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FM24 Family Medicine
Common Presenting Problems
Toronto Notes 2019
Figure 9. Types of insulin preparation
Hours After Injection
At diagnosis of Type 2 DM
glulisine, aspart, lispro regular
NPH
0 6 12 18 24
glargine, detemir
A1C <8.5%
If not at glycemic target (2-3 mo)
A1C ≥8.5%
Start metformin immediately Consider initial combination with another antihyperglycemic agent
If not at glycemic targets
Symptomatic hyperglycemia with metabolic decompensation
Initiate insulin ± metformin
Start lifestyle intervention (nutrition therapy and physical activity) ± Metformin
Start or increase metformin
Add another agent best suited to the individual by prioritizing patient characteristics:
PATIENT CHARACTERISTIC
CHOICE OF AGENT
Priority: Clinical cardiovascular disease
• Degree of hyperglycemia
• Risk of hypoglycemia
• Overweight or obesity
• Cardiovascular disease
• Comorbidities (renal, CHF, hepatic) • Preferences and access to treatment
SGLT2 inhibitor with demostrated CV outcome benefit
• Consider relative A1C lowering
• Rare hypoglycemia
• Weight loss or weight neutral
• Effect on cardiovascular outcome
• See therapeutic considerations, consider eGFR • See cost column; consider access
Class
α-Glucosidase inhibitor (acarbose)
Incretin agents: DPP-4 inhibitors
GLP-1R agonists Insulin
Insulin secretagogue; Meglitinide
Sulfonylurea SGLT2 inhibitors
Thiazolidinediones
Weight loss agent (orlistat)
A1C = glycated hemoglobin alo = alogliptin
CHF = congestive heart failure DPP-4 = dipeptidyl peptidase 4
Relative Hypoglycemia A1C
Lowering
Weight
Neutral to
Neutral to
  
 
 
Effect in Cardiovascular Outcome Trial
Neutral (alo, saxa, sita)
Neutral (lixi) Neutral (glar)
Superior (empa in T2DM patients with clinical CVD)
Neutral
Other Therapeutic Considerations Cost
Improved postprandial control, GI side-effects $$
Caution with saxagliptin in heart failure $$$
GI side effects $$$$ No dose ceiling, flexible regiments $-$$$$
Less hypoglycemia in context of missed meals, $$ but usually requires TID to QID dosing
Gliclazide and glimepiride associated with less $ hypoglycemia than glyburide
Genital infections, UTI, hypotension, dose- $$$ related changes in LDL-C, caution with renal dysfunction and loop diuretics, dapagliflozin
not to be used if bladder cancer, rare
diabetic ketoacidosis (may occur with no hyperglycemia)
CHF, edema, fractures, rare bladder cancer $$ (ploglitazone), cardiovascular controversy (rosiglitazone), 6-12 wk required for max effect
Add another class of agent best suited to the individual (classes listed in alphabetical order):
 Rare
 Rare
 to  Rare  Yes  Yes
 Yes  to  Rare
 Rare  None
empa = empagliflozin
GI = gastrointestinal
glar = glargine
GLP-1 = glucagon-like peptide 1
GI side-effects
$$$
If not at glycemic targets
Note: Physicians should refer to the most recent edition of the Compendium of Pharmaceuticals and Specialties (Canadian Pharmacists Association, Ottawa, Ontario, Canada) for product monographs and for detailed prescribing information
Figure 10. Management of hyperglycemia in type 2 diabetes
lixi
saxa = saxagliptin
sita = sitagliptin
TZD = thiazolidinedione
= lixisenatide
Add another agent from a different class; add or intensify insulin regimen
Make timely adjustments to attain target A1C within 3-6 mo
With permission of: Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Pharmacologic Management of Type 2 Diabetes. Can J Diabetes 2013;37:S61-S68
© Leanne Chan 2011
Plasma Insulin Levels