|Clinical Guidelines for Type 2 Diabetes|
|Algorithm for Rx of Type 2's|
Reload The National Diabetes Center
a-Glucosidase Inhibitors (Precose)
(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
(1) Consider first line in the non-obese diabetic.
(2) STOP when failure occurs. Do NOT add on other oral agents. Switch to insulin
(1) Add on to metformin in the obese diabetic who is failing metformin
(2) Add INSULIN when failure occurs (to minimize weight gain)
(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
(4) Monitor creatinine every 3 months with HbA1c.
(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
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.
(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 .
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