There are a slew of medications available for type II diabetes. The American Association of Clinical Endocrinologists has put together a nice algorithm for management (click on the PPT links).
Rather than go through the pharmacokinetics, mechanism, and granular details of each medication, here are some tips that I thought were important:
Lifestyle changes are the first thing that should be tried. In patients with newly discovered/early diabetes, take a cue from Will Ferrell and be, be, aggressive! Have patients record not only their blood glucose, but also what they ate and how much they exercised.
- You can go up to 2000 mg/day, and it’s cheaper to prescribe 500 mg increments rather than the 1000 mg.
- Start with 500 mg once daily, and work up to the max dose if you have to
- Monitor creatinine: avoid prescribing in men with a Cr<1.4 and women with Cr <1.5
- You may have to add on B12 supplementation, as metformin can interfere with B12 absorption
The max benefit of sulfonylureas (glimepiride, glipizide, etc) are reached at half the max dose….so there’s no need to prescribe above that.
GLP-1 agents (exenatide is an example) have systemic effects on the brain, liver, and pancreas that make it really effective for treating diabetes. Patients can even lose weight! Avoid prescribing in patients with pancreatitis or a family history of medullary thyroid cancer, since this med has a tiny association with both. Barriers to using this med include that it is a subcutaneous injection, and is expensive.
DPP4 inhibitors (such as Januvia) raise GLP-1 to physiologic levels. They’re pretty decent, but won’t have quite the same effect that GLP-1 agents have. However, they can be taken by mouth, and are cheaper.
TZDs (like pioglitazone and rosaglitazone) may be associated with adverse cardiovascular events and are contraindicated in patients with NYHA class III/IV CHF- there is a black box warning.
SGLT-2 inhibitors (dapafliglozin, for example) block sodium reabsorption in the glomerulus. This results in the patient peeing out more glucose, which, logically, is associated with diuresis, risk of dehydration, and questionably, greater risk of UTIs. The FDA has also recently warned about an increased risk of ketoacidosis.