Type 2 Diabetes Initial Oral Therapy Flashcards
Metformin
Slight risk reduction
- Pretty safe
Acarbose
Slight risk reduction
- Causes serious GI side effects
Pioglitazone
Strongest risk reduction
- Causes heart failrues
Rosiglitazone
Strong risk reduction
- Causes CV side effects (No longer on market)
Ramipril
No significant difference
Muscle and Liver
- Diabetes Pathophysiology
- Drugs
Insulin Resistance
Decrease Insulin Resistance
- Thiazolidinediones
Pancreatic Beta Cells
- Diabetes Pathophysiology
- Drugs
Decreases Insulin Secretion
Increases Insulin Secretion
- Thiazolidinediones
- GLP1ra
- DPP4i
- Sulfonylureas
- Non-sulfonylurea Secretagogues
- Insulin
Liver
- Diabetes Pathophysiology
- Drugs
Increase Hepatic Glucose Production
Decreases Hepatic Glucose Production
- Metformin
- Thiazolidinediones
- GLP1ra
- DPP4i
Small Intestine
- Diabetes Pathophysiology
- Drugs
Decreases Incretin Hormone Secretion
Increases Incretin Hormone Secretion
- GLP1ra
- DPP4i
Alpha-glucosidase Inhibitors (Acarbose)
- Inhibits breakdown of complex carbohydrates
Adipose Tissue
- Diabetes Pathophysiology
- Drugs
Increases Release of Free Fatty Acids
Prevents release of free fatty acids
- Thiazolidinediones
Pancreatic alpha cell
Increases Glucagon Secretion
- GLP1ra
- DPP4i
Kidney
Increases Glucose Reabsorption by Sodium/Glucose Co-Transporter 2
Inhibits SGLT2
- SGLT2i
Brain
Neurotransmitter Dysfunction
- GLP1ra
What Type 2 Diabetes Drugs have been removed from practice
Thiazolidinediones (Heart Attack/Failure)
Alpha-glucosidase Inhibitors (Nasty GI AE)
- Acarbose
Sulfonylurea (High Hypoglycemia Risk)
Non-Sulfonylurea Secretagogues
Goals of Therapy
- Type 2 Diabetes
Treat Normally:
- Maintain Targets (A1c/FPG/2-Hour Post-Prandial Blood Glucose)
Treat Agressively
- Reduce Microvascular and Macrovascular complications
- Minimize risk of hypoglycemia
- Maintain targets for CV risk factors
Type 2 Diabetes Guidelines
- Initial Therapy
- Healthy Behaviour Interventions
- Can add Metformin if needed
- Can add drugs for CV and Kidney - Add Antihyperglycemic Therapy if targets not reached within 3 months
- Add Metformin before other therapies - A1c is above 1.5% target
- Combine Metformin with a second antihyperglycemic agent - If patient has metabolic decompensation
- Start Insulin with or without Metformin
How long to reach target for Type 2 Diabetes
3-6 months
How much can Metformin shift A1c
By 1.5%
Metabolic Decompensation
- Symptoms
Marked Hyperglycemia
Ketosis
Unintentional Weight Loss
Initial Choice of Therapy
- A1c is less than 1.5% over target
Initiate healthy behaviour interventions and start Metformin if not at target in 3 months
OR
Start Metformin with Initiate healthy behaviour interventions
Initial Choice of Therapy
- A1c is greater than 1.5% over target
Start metformin with Healthy Behaviour Interventions AND Consider second concurrent agent
Initial Choice of Therapy
- When to start Insulin
Signs of Hyperglycemia and/or Metabolic Decompensation:
- Polyuria
- Polydipsia
- Weight Loss
- Volume Depletion
Start Insulin +/- Metformin
Why is Metformin the Initial Agent
- Efficacy in Lowering A1c
- Favourable Side Effect Profile
- Low Risk of Hypoglycemia
- Weight Gain is minimal/neutral - Cost Effective
Metformin
- Clinical Evidence
Only lowers blood sugars
- Does not reduce CV events or reduce progression of diabetes
Trials that do show CV benefits did not have many participants
Intolerances of Metformin
GI Side Effects (Nausea, Vomiting, Flatulence, Abdominal discomfort)
- Should go away after 2 weeks
Metallic Taste
- Does not go away
Renal Impairment
- Can not use if eGFR is less than 30
Alternatives to Metformin
SGLT2i
DPP4i
GLP1ra
- Oral agents are expensive
- Injectables are an option
Sulfonylureas are not used anymore
Dosing of Antihyperglycemic Agents
Better to use combinations with submaximal doses rather than max dose of monotherapy
- Will produce more rapid and improved glycemic control
- Will cause less side effects
