Clinical Guidelines for Type 2 Diabetes

 

Algorithm for Rx of Type 2's

Biguanides:-
Glucophage®/metformin

DPP-4 Inhibitors:-
Januvia/sitagliptin

GLP-1 Agonists:-
Byetta®/exenatide

Insulins:-
Basal-Bolus

Latest News

Lipid Lowering Agents:-
Statins, Fibrates, Fish Oils, Niacin

Sulfonylureas/meglitinides:-
Amaryl®/ glimepiridide, Micronase®/Glynase®/Diabeta®/glyburide, Glucotrol®/glipizide,Prandin®/repaglinide

Thiazolidinediones:
Rezulin®/troglitazone, Avandia®/rosiglitazone, Actos®/pioglitazone data set

Weight Loss Therapy:-
Accomplia®/rimonabant, Byetta®/exenatide, Xenical®/tetrahydolipistatin, Bariatric Surgery

Reload The National Diabetes Center Frames
Home Page

 

 

 




a-Glucosidase Inhibitors (Precose)

 

Recommendations:-

(1) Consider first-line as add-on in the obese diabetic failing metformin.

(2) Consider in any diabetic patients with IGT and/or elevated post-prandial sugars who has normal creatinine levels

(3) Consider for weight maintenance programs

Top

 

 

 


DPP-4 Inhibitors (Januvia)

Recommendations:-

(1) Consider first line in the non-obese diabetic.

(2) STOP when failure occurs. Do NOT add on other oral agents. Switch to insulin

Top

 

 

 

 

 



GLP-1 Agonists

Recommendations:-

(1) Add on to metformin in the obese diabetic who is failing metformin

(2) Add INSULIN when failure occurs (to minimize weight gain)


Top

 

 

 

 

 


Insulins

Recommendations:-

(1) Use ASAP when single oral agents fail

(2) Only combine with metformin, acarbose, or exenatide

(3) Use long-acting analog initially (Lantus)

(4) Add on short-acting analog for post-prandial control (Epidra)

(5) AVOID Inhaled Insulin

 

 

Top


Metformin (Glucophage) 

Recommendations:-

(1) Use metformin as initial therapy in the obese (BMI>30) Type 2 diabetic.

(2) Use metformin with caution in combination with sulfonylureas or meglitinides. Avoid adding sulfonylureas or meglitinides in patients with coronary heart disease. Avoid hypoglycemia.

(3) Do not use metformin if the serum creatinine is over 1.4 mg/dl or in the presence of any decrease in myocardial contractility. Use with extreme caution in the elderly population.

(4) Monitor creatinine every 3 months with HbA1c.

Top

 

 


Weight Loss Therapy:

Recommendations:-

(1) Use Accomplia (rimonabant)first line one approved

(2) Until then, consider Xenical as first-line. AVOID sibutramine.

(3) Consider Bariatric surgery in the morbidly obese

(4) Consider acarbose for weight maintenance


Top

 

 

 

 




Reload The National Diabetes Center Frames
Home Page






 

Sulfonylurea 

Recommendations:-

(glyburide/Micronase®/Glynase®/Diabeta®-; glipizide/Glucotrol®;repaglinide/Prandin®)
 
 

(1) Try to AVOID sulfonylureas if possible especially if coronary heart disease is suspected.

(2) Use sulfonylureas cautiously when in combination with metformin/Glucophage and try to avoid hypoglycemia.

(3) Utilize SASKA's (selective ATP-sensitive K-channel antagonists) such as glimepiride or meglitinides preferentially over non-SASKA sulfonylureas - and only if necessary as monotherapy in the non-obese.
  


Reload The National Diabetes Center Frames
Home Page


ThiazolidinedioneRecommendations

(1) Try to AVOID. If you cannot, then you must be scrupulous in decreasing cardiovascular risk

Consider Avandia® (rosiglitazone) or Actos® (pioglitazone) for initial monotherapy in the non-obese

Consider Actos® (pioglitazone) if LDL-cholesterol is elevated AND no other drugs metabolized by the p-450 3A3,4,5 system are used.

***Avoid Actos® (pioglitazone) in combination with statins as CPK elevations and/or myositis and/or rhabdomyolysis have been reported similar to the fibrate + statin combination. [Actos® (pioglitazone) may have innate PPAR-alpha activity similar to the fibric acid derivatives.]***

Otherwise use Avandia® (rosiglitazone) and add an HMG-coA Reductase Inhibitor (except pravastatin) if LDL-cholesterol is elevated.

(2) Consider Avandia® (rosiglitazone) or Actos® (pioglitazone) for combination therapy with metformin in the obese metformin secondary failure population. Consider Actos® (pioglitazone) if LDL-cholesterol is elevated AND no other drugs metabolized by the p-450 3A3,4,5 system are used. Otherwise use Avandia® (rosiglitazone) and add an HMG-coA Reductase Inhibitor (except pravastatin ) if LDL-cholesterol is elevated.

(3) Follow FDA guidelines. Monitor CPK as well as LFT's periodically.

(4) Do not use thiazolidinediones in the presence of heart failure. Avoid rosiglitazone in patients with Type II hyperlipoproteinemias unless on hypolipidemic therapy (except pravastatin).

(5) Discontinue if edema, heart failure, anemia, CPK elevation, myositis, transaminase elevation, or weight gain (>3%) occurs.

(6) Remember that the allele frequency of the PPAR gamma 2 missense mutation Pro12Ala variant is 0.12 in Caucasian Americans, 0.10 in Mexican Americans, 0.08 in Samoans, 0.03 in African Americans, 0.02 in Nauruans, and 0.01 in Chinese .

Comparison Chart

  Avandia® Actos®
     
Potency/mg 5.625x  1x
Edema   + ++
Anemia + +   
Wt gain        +    +
LDL increase ++  (p<0.05) ± (n.s.)
Triglyceride decrease   ±(n.s.) ++ (p<0.05)
Drug interactions       + +++
Monotherapy ++ ++
Rx+Metformin ++++ +++
Rx+Insulin Not approved +++
Rx+SFU  Not approved Not recommended
Use in Heart Failure Avoid Avoid
Cardiomegaly (CXR) [data requested] 0.197% (p<0.1)
Dosing Interval b.i.d except high dose metformin combination o.d. all indications
Costs  $$$ $$$


Reload The National Diabetes Center Frames
Home Page

 


Lipid Therapy 

Recommendations:-

(1) Regard all diabetics as having established coronary artery disease

(2) Use NCEP II/III guidelines to keep LDL-cholesterol below 100 mg/dl N.B. No benefit has been demonstrated from further lowering LDL-cholesterol and the risks of myopathy (myositis/rhabdomyolysis) are considerably increased.

(3) Do NOT follow NCEP III recommendations for triglyceride elevations. Repeat, do NOT follow NCEP III recommendations for triglyceride elevations. AVOID ALL FIBRIC ACID DERIVATIVES, if at all possible.

(4) DO ADD fish oils (omega-3 fatty acids/EPA/DHA) at doses of 6-9g/day for fasting triglycerides above 120 mg/dl

(5) DO ADD Niacin (Nicotinic acid) but beware of myositis/rhabdomyolysis when used in combination with statins

Reload The National Diabetes Center Frames
Home Page
 
 


 

| Contact Us | 

Reload The National Diabetes Center Frames
Home Page

©1995-1999 The National Diabetes Center. All rights reserved. All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions.