Current Issues in Diabetes Management Flashcards
Metformin
- Use in Type 1 Diabetes
- Reduces insulin requirement
- Reduces/Maintains weight
- Reduces A1c if started at diagnosis (Mixed effects otherwise)
AE: GI side effects
Metformin
- When to use
Can help lower insulin use and decrease weight gain in overweight patients
Can help lower insulin use and help with weight in pediatrics
- Stronger efficacy in reducing A1c in younger patients
SGLT2i
- Use in Type 1 Diabetes
- Weight loss
- Better glycemic control
- Reduction of insulin dose
AE: Diabetic Ketoacidosis
- Ensure to select patient carefully to assess risk factors and provide monitoring techniques
SGLT2i
- Diabetic Ketoacidosis Symptoms
High blood sugar
Thirst
Nausea
Vomiting
Abdominal Pain
Confusion
SGLT2i
- Who is affected by Diabetic Ketoacidosis
More common in Type 1
Can occur even in euglycemic patients
SGLT2i
- Limiting Factor
Risk of DKA is the reason why SGLT2i have not been approved for Type 1 diabetes
- Is not the primary cause, just exacerbates other conditions/patient factors
GLP-1 Receptor Agonists
- Use in Type 1 Diabetes
- Reduce insulin need
- Improve glycemic control
- Reduces weight
- Variable effectiveness in patients
AE:
- Diabetic Ketoacidosis (Less than SGLT2i)
- Nausea
- Hypoglycemia (When used with insulin)
GLP-1 Receptor Agonists
- When to use
Most effective with overweight patients with detectable C-peptide levels
- Early initiation produces great results and can even eliminate insulin dependency later
Low Carbohydrate Diet
- Effects of nutrition therapy
Switching to low glycemic index carbohydrates
- Can reduce A1c by 1.0 - 2.0%
Low Carbohydrate Diet
- Calorie Intake
For people that are obese or overweight
- Reduce calorie intake to maintain healthier body to reach treatment goal
Low Carbohydrate Diet
- Consistiency
Spacing meal consumption and carbohydrate intake can help control blood glucose and weight
Low Carbohydrate Diet
- Registered Dietician
People with diabetes should get nutrition counseling
Low Carbohydrate Diet
- Patient decision
In the end patient should decide the dietary plan best suited to them
Low Carbohydrate Diet
- Recommendations
Less than 45% of daily energy from carbs
Low Carbohydrate Diet effect on Diabetes Management
Increased risk of Hypoglycemia if used with Insulin, sulfonylyrea, megltinides
- Have to decrease dose
Increased risk of DKA if used with SGLT2i
- Usually stop in community setting
Need to weight benefits and risks:
- Metformin, GLP1ra, DPP4i, acarbose
Need constant blood glucose monitoring
Deprescribing
- Indications
Risk of hypoglycemia
Risk of other antihyperglycemic adverse effects
Renal clearance decreases
Harm is more likely than benefit
- Frail, dementia, limited life expectancy
Deprescribing
- Medications with risk of hypoglycemia
Insulin (NPH and Regular have highest risk)
Sulfonylurea (Glyburide has highest risk, gliclazide has lower risk)
Meglitinides (Low risk)
Deprescribing
- Medications that are renally cleared
Metformin
Sulfonylurea
Insulin
Deprescribing
- Medications with other potential adverse effects
SGLT2i can cause DKA
Drug-Disease Interactions
- Cancer
- Metformin: Lower risk
- Insulin: Long acting analogue has risk
- Pioglitazone: Bladder cancer
Drug-Disease Interactions
- Drugs that cause diabetes
- Atypical Antipsychotics
- Antidepressants
Drug-Disease Interactions
- Drugs that increase blood glucose
Beta Adrenergic Agonists (Decongestants)
Glucocorticoids (Prednisone)
Protease Inhibitors (Ritonavir)
Calcineurin Inhibitors (Cyclosporine)
Thiazide Diuretics ()
Drug-Disease Interactions
- Beta Blockers
Medication Induced Hyperglycemia
- Blocking of epinephrine prevents release of insulin
Can exacerbate hypoglycemia
- Inhibits hepatic glucose production
- Masks symptoms of hypoglycemia (tremors, palpitations, tachycardia)
- Patient will still sweat
Emerging Treatments for Type 2 Diabetes
Tirzepatide
- Both GLP1ra and GIP
Insulin Icodec
- Once weekly insulin formulation, similar efficacy to daily insulin
Generic DPP4i and SGLT2i
Biosimilar Insulin
Biologic and Biosimilar
To ensure tracability record brand name and active ingredient name
Only interchange with a biosimilar with explicit knowledge and consent from patient and their health care provider
