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ADA Diagnostic Criteria for Prediabetes
A1C 5.7-6.4
OR
FPG 100-125
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ADA Diagnostic Criteria for DMII
A1C > or = 6.5 -OR-
FPG > or = 126 -OR-
2-h OGTT > or = 200 -OR-
S&S of DM with random BG > or = 200
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ADA Goals of Treatment for DMII (non-pregnant adults)
A1C < 7% (more stringent <6.5 for younger persons, longer life expectancy, no comorbidities, etc.) (Less stringent, <8, for lower life expectancy, hx severe hypoglycemia, advanced complications, extensive comorbid conditions, long-standing DM.)
FBG 70-130
Post-prandial <180
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1st line medication therapy for DMII or Prediabetes
metformin (biguanide) - decreases hepatic glucose production, increases peripheral skeletal muscle sensitivity to insulin.
Good for pre- and post-prandial control. Will lower A1C 1-2%.
Advantage: weight loss, no effect on hypoglycemia, may decrease CVD risk.
S.E.: GI side effects (diarrhea), lactic acidosis, Vitamin B12 def.
Contraind. in ETOH, renal impairment or others at risk for lactic acidosis (dehydration, hypoxia).
Renal impairment: Not for Men with Cr > 1.5, or women with Cr > 1.4.
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Consider dual medication therapy in DMII when...
A1C > or = 9%.
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Consider insulin with initial treatment option when...
A1C 10-12%
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Sulfonylureas
glipizide, glyburide, glimeperide
- NOT FOR PREGNANCY
- NO glyburide in renal patients
- insulin secretagogues, stimulate beta-cells to increase insulin secretion
- given daily or 2x/daily
- Can cause hypoglycemia, weight gain. May increase islet failure
- May decrease CVD risk
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Meglitinides (glinides)
repaglinide, nateglinide
- short-acting insulin secretagogues; given before each meal
- good for post-prandial hyperglycemia
- less hypoglycemia (shorter acting)
- weight gain, hypoglycemia
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Thiazolidinediones (TZD)
pioglitazone (Actos)
- PPAR-Y activator, increases insulin sensitivity; once daily
- no hypoglycemia, may have beneficial CVD effects (increase HDL, lower TG)
- Inc.risk of fractures, bladder CA, weight gain, edema/HF
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alpha-glucosidase inhibitors
acarbose, miglitol, voglibose
- inhibits intestinal a-glucosidase which slows intestinal carb.digestion/absorption
- no hypoglycemia
- good for post-prandial control (taken w/ meals), non-systemic
- only modest A1C lowering, GI side effects (flatulence, diarrhea)
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DPP-4 Inhibitors
sitagliptin (all -gliptins)
- inhibit DPP-4 activity, which in turn increases incretin activity (GLP-1, GIP)
- increased insulin secretion (glucose-dependent)
- Decreased glucagon secretion (glucose-dependent)
- no hypoglycemia
- only modest A1C lowering, S.E. urticaria/angioedema, ? pancreatitis
DECREASE DOSE IN RENAL PTS.
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GLP-1 receptor agonists
exenatide (-tides) "Byetta"
injected
- activates GLP-1 receptors
- increases insulin secretion (glucose dependent)
- decreased glucagon secretion (glucose dependent)
- slows gastric emptying, increased satiety
-may preserve/increase beta cell mass/function
- no hypoglycemia, helps weight loss, CV protection?
- S.E. GI (N/V)
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Amylin Mimetics
pramlintide
- injected
- decreases glucagon secretion, slows gastric emptying, increases satiety
- good for postprandial control & weight loss
- only modest A1C lowering, GI side effects common, hypoglycemia w/ insulin
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