44. Diabetes Flashcards
Diabetes is due to decreased___ , ____, or both
insulin secretion, insulin sensitivity
Define T1DM
Autoimmune destruction of beta-cells (no beta-cells = no insulin production)
Define T2DM
insulin resistance and insulin deficiency due to beta-cell damage
Metformin can be used in prediabetes pts with BMI ___, age ___, and women with hx of ____
BMI ≥35, age <60 yo, and women with hx of GDM
Pregnant women are tested for GMD at ___ using ____
24-28 weeks using oral glucose tolerance test (OGTT)
Risk factors of DM
Physical inactivity
Overweight (BMI ≥25 or 23 in asian-americans)
Race (AA, asian-american, latino/hisptanic-american, native american, pacific islander)
Hx of GDM
A1C ≥ 5.7%
First-degree relative with DM (sibling/parent)
HLD, HTN, CVD, smoking
Other conditions that cause insulin resistance (e.g. acanthosis, nigricans, PCOS)
Symptoms of DM
Polyuria, polyphagia, polydipsia, fatigue, blurry vision, erectile dysfunction, vaginal fungal infections
T1DM - initial presentation is often DKA
Screening start age
35 yo
All asymptomatic children, adolescents, and adults who are ____ and have at least 1 other risk factor should be tested and repeat every ____ years if normal
overweight (BMI ≥25 or 23 for asian-americans), repeat every 3 years
There are 3 types of DM tests: ___, ___, and ___. ___ is preferred.
Hg A1C, fasting plasma glucose (FPG), and OGTT. No single test is preferred.
T/F: Positive DM test does not require another test to confirm
Positive test should be confirmed with a second abnormal test result unless clear clinical diagnosis (e.g classic symptoms + random BG ≥ 200)
Diagnosis Criteria for DM A1C
A1C ≥ 6.5%
Diagnosis Criteria for Pre-diabetes A1C
5.7-6.4
Diagnosis Criteria for DM FPG (mg/dL)
≥126
Diagnosis Criteria for Pre-diabetes FPG (mg/dL)
100-125
Diagnosis Criteria for DM OGTT (2hr BG, mg/dL)
≥ 200
Diagnosis Criteria for Pre-diabetes OGTT (2hr BG, mg/dL)
140-199
Treatment goals for A1C for non-pregnant
<7
Treatment goals for Pre-prandial for non-pregnant
80-130
Treatment goals for Pre-prandial for pregnant
≤95
Treatment goals for 2hr PPG for non-pregnant
<180
Treatment goals for 1hr PPG for pregnant
≤140
Treatment goals for 2hr PPG for pregnant
≤120
A1C testing frequency if not at goal
every 3 months
A1C testing frequency if at goal
every 6 months
A1C to estimated average glucose (eAG) math
A1C 6% = 126 mg/dL + additional 1% = 28 mg/dL
Waist circumference goal for females
<35 inches
Waist circumference goal for females
<40 inches
1 serving = ___ grams of carbs (list examples)
15 g of carbs = 1 small piece of fruit, 1 slice of bread, OR ⅓ cup of cooked rice/pasta
Physical Activity recommendation
At least 150 min/week of moderate intensity activity
Reduce sedentary habits, stand every 30 min at minimum
Micro or macrovascular disease: Retinopathy
Microvascular
Micro or macrovascular disease: Diabetic kidney disease (i.e. neuropathy)
Microvascular
Micro or macrovascular disease: Peripheral neuropathy (i.e. loss of sensation, often in feet, increased risk of foot infections and amputations)
Microvascular
Micro or macrovascular disease: Autonomic neuropathy (gastroparesis, loss of bladder control, erectile dysfunction)
Microvascular
Micro or macrovascular disease: Coronary artery disease (CAD), including MI
Macrovascular
Micro or macrovascular disease: Cerebrovascular disease (CVA), including stroke
Macrovascular
Micro or macrovascular disease: Peripheral artery disease (PAD)
Macrovascular
T/F: ASA 81mg is recommended for primary prevention in all patients
False - ASA 81mg daily is recommended for ASCVD secondary prevention (e.g. post-MI)
Alternative for secondary ASCVD prevention in DM patients if aspirin allergy
clopidogrel 75mg daily
High or moderate intensity statin: DM patient with ASCVD
High intensity
High or moderate intensity statin: DM patient age 40-75yo with ≥ 1 ASCVD risk factor
High intensity
High or moderate intensity statin: DM patient age 40-75yo (no ASCVD)
Moderate intensity
High or moderate intensity statin: DM patient age <40 yo with ASCVD risk factors
Moderate intensity
Icosapent ethyl (Vascepa) can be added on for cholesterol control if LDL ___ and TG ____
LDL is controlled but TG is 135-299 mg/dL
DM patient lipid panel monitoring frequency
Annually, 4-12 weeks after starting statin or increasing dose
DM patient eye exam monitoring frequency
eye exam at dx, annually if retinopathy, can defer to every 1-2 years otherwise
Required vaccinations for DM patients (in addition to all childhood vaccines)
Hep B, influenza (annually), pneumococcal vaccines
Diabetic kidney disease definition
eGFR < 60 and/or albuminuria (urine albumin ≥ 30mg/24hrs or UACR≥30 mg/g)
Treatment options for diabetic kidney disease
ACEi/ARB, SGLT2i (if eGFR ≥20) or finerenone (once on max tolerated dose of ACEi/ARB)
DM neuropathy monitoring frequency
Sensation - annually with 10g monofilament test and 1 other test (pinprick, temp, vibration)
Comprehensive foot exam - at least annually
DM Foot care counseling points
Daily: wash, dry, and examine feet, moisturize top and bottom of feet but NOT between toes
Each office visit: check feet
Annually: foot exam by podiatrist
Trim toenails with nail file
Wear socks and shoes, elevate feet when sitting
BP goal for DM patient
<130/80
BP treatment options for DM with no albuminuria or CAD
thiazide, DHP CCB, ACEi/ARB
BP treatment options for DM with albuminuria or CAD
ACEi/ARB
Natural products used for DM
cinnamon, alpha lipoic acid, chromium
LDL goal for DM patients
LDL <55 if ASCVD, <70 for all others
Insulin can be used initially in T2DM patients if ___ or ____
severe hyperglycemia: A1C > 10% or BG ≥ 300
Recommended to start 2 drugs at baseline in T2DM patients if A1C ____
8.5-10%
Start ___ or ___ if T2DM patients has ASCVD, HF, or CKD
GLP1RA or SGLT2i
T2DM medication combinations to avoid
DPP-4i + GLP1RA
SU + insulin
GLP-1 RA MOA
Analogs of GLP-1 hormone which increases glucose-dependent insulin secretion, decreases glucagon secretion, slows gastric emptying/improves satiety (=weight loss)
GLP1RA dose frequency:
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Semaglutide (Ozempic)
Exenatide (Byetta)
Exenatide ER (Byetta BCise)
Liraglutide (Victoza) - SC daily
Dulaglutide (Trulicity) - SC once weekly
Semaglutide (Ozempic) - SC once weekly, PO once daily
Exenatide (Byetta) - SC BID
Exenatide ER (Byetta BCise) - SC once weekly
Dual GLP-1 and GIP agonist dose frequency: Tirzepatide (Mounjaro)
SC weekly
Which GLP1RAs are recommended in patients with ASCVD (or high risk) and as an alternative in CKD because of CV benefits?
Liraglutide (Victoza)
Dulaglutide (Trulicity)
SC semaglutide (Ozempic)
Which GLP1RA also comes in an oral tablet formulation?
Semaglutide (Rybelsus)
GLP1 RA names end in “-___”
“-tide”
GLP1 RA (except Byetta) Boxed warning
increased risk of thyroid C-cell carcinoma
Do NOT use if personal or family hx of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2)
GLP1 RA Warnings
Pancreatitis (can be fatal, RF: gallstones, alcoholism, or increased TGs)
NOT recommended in pts with severe GI disease, including gastroparesis
Bydureon BCise warnings
Serious injection-site reactions (e.g. abscess, cellulitis, necrosis) with or w/o SC nodules
Ozempic and Mounjaro warnings
increased complications with diabetic retinopathy
Which GLP1RAs have increased complications with diabetic retinopathy
Ozempic and Mounjaro
Side effects of GLP1RAs and GIP agonists
Weight loss, N/V/D (reduced with dose titration), hypoglycemia, injection site reactions, AKI, gallbladder disease
Tirzepatide: increased HR
GLP1 RA and GIP agonist A1C decrease %
0.5-1.5%
GLP1 RA and GIP agonist effect on BG
decreases postprandial BG
GLP1 RA and GIP agonist hypoglycemic risk
Low
Do NOT use GLP1 RA and GIP agonists with ___ (overlapping mechanism)
DPP-4 inhibitors
Exenatide (Byetta) dose timing with meals
within 60min of meals
Semaglutide (Rybelsus) dose timing with meals
Take does ≥30 min before first food/drink/meds of the day
Pen needles are not provided with ___ or ____ but provided with all other GLP1RAs
Byetta or Victoza
T/F: Glucose-lowering effects are often seen immediately with initial doses of GLP1 RAs
False - often not seen with initial doses (titrated to reduce GI ADEs)
GLP1RAs can (increase/decrease) INR in patients on warfarin
Increase
SGLT2 inhibitor MOA
Inhibits SGLT2 (expressed in proximal renal tubules, responsible for reabsorption of filtered glucose), reduces reabsorption of glucose and increases glucose in urine excretion (decrease BG)
Which SGLT2is have shown benefits in patients with HF, CKD, and/or ASCVD?
Canagliflozin, dapagliflozin, and empagliflozin
SGLT2i names end in “-____”
“-gliflozin”
SGLT2i dosing frequency and timing
once daily in the morning
SGLT2i contraindications
Dialysis
SGLT2i warnings
Ketoacidosis (can occur with BG <250, D/C prior to surgery d/t risk)
Genital mycotic infections, urosepsis, pyelonephritis, necrotizing fasciitis (perineum)
Hypotension, AKI, and renal impairment (d/t intravascular volume depletion)
Canagliflozin (Invokana) warnings
Increase risk of leg and foot amputations, higher risk with hx of amputation, PAD, peripheral neuropathy and/or diabetic foot ulcers
Hyperkalemia risk when used with other drugs that increase potassium
Risk of fractures
SGLT2i side effects
weight loss, increase urination, increase thirst, hypoglycemia, increase Mg/PO4
SGLT2i A1C lowering %
0.7-1%
SLGT2i hypoglycemia risk
low (unless used with insulin)
SGLT2i have increased risk of intravascular volume depletion (causing ___ and ___) if used in combination with ____, ___, and ____
causing hypotension and AKI if used in combination with diuretics, RAAS inhibitors, or NSAIDs
Uridine diphosphate glucuronosyltransferase (UGT) inducers (e.g. ___, __, ____) can (increase/decrease) canagliflozin levels
rifampin, phenytoin, phenobarbital can decrease canagliflozin levels
Consider using 300mg dose if used in combo and eGFR≥60
Metformin MOA
decrease hepatic glucose production
increase insulin sensitivity
decrease intestinal absorption of glucose
Metformin boxed warning
Lactic acidosis - increased risk with renal impairment, contrast dye, and excessive alcohol/drugs
Metformin contraindications
eGFR <30, acute or chronic metabolic acidosis (includes DKA)
Metformin warnings
NOT recommended to start if eGFR 30-45 (reassess if already taking and eGFR falls <45)
VitB12 deficiency: s/sx can include peripheral neuropathy and cognitive impairment; monitor B12 levels periodically (e.g. every 1-2 years)
Metformin ADEs
GI effects (diarrhea, nausea, flatulence, cramping)
Typically transient
Metformin A1C lowering %
1-2%
Metformin weight effect
Neutral
Metformin hypoglycemia risk
No hypoglycemia
Metformin ER can leave ____ in stool
ghose tablet
Intra-arterial ____ (used for imaging studies) can increase risk of lactic acidosis. Discontinue metformin before imaging procedure. Restart metformin ___ after procedure if eGFR is stable.
Iodinated contrast media, 48hrs
Alcohol can ____ risk of lactic acidosis
increase
excessive intake, acute or chronic, should be avoided
Which can increase risk of lactic acidosis with metformin?
Iodinated contrast media
alcohol
topiramate + metformin
SUs and meglitinides MOA
stimulate insulin secretion from pancreatic beta-cells to decrease postprandial BG
Meglitinides have (faster/slower) onset and (shorter/longer) duration of action compared to SUs
faster onset (15-60min) and shorter duration of action
Name 3 older, first generation SUs (should NOT be used)
chlorpropamide, tolazamide, and tolbutamide
Meglitinide names end in “-____”
“-glinide”
SUs names start with “__” and end in “-___”
Start with G and end with “-ide”
SUs contraindications
Sulfa allergy ( not likely to cross-react)
SUs warnings
hypoglycemia
SUs ADEs
Weight gain, nausea
SUs A1C lowering %
1-2%
T/F: Efficacy of SUs increase the longer you use it
False - decreased efficacy after long-term use (as pancreatic beta-cell function declines)
Glipizide IR dose timing with meals
Take 30 min before meals
All other products taken with breakfast or first meal of the day
May need to hold doses if NPO
Glucotorol XL is an OROS formulation and can leave a ___ in stool
ghost tablet
Which SUs are not preferred in elderly (Beers criteria) d/t hypoglycemia risk
Glimepiride, glyburide
Patients with ___ deficiency can be increased risk of hemolytic anemia with SUs
G6PD
Repaglinide dose timing with meals
Take 15-30 min before meals
Nateglinide dose timing with meals
1-30 min before meals
Meglitinides contraindications
T1DM, DKA
Meglitinides warnings
Hypoglycemia, caution with severe liver/renal impairment
Meglitinides ADEs
weight gain, HA, URTIs
Meglitinides A1C lowering %
0.5-1.5%
SUs are CYP___ substrates, use caution with inducers or inhibitors
CYP2C9
___ and ___ can increase repaglinide, leading to decrease BG
Gemfibrozil and clopidogrel
Repaglinide is contraindicated with ___
Gemfibrozil
___ can increase the risk for delayed hypoglycemia when taking insulin or insulin secretagogues (SUs or meglitinides)
Alcohol
DPP-4i prevent enzyme DPP-4 from breaking down ____
incretin hormones, GLP1 and GIP
DPP-4i MOA
prevent DPP-4 breakdown of GLP1 and GIP, increase insulin release from pancreatic beta-cells and decrease glucagon secretion (decreases hepatic glucose production) from pancreatic alpha-cells
Enhance the effects of the body’s own incretins
DPP-4i names end in “-___”
“-gliptin”
Which DPP-4is require renal dose adj
Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Alogliptin (Nesina)
Which DPP-4is do NOT require renal dose adj
Linagliptin (Tradjenta)
DPP-4i warnings
Pancreatitis, severe arthralgia (joint pain), acute renal failure, hypersensitivity reactions, bullous pemphigoid (blisters/erosions requiring hospitalization)
Risk of HF wtih saxagliptin and alogliptin, but warning added for class
Alogliptin: hepatotoxicity
Which DPP-4i has warning of hepatotoxicity?
Alogliptin (Nesina)
DDP-4i ADEs
generally well tolerated, can cause nasopharyngitis, URTIs, UTIs, peripheral edema, rash
DPP-4i A1C lowering %
0.5-0.8%
DPP-4i weight effect
neutral
DPP-4i hypoglycemia risk
Low
DPP-4i and ___ have overlapping mechanisms and should be used together
GLP1RA
Saxagliptin is a major substrate of CYP___ and ___. Limit the dose to ___ with strong inhibitors including protease inhibitors (e.g. ___,____) and anti-infectives (___,___,___)
CYP3A4 and P-gp
Limit dose to 2.5mg
atazanavir, ritonavir
Clarithromycin,itraconazole, ketoconazole
Linagliptin is a major substrate of CYP___ and ___. Decreased linagliptin levels with strong inducers (e.g. ___, ___, ___, ___)
3A4 and pgp
Carbamazepine, phenytoin, rifampin, St. John’s wort
Thiazolidinediones (TZDs) MOA
Perozisome proliferator-activated receptor gamma (PPAR𝛾) agonist that increase peripheral insulin sensitivity (increase uptake and utilization of glucose by peripheral tissues, aka insulin sensitizers)
___ is currently the only TZD available in the US
Pioglitazone
TZD boxed warning
Can cause or exacerbate HR, do NOT use with NYHA class III/IV HF
TZD Warning
Edema (including macular edema), risk of fractures, hepatic failure, can stimulate ovulation (can lead to unintended pregnancy)
Increase risk of bladder cancer (do NOT use in pts with hx of bladder cancer)
TZD ADEs
Peripheral edema, weight gain, URTIs, myalgia
TZD A1C Lowering
0.5-1.4%
TZD hypoglycemia risk
Low
TZD is a major substrate of CYP___, use caution with inducers (e.g. ___) or inhibitors (e.g.___)
2C8
rifampin
gemfibrozil
When using ___ and hypoglycemia occurs, it cannot be treated with sucrose (fruit juices, table sugar, or candy); glucose tablets/gel must be used to treat hypoglycemia
Alpha-glucosidase inhibitors - acarbose or miglitol (Glyset)
Alpha-glucosidase inhibitors (acarbose, miglotiol (Glyset)) administration instructions
Each dose should be taken with first bite of each meal
Pramlintide (Symlin) hypogylcemia risk
Significant hypoglycemia risk - must reduce mealtime insulin dose by 50% when starting
Basal insulin examples
glargine
detemir
degludec
Rapid-acting insulin examples
aspart
lispro
glulisine
Short-acting insulin
regular insulin
What insulin is contraindicated in any lunch disease, including asthma or COPD?
Inhaled insulin (Afrezza)
General side effects of insulin
Weight gain
Lipoatrophy (loss of SC fat at injection site, disfigures skin)
Lipohypertrophy (accumulation of fat lumps under injection site)
Tip: Rotate injection sites and use analog insulins (lower risk than older insulins)
Most insulin vials are ___mL and most insulin pens are ___mL
10mL
3mL
Any percentage mixture of NPH and regular (or rapid-acting) can be made by mixing in a syringe. Which insulin should be drawn up first?
Draw up regular insulin (or rapid-acting, clear insulin) first
Then NPH (cloudy)
____ is a ready to use (TRU) regular insulin IV bag
Myxredlin
___ insulin is preferred for IV infusions, including parenteral nutrition; less expensive than other insulins and onset is immediate when administered as continuous IV (Note: should be prepared in non-PVC container)
Regular insulin
When should regular insulin be administered?
SC 30 min before meals
When should aspart or lispro insulin be administered?
SC 5-15 min before meals
Lispro can also be administered right after eating
Fiasp-aspart and Lyumjev-lispro can be injected with first bite or within 20 min of starting a meal
Regular U-500 has many safety risks. In what situations can you use it?
When patients require > 200 units of insulin per day
Note: U-500 insulin syringes must be prescribed to avoid errors, do NOT mix with any other insulin
GLP1RAs are typically preferred before starting insulin. When would you temporarily initiate insulin in T2DM patients?
If A1C >10% or BG ≥300
Explain starting step-approach regimen for insulin in T2DM
Basal first - 10 units SC daily or 0.1-0.2 units /kg/day (titrate)
If not at goal, add prandial - 4 units or 10% basal dose once daily prior to largest meal (titrate)
If not at goal, full basal/bolus regimen or mixed insulin
Explain starting basal-bolus insulin regimen for insulin in T1DM
Calculate TDD (0.5 units/kg/day, using TBW)
50% is bolus, 50% basal
Bolus split evenly into 3 meals
Note: if NPH and regular regimen (not preferred): split 2/3 NPH and 1/3 regular
Which parts of the insulin pump need to be replaced regularly?
insulin reservoir, tubing, and infusion set
___ insulin uses Rule of 450 and ___ insulin uses Rule of 500 for insulin-to-carbohydrate ratio (ICR)
Regular = rule of 450
Rapid-acting = rule of 500
___ insulin uses Rule of 1500 and ___ insulin uses Rule of 1800 for correction factor
Regular = rule of 1500
Rapid-acting = rule of 1800
Correction dose formula
(BG now - Target BG) / correction factor
Converting between insulins: NPH to glargine
80% of NPH dose
Converting between insulins: Toujeo to glargine or determir
80% of Toujeo dose
Converting between insulins: Rapid to Short-acting insulin
1:1 ratio
All insulin pens contain 3mL of insulin except Toujeo which is available in __ and ___
1.5mL and 3mL
Room temp stability: Humalog mix 0/50 and 75/25 pens
10 days
Room temp stability: Humulin 70/30 pen
10 days
Room temp stability: Humulin N pen
14 days
Room temp stability: Novolog Mix 70/30 pen
14 days
Room temp stability: Apidra, Humalog, Novolog, Amdelog, Lyumjev, Fiasp pens and vials
28 daysM
Room temp stability: Humalog Mix 75/25 vial
28 days
Room temp stability: Novolog Mix 70/30 vial
28 days
Room temp stability: Novolin R U-100, N and 70/30 pens
28 days
Room temp stability: Humulin R U-500 pen
28 days
Room temp stability: Lantus, Basaglar, Semglee vials and pens
28 days
Room temp stability: Humulin R U-100, N, and 70/30 vials
31 days
Room temp stability: Humulin R U-500 vial
40 days
Room temp stability: Novolin R U-100, N, and 70/30 vials
42 days
Room temp stability: Levemir vial and pen
42 days
Room temp stability: Tresiba pen
56 days
Room temp stability: Toujeo pen
56 days
Use a ___ insulin syringe for < 30 units
0.3 mL
Use a ___ insulin syringe for 30-50 units
0.5 mL
Use a ___ insulin syringe for 51-100 units
1mL
What color are U-500 syringes vs U-100 syringes caps?
U-500 are GREEN
U-100 are ORANGE
Higher the gauge, (thicker/thinner) the needle
Thinner
S/sx of hypoglycemia
Dizziness, anxiety/irritability, shakiness, HA, diaphoresis (sweating), hunger, confusion, nausea, ataxia, tremors, palpitations/tachycardia and blurred vision
(Severe = seizures, coma, and death)
Beta-blockers, especially if ____, can cause hypoglycemia and mask adrenergic symptoms. ___ and __ are NOT masked.
Non-selective
Sweating and hunger are NOT masked
Drug list that increase BG
Beta-blockers (+/-)
Thiazide and loop diuretics
Tacrolimus, cyclosporine
Protease Inhibitors
Quinolones (+/-)
Antipsychotics (e.g. olanzapine, quetiapine)
Statins
Steroids (systemic)
Cough syrups
Niacin
Others: Azole antifungals (systemic), beta-agonists, octreotide (+/-)
Drug list that decrease BG
Beta-blockers (+/-)
Quinolones (+/-)
Tramadol
Others: linezolid, octreotide (+/-), pentamidine, quinine
Inpatient target BG range
140-180
DKA can be recognized by 3 things: ___, ___, and ___
BG > 250
Ketones (urine and serum, “fruity breath”), abdominal pain, N/V, dehydration
Anion gap (arterial pH <7.35, anion gap > 12)
DKA is more common in Type __ DM while hyperosmolar hyperglycemic state (HSS) is more common in Type __ DM
DKA = T1DM
HHS = T2DM
Pirmary cause of HHS is ___
illness that leads to less fluid intake
HHS is recognized by 4 things: ___, ___, ___, and ___
Confusion ,delirium
BG > 600 with high serum osmolality > 320 mOsm/L
Extreme dehydration
pH > 7.3, bicarbonate > 15 mEq/L
DKA and HHS treatment
Primary = fluids
Regular insulin infusion (0.1 units/kg bolus and then 0.1 units/kg/hr cont infusion OR 0.14 units/kg/hr continuous infusion)
Prevent hypokalemia - monitor K
Treat acidosis if pH <6.9 (sodium bicarb prn)
Regular insulin infusion dosing (2 ways)
- 0.1 units/kg bolus, 0.1units/kg/hr continuous infusion
- 0.14 units/kg/hr continuous infusion (no bolus)
Which DM meds should be avoided: cancer (thyroid, including medullary thyroid carcinoma)
GLP-1 agonists, GLP-1/GIP agonists
Which DM meds should be avoided: Gastroparesis, GI disorders
GLP-1RA, GLP-1/CIP agonists, pramlintide
Which DM meds should be avoided: Genital infection/UTI
SGLT2i
Which DM meds should be avoided: HF
TZDs, alogliptin, saxagliptin
Which DM meds should be avoided: hypoglycemia
insulin, SU, meglitinides, pramlintide
Which DM meds should be avoided: hypotension/dehydration
SGLT2i
Which DM meds should be avoided: hypokalemia
insulin
Which DM meds should be avoided: Ketoacidosis
SGTL2i (can occur when BG <250); increased risk with acute illness, dehydration, renal impairment – d/c prior to surgery to reduce risk
Which DM meds should be avoided: Lactic acidosis
Metformin; increased risk with renal impairment, alcoholism, hypoxia
Which DM meds should be avoided: osteopenia/osteoporosis
Canagliflozin (Invokana) (decreased BMD, fractures), TZDs (fractures)
Which DM meds should be avoided: Pancreatitis
DPP-4i, GLP1RA, GLP-1/GIP agonists
Which DM meds should be avoided: Peripheral neuropathy, PAD, foot ulcers
canagliflozin (Invokana)
Which DM meds should be avoided: Sulfa allergy, severe
SU consider avoiding or use cautiously
Which DM meds should be avoided: renal insufficiency (eGFR or CrCl <30)
Metformin, exenatide, glyburide; may need to start insulin at lower dose
Which DM meds should be avoided: weight gain/obesity
SU, meglitinides, TZDs, insulin
