Latest 2023 / 2024
Type 1 Diabetes
- All are on insulin
Type 2 Diabetes: Step 1
- Lifestyle changes plus metformin
Type 2 Diabetes: Step 2
- Lifestyle changes plus metformin and add a second drug such as:
Thiazolidinedione, dipeptidyl peptidase-4 (DPP-4) inhibitor, sodium- glucose cotransporter 2 (SGLT-2) inhibitor, glucagon-like peptide -1 (GLP-1) receptor agonist, sulfonylurea or basal insulin if goals are not achieved.
Type 2 Diabetes: Step 3
- Three drug combination (inclusive of metformin)
Type 2 Diabetes: Step 4
- Three drug therapy and basal insulin fails to reach goals after 3-6
months. Injectable regimen inclusive of insulin and possibly GLP-1 receptor agonist. 1 / 3
Diabetes EXCEPTIONS:
- Patients with A1C greater than 9% or greater start dual therapy
(start at step 2) and patients with A1C greater than 10% or fasting blood glucose of 300 or more/symptomatic may be started on combination injectable therapy immediately.
Time interval for hbA1C recheck.
- Every 3 months until A1C drops below 7% and then every 6 months
after.
Action of Insulin
- Anabolic-promotes conservation of energy and buildup of energy
stores (Glycogen)
- Stimulates cellular transport (uptake) of glucose, amino acids,
nucleotides & K
- Promotes synthesis of complex molecules.
- Promotes cellular growth and division
- Energy conservation
Pioglitazone Contraindications
- Contraindicated in patients with severe heart failure and should be
used with caution in patients with mild heart failure.should not be used in patients that have active bladder cancer or a history of bladder cancer.
GLP-1: Glucagon-like Peptide-1 Receptor Agonist
- augment effects of incretin hormone GLP-1 can increase insulin
product and inhibits postprandial glucagon release. 2 / 3
TZD: (thiazolidinedione)
- Decreases insulin resistance
DPP-4i: Dipeptidyl Peptidase-4 Inhibitors (Gliptins)
- Inhibits DPP-4 activity and increases active incretin concentration
which results in increase insulin secretion and decreased glucagon.
SGLT2: Sodium-Glucose Cotransporter 2 Inhibitors
- Blocks glucose reabsorption by the kidneys and the proximal
nephron and increases the release of glucose in the urine. SGLT2i:
limits reabsorption of glucose in the renal tubules
Sulfonylureas
- Acts primarily by stimulating the release of insulin from pancreatic
islets. They promote insulin release by binding with and thereby blocking adenosine triphosphate (ATP)- sensitive potassium channels in the cell membrane. As a result, the membrane depolarizes, thereby permitting influx of calcium, which in turn causes insulin release. The extent of release is glucose dependent and diminishes when plasma glucose declines.
*Should NOT be used in pregnancy or in renal or hepatic impairment.
Which drug class should be considered for diabetes prior to insulin
- Metformin.
Total daily insulin dose calculation
- Includes basal insulin replacement and bolus insulin replacement.
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