Biguanides:-
Glucophage®/metformin
alpha-Glucosidase Inhibitors:-
SGLT-2 antagonists:-
Lipid Lowering Agents:-
Statins, Fibrates, Fish Oils, Niacin
| Clinical Guidelines for Type 2 Diabetes |
| Algorithm for Rx of Type 2's
Biguanides:- alpha-Glucosidase Inhibitors:- SGLT-2 antagonists:- Lipid Lowering Agents:- |
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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
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
Recommendations:-
(1) Add on to metformin in the obese diabetic who is failing metformin
(2) Add BASAL INSULIN adjusted to keep FBS>100 mg/dl
(3) D/C Short acting Insulins and Insulin secretagogues
Recommendations:-
(1) Use when c-peptide is > 2.5 to reduce incidence of DKA
(2) Add on to metformin in the obese diabetic who is failing metformin
(3) Add BASAL INSULIN adjusted to keep FBS>100 mg/dl
(4) D/C Short acting Insulins and Insulin secretagogues
Recommendations:-
(1) Use ASAP when oral agents fail
(2) Only combine with metformin, acarbose, or GLP-1
(3) Use long-acting analog initially (Lantus)
(4) Avoid short-acting analogs
(5) AVOID Inhaled Insulin
Metformin (Glucophage)Recommendations:-(1) Use metformin as initial therapy in the obese (BMI>30) Type 2 diabetic. (4) Monitor creatinine every 3 months with HbA1c. 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 |
| Sulfonylurea
Recommendations:- (glyburide/Micronase®/Glynase®/Diabeta®-; glipizide/Glucotrol®;repaglinide/Prandin®) (1) Try to AVOID sulfonylureas if possible especially if coronary heart disease is suspected. (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.
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. Comparison Chart
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