Block 3: Diabetes III-T2DM Flashcards
What are the treatment options for T2DM?
- Lifestyle mod: diet and exercise
- Oral agents, insulin, injectable agents
- Treat co-morbid conditions to prevent complications
What is the rule of thumb when it comes to diabetes treatment?
Tx should always be directed at the individual patient
What is the diabetes tx option for patients with ASCVD?
Add GLP1 with proven CVD benefit:
* Dulagutide
* Liraglutide
* Semaglutide
OR
Add SGLT-2 inhibitor with proven CVD benefit:
* Canagliflozin
* Empagliflozin
What is diabetes tx option for patients with HF?
Add SGLT-2 inhibitor with proven HF benefit
* Canagliflozin
* Empagliflozin
* Dapagliflozin
* Ertugliflozin
What is diabetes tx option for patients with CKD?
Add a SGLT-2 inhibitor (Preferred) with evidence of slowing CKD progression:
* Canagliflozin
* Empagliflozin
* Dapagliflozin
OR
Add a GLP-1 with proven CKD benefit, if SGLT-2 inhibitor is contraindicated or NOT tolerated:
* Dulagutide
* Liraglutide
* Semaglutide
What is diabetes tx option for patients with hypoglycemia?
- Metformin
- TZD
- DDP-4
- GLP-1 RA
- SGLT2
What is diabetes tx option for patients with weight management?
- GLP1
- SGLT2
- Metformin
What is diabetes tx option if cost was an issue?
- Metformin
- SU
- TZD
What is considered first line for T2DM?
Metformin
What should you consider when using metformin?
- Initial pharmacologic agent for the treatment of hyperglycemia (alone or in combo)
- Continue as long as tolerated and NOT contraindicated
- Check B12 levels periodically
Dual therapy initially when A1c is >2.5 mg/dL above glycemic goal
What should you consider when using insulin?
- Evidence of catabolism (weight loss)
- Sx of hyperglycemia
- A1c > 10% or blood glucose >300 mg/dl
What do are the factors you need to consider when selecting an appropriate diabetic tx?
- Tx goals
- Efficacy
- Co-morbidities
- Snergy of MOA
- ADRs and tox
- PO vs inj
- Risk of hypoglycemia
- Impact on weight
- COst
What do you do when combo PO therapies arent sufficient to reach A1c goal?
- Consider a GLP 1 (Preferred) unless CI
- Initiate insulin with basal insulin unless CI
What is initiation dose for prandial insulin?
4 units/day or 10% of basal insulin dose
What is the titration dose for prandial insulin?
Increase dose by 1-2 units or 10-15% BID
What is basal insulin?
- Constant low levels
- Controls glucosse levels in the fasting state
What is bolus insulin?
- Intermittent spikes in response to food
- Controls glucose levels in the post-prandial state
What products can we use for basal?
Intermediate or Long-Acting Insulin
What is the T2DM starting dose of Basal?
Start with low dose at bedtime:
10 units or 0.1-0.2 IU/kg/day
How should you titrate basal for T2DM?
- Set FPG target
- Use titration algorithm to adjust insulin dose
* Increase dose according to the algorithm q3 days until target is reached
* Avoid hypoglycemia (decrease dose by 10-20%, if needed)
May continue PO agents at same dose
How do you convert NPH and regular insulin to long acting (Lantus) and Rapid acting (Humalog)?
Start the long-acting insulin at 80% of the total daily NPH dose
Start the rapid-acting insulin at 1:1 unit per unit per dose (regular)
What does standard basal insulin dosing need to consider?
- 50% of total daily insulin needs
- Constant kinetic profile needed
- Lowers glucose all day long
What does standard bolus insulin dosing need to consider?
- 10-20% of total daily insulin needs at each meal
- Kinetic profile should peak quickly then disappear quickly
- Lowers glucose after meals
When would you consider progressing basal bolus insulin dosing?
- When FPG is okay, but PPG elevated or A1c >7%
- Add rapid or short acting insulin at mealtime
- Continue long acting insulin at bedtime
- Stop Sulfonylureas
- Continue metformin or TZDs
When would you consider adding prandial mealtime or bolus insulin?
- Add rapid or short acting insulin at mealtime
- Initial dose: 4 or 5 units SubQ before a meal, May start with 1 mealtime dose with the largest meal of the day
- Titrate to target
- Avoid hypoglycemia
