 5-10 min before meals
2.6.1.2. ONSET: 15min
2.6.1.3. PEAK: 1-3h
2.6.1.4. DURATION: 3-5h
2.6.2. INSULIN LISPRO (HUMALOG)
2.6.2.1. .5-1 U/kg/day
2.6.2.1.1. <15min before or after meals
2.6.2.2. ONSET < 30min
2.6.2.3. PEAK .5-1.5 hr
2.6.2.4. DURATION <6h
2.6.3. INSULIN GLULISINE (Apidra)
2.6.3.1. .5-1 u/kg/day <15min before or after food
2.6.3.2. ONSET <30min
2.6.3.3. PEAK: .5-1.5h
2.6.3.4. DURATION <6h
2.7. SHORT
2.7.1. REGULAR (Humulin R, Novolin R)
2.7.1.1. .5-1 u/kg/day
2.7.1.2. ONSET .5-1h
2.7.1.3. PEAK: 2-4h
2.7.1.4. DURATION 6-12h
2.8. INTERMEDIATE
2.8.1. NPH INSULIN ISOPHANE (Humulin N)
2.8.1.1. .5-1 u/kg/day
2.8.1.2. ONSET: 1-2h
2.8.1.3. PEAK: 4-14h
2.8.1.4. DURATION: 10-24h
2.9. LONG
2.9.1. INSULIN DETEMIR (levemir
2.9.1.1. WORKS BETTER FOR BID
2.9.1.2. Type I = .5-1 u/kg/day
2.9.1.3. Type II = 10 U/day qd-BID
2.9.1.4. ONSET: 1 hr
2.9.1.5. NO PEAK
2.9.1.6. DURATION: 6-24 hr
2.9.2. INSULIN GLARGINE (Lantus)
2.9.3. up to 50 units TID, daily, or BID
2.9.4. .1-.3u/kg (8-10 units/day)
2.9.4.1. add 2 units every day your blood sugar is over 150 - self titration
2.9.5. ONSET: 1 hr
2.9.6. NO PEAK
2.9.7. DURATION: 24hr
2.10. BASAL/BOLUS
2.10.1. when Glargine >.5 U/kg
2.10.2. add rapid insulin at meals if post postprandial increases >40
2.10.3. test, treat, and eat
2.10.4. TOUJEO - 300U in 1mL
2.11. STOP SU, SECRETAGOGUES BEFORE INSULIN TX
3. DPP-IV INHIBITORS
3.1. lower A1C .5-.8%
3.2. decrease breakdown of incretins by inhibiting DPP4
3.3. can use with metformin and SU
3.4. MONO/DUAL/TRIPLE THERAPY
3.5. CI: DM1, CrCl<50, other gliptins
3.6. AE: pancreatitis, renal failure, URI, HA, diarrhea, arthralgia
3.7. FIRST LINE
3.7.1. SITAGLIPTIN (Januvia)
3.7.1.1. 100mg PO qd
3.7.1.1.1. reduced to 50/25mg for renal impairment
3.8. SECOND LINE
3.8.1. SAXAGLIPTIN (Onglyza)
3.8.1.1. 2.5-5mg PO qd
3.8.1.1.1. MAX: 5mg/day
3.8.1.1.2. do not cut tab
3.8.1.1.3. reduced for renal impairment
4. LONG ACTING SECRETAGOGUES
4.1. SULFONYLUREAS
4.1.1. risk of low blood glucose
4.1.2. flog the pancreas
4.1.3. **GLIPIZIDE (Glucotrol)
4.1.3.1. second generation
4.1.3.2. go to sulfonylurea
4.1.3.3. START: 5mg PO qd
4.1.3.3.1. 2.5mg PO qd in elderly
4.1.3.3.2. dose 30min before meals
4.1.3.3.3. MAX: 40mgday
4.1.3.4. CI: DKA, PREGNANCY, renal impairment, hepatic impairment, malnutrition, nateglinide,
4.1.3.5. AE: hypoglycemia, agranulocytosis, hemolytic anemia, hepatitis, jaundice, hyponatremia, SIADH, N/D, HA, rash, itching, nervousness
4.1.4. GLIMEPIRIDE (Amaryl)
4.1.4.1. second generation
4.1.4.2. START: 1-2mg PO qd
4.1.4.2.1. increase by 1-2mg/day q1-2wk
4.1.4.2.2. MAX: 8mg/day
4.1.4.2.3. give with first meal
4.1.4.3. CI: DKA, G6PD, hypoglycemia, elderly, nateglinide, PREGNANCY
4.1.4.4. AE: hypoglycemia, hepatotox, thrombocytopenia, hyponatremia, dizziness, hA, nausea, photosensitivity
4.1.5. CHLORPROPAMIDE (Diabeinese)
4.1.5.1. first generation - NEVER USED
4.1.5.2. very fast acting, hypoglycemia risk
4.1.5.3. START: 100-125mg PO qd
4.1.5.3.1. MAX: 750mg/day
4.1.5.4. CI: DM1, PREGNANCY, hepatic/renal impairment, malnutrition, elderly, -navir
4.1.5.5. AE: hypoglycemia, aplastic anemia, jaundice, hepatitis, N/V/D, anorexia, pruritus,
4.2. NON SU SECRETAGOGUES
4.2.1. faster release insulin with meals
4.2.2. CYP
4.2.3. MEGLITINIDE
4.2.4. NATEGLINIDE (Starlix)
4.2.4.1. START: 120mg PO TID
4.2.4.1.1. 60mg PO TID if close to goal A1C
4.2.4.1.2. give 1-30min before meal
4.2.4.2. CI: Mifepristone, DKA, DM1, elderly
4.2.4.3. AE: hypoglycemia, URI, back pain, dizziness, diarrhea, cough, bronchitis,
4.2.5. REPAGLINIDE (Prandin)
4.2.5.1. .5-4mg PO 15-30min before each mean
4.2.5.1.1. START: .5mg
4.2.5.1.2. MAX: 4mg/dose up to 16mg/day
4.2.5.2. CI: DM1, DKA, hepatic impairment, CrCl <40, gemfibrozil, mifepristone
4.2.5.3. AE:Hypoglycemia, leukopenia, pancreatitis, diarrhea, back pain, N/V/C, CP
5. GLP-1 AGONISTS
5.1. INCRETINS
5.1.1. can use with glargine
5.1.2. BEST FOR WEIGHT LOSS
5.1.3. AE: nausea, pancreatitis, weight loss, GI sx
5.1.4. CI: CrCl <30, cidofovir, streptozocin
5.1.5. incretin mimetic - lowers breakdown of incretin, increase insulin, decreases gastric emptying, increases satiety,
5.1.6. MONO/DUAL/TRIPLE THERAPY
5.1.7. LIRAGLUTIDE (Victoza)
5.1.7.1. Victoza = daily
5.1.7.2. Trulicity = Weekly
5.1.7.3. .6mg SC qd x 1 wk, then 1.2mg SC qd
5.1.7.3.1. MAX: 1.8mg/day
5.1.7.3.2. retitrate from .6mg SC qd if tx interrupted
5.1.7.4. BLACK BOX: Thyroid C cell tumor
5.1.8. EXENATIDE (Byetta)
5.1.8.1. BID = Byetta
5.1.8.2. Weekly = Bydureon
5.1.8.3. START: 5mcg SC BID x 1 mo,
5.1.8.3.1. then increase to 10mcg SC BID
5.1.8.3.2. give within 1 hr before AM/PM meals
6. SGLT2
6.1. CANAGLIFLOZIN (Invokana)
6.1.1. blocks kidney reabsorbing glucose = glucosuria
6.1.2. START: 100mg PO qd
6.1.2.1. give before 1st meal
6.1.2.2. D/C if GFR <45
6.1.3. can use with metformin
6.1.4. AE: UTI, weight loss, renal failure, uTI, ketoacidosis, pancreatitis, bone density loss, hyperkalemia, hypoglycemia, thirst, N/C
6.1.5. CI: genital mycotic infx, GFR <45, PREGNANCY, hypotension, etoh, dapagliflozin, venetoclax, yohimbe
7. THINGS NOT USED
7.1. A-GLUCOSIDASE INHIBITORS
7.1.1. Slows CHO absorption, has to be taken with meals, makes people gassy and bloated
7.1.2. ACARBOSE (Precose)
7.1.3. MIGLITOL (Glyset)
7.2. BILE ACID SEQUESTRANTS
7.2.1. Origin for lipids, lowers glucose but not A1C
7.2.2. Chloestyramine
7.2.3. COLESEVELAM
7.2.4. COLESTIPOL
7.3. DOPAMINE 2 AGONISTS
7.3.1. BROMOCRIPTINE (Parlodel)
7.3.2. central acting, AM use, circadian neuronal drive reset increases glucose set point
7.3.3. AE: N/V fatigue