Glucose control and vascular complications in veterans with type 2 diabetes [published correction appears in N Engl J Med. Lifestyle and nutrition counseling is essential for patients with prediabetes or new-onset diabetes to slow the progression of type 2 diabetes. The intensive intervention consisted of baseline diabetes education; frequent individual and group counseling from dietitians, behavioral psychologists, and exercise specialists; caloric restriction; and regular exercise.
Participants in the intensive intervention group achieved an average weight loss of 8. A subsequent study analyzed the weight-loss strategies used by the patients in the intensive intervention group and found that weekly self-weighing, regular consumption of breakfast, and reduced intake of fast food were associated with a lower body mass index in overweight patients. Medications for type 2 diabetes target multiple sites throughout the body to lower blood glucose levels eTable B.
The ADA recommends starting therapy with metformin, because it is the only medication shown to reduce mortality and complications in randomized controlled trials RCTs. Decrease hepatic glucose production; increase insulin sensitivity peripherally; and decrease intestinal absorption of carbohydrates. Lower renal threshold for glucose and reduce reabsorption of filtered glucose from tubular lumen; increase urinary glucose excretion.
Increase hepatic glucose uptake; decrease hepatic glucose production; increase insulin sensitivity in the muscle, adipose tissue.
American Diabetes Association. Standards of medical care in diabetes— Diabetes Care. Chapter Endocrine pancreas and pharmacotherapy of diabetes mellitus and hypoglycemia. Flatulence, diarrhea, abdominal bloating. Nausea, diarrhea, abdominal bloating. Estimated GFR 30 to 44 mL per minute per 1. Dipeptidyl-peptidase-4 inhibitors.
Linagliptin does not require dosage adjustment in renal insufficiency. Glucagon-like peptide-1 receptor agonists. Nausea, vomiting, sense of fullness. Boxed warning for personal or family history of medullary thyroid carcinoma; patients with multiple endocrine neoplasia type 2. Sodium-glucose cotransporter 2 inhibitors. Increased urinary tract and genital infections, increased low-density lipoprotein cholesterol level.
Dosage adjustment required in renal insufficiency. Information from references 1 and 9. Acarbose Precose. Alogliptin Nesina. Exenatide Byetta, Bydureon. Bydureon: 2 mg once weekly. Nateglinide Starlix.
Canagliflozin Invokana. Glimepiride Amaryl. Pioglitazone Actos. Metformin is the initial agent to reduce microvascular complications, assist in weight management, reduce the risk of cardiovascular events, and reduce the risk of mortality in patients with type 2 diabetes. Metformin is either weight neutral or induces moderate weight loss, and it reduces mortality and cardiovascular events in patients with type 2 diabetes.
Type 2 diabetes: pharmacological management strategies | Learning article | Pharmaceutical Journal
To combat potential gastrointestinal adverse effects, physicians should prescribe a lower dose initially and titrate slowly or use the extended-release formulation to improve tolerance. Patients should be counseled to take metformin with a meal to lessen the likelihood of adverse effects. According to prescribing information, metformin is contraindicated in men with a serum creatinine level of 1. However, the Kidney Disease: Improving Global Outcomes guidelines state that metformin use should be continued in patients with an estimated glomerular filtration rate GFR of 45 mL per minute per 1.
Glimepiride Amaryl , glipizide Glucotrol , and glyburide are insulin secretagogues with common adverse effects of hypoglycemia and weight gain.
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All second-generation sulfonylureas are available as generic formulations and are relatively inexpensive. Alogliptin Nesina , linagliptin Tradjenta , saxagliptin Onglyza , and sitagliptin Januvia are members of a newer class of oral diabetes medications.
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When used as monotherapy or in conjunction with metformin, dipeptidyl-peptidase-4 inhibitors have a low risk of hypoglycemia. These medications are weight neutral and generally well tolerated. Although their use has been associated with pancreatitis, a cause and effect relationship has not been established.
Physicians should monitor for signs and symptoms of pancreatitis, and discontinue therapy if pancreatitis occurs. Pioglitazone Actos and rosiglitazone Avandia are in the thiazolidinedione class of diabetes medications. Both medications are metabolized by cytochrome P enzymes in the liver, so precautions should be taken when given concomitantly with other cytochrome P inducers or inhibitors.
These medications commonly cause weight gain and edema, which is especially troublesome in patients with congestive heart failure; therefore, these medications are contraindicated in patients with New York Heart Association class III or IV heart failure. In , the FDA warned against the use of pioglitazone in patients with active bladder cancer and cautioned against its use in patients with a history of bladder cancer.
Additionally, thiazolidinediones have a boxed warning for an increased risk of bone fractures in women, especially of the distal upper and lower limbs. Albiglutide Tanzeum, once weekly , dulaglutide Trulicity, once weekly , exenatide Byetta, twice daily; Bydureon, once weekly , and liraglutide Victoza, once daily are injectable medications that affect fasting and postprandial glucose levels. They should be avoided in patients with gastroparesis and in those with severe renal impairment, defined as creatinine clearance less than 30 mL per minute per 1.
These medications are contraindicated in patients with active multiple endocrine neoplasia type 2 or with a personal or family history of medullary thyroid carcinoma. Additionally, this medication class may increase the risk of pancreatitis; proper monitoring is recommended and alternate therapy is required if pancreatitis is confirmed. Other therapies have been approved for the treatment of type 2 diabetes, but are less widely used and are not included in the ADA treatment algorithm.
These medications are typically expensive, not well tolerated, and only minimally effective. The amylin analogue pramlintide Symlin may be used to treat type 1 or type 2 diabetes. It has a boxed warning for the risk of severe hypoglycemia. Despite adverse effects of increased urination, increased genital mycotic infections in women more often than in men , and increased urinary tract infections, sodium-glucose cotransporter 2 inhibitors are associated with minimal hypoglycemia.
Guidelines from the ADA and the American Association of Clinical Endocrinologists recommend a comprehensive, patient-centered approach for achieving and maintaining glycemic control. Figure 1 provides multiple pharmacotherapy options based on A1C levels, fasting or postprandial glucose control, weight loss, and adverse effects.
Algorithm for the management of type 2 diabetes mellitus.
Information from references 1 , 12 , and Metformin should be used as initial therapy if there are no contraindications Figure 1 1 , 12 , If A1C levels remain above goal after three months of therapy, a second agent should be added e. Progression to triple therapy is recommended if the A1C level is above goal after three months of dual therapy.
To help guide treatment decisions, physicians have traditionally recommended self-monitoring of blood glucose levels. A meta-analysis of 12 RCTs found that patients who had diabetes for more than one year and who were randomized to self-monitoring of blood glucose had no additional A1C lowering at 12 months compared with control groups.
Data Sources : We searched PubMed using the following terms: type 2 diabetes treatment, prediabetes treatment, hypoglycemic agents, nutrition and diabetes, diabetes and cardiovascular disease. We also used an evidence summary from the online medical reference Essential Evidence Plus. Search dates: April and May , and May 1, Already a member or subscriber? Log in. LUCY L. Address correspondence to Christa M. Reprints are not available from the authors. Nutrition therapy recommendations for the management of adults with diabetes.
Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes [published correction appears in N Engl J Med. Oral diabetes medications for adults with type 2 diabetes: an update.
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