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πŸ”₯+ diabetes type 2 cost 12 Jul 2020 A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), which ...

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By

Erika F. Brutsaert

, MD, New York Medical College

Last full review/revision Jan 2019| Content last modified Jan 2019
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Topic Resources

General treatment of diabetes for all patients involves lifestyle changes, including diet and exercise. Regular monitoring of blood glucose levels is essential to prevent complications of diabetes. (See also Diabetes Mellitus.)

Patients with type 1 diabetes mellitus are treated with insulin as well as diet and exercise.

Patients with type 2 diabetes mellitus are often initially treated with diet and exercise. If those measures are not sufficient for glycemic control, patients may be prescribed oral antihyperglycemic drugs, injectable glucagon-like peptide-1 (GLP-1) receptor agonists, insulin, or a combination of these drugs.

For some patients with diabetes, renin-angiotensin-aldosterone system blockers (ACE inhibitors or angiotensin II receptor blockers), statins, and the 1 last update 12 Jul 2020 aspirin aspirin often are given to prevent complications.

Insulin

Insulin is required for all patients with type 1 DM if they become ketoacidotic without it; it is also helpful for management of many patients with type 2 DM.

Insulin replacement in type 1 DM should ideally mimic beta-cell function using 2 insulin types to provide basal and prandial requirements (physiologic for 1 last update 12 Jul 2020 replacement); this approach requires close attention to diet and exercise as well as to insulin timing and dose. Insulin replacement in type 1 DM should ideally mimic beta-cell function using 2 insulin types to provide basal and prandial requirements (physiologic replacement); this approach requires close attention to diet and exercise as well as to insulin timing and dose.

diabetes type 2 cost meal plan (πŸ‘ hypoglycemia) | diabetes type 2 cost breadhow to diabetes type 2 cost for When insulin is needed for patients with type 2 DM, glycemic control can often be achieved with basal insulin combined with non- insulin anti-hyperglycemic drugs, although prandial insulin may be needed in some patients.

Except for use of regular diabetes type 2 cost medications (πŸ”₯ common complications) | diabetes type 2 cost kidshow to diabetes type 2 cost for insulin, which is given IV in hospitalized patients, insulin is almost always administered subcutaneously. Recently, an inhaled diabetes type 2 cost sugar (β˜‘ with keto) | diabetes type 2 cost overviewhow to diabetes type 2 cost for insulin preparation has also become available.

Insulin preparations

Most insulin preparations are now recombinant human, practically eliminating the once-common allergic reactions to the drug when it was extracted from animal sources. A number of analogs are available. These analogs were created by modifying the human insulin molecule that alters absorption rates and duration and time to action.

Insulin types are commonly categorized by their time to onset and duration of action (see table Onset, Peak, and Duration of Action of Human Insulin Preparations). However, these parameters vary within and among patients, depending on many factors (eg, site and technique of injection, amount of subcutaneous fat, blood flow at the injection site).

Table

Onset, Peak, and Duration of Action of Human Insulin Preparations*

Insulin Preparation

Onset of Action

Peak Action

Duration of Action

Rapid-acting

Lispro, aspart, glulisine†

5–15 min

45–75 min

3–5 for 1 last update 12 Jul 2020 h3–5 h

Inhaled regular

< 15 the 1 last update 12 Jul 2020 min< 15 min

50 min

2–3 h

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Short-acting

Regular

30–60 min

2–4 the 1 last update 12 Jul 2020 h2–4 h

6–8 the 1 last update 12 Jul 2020 h6–8 h

Intermediate-acting

NPH

About 2 h

4–12 h

18–26 h

U-500 regular

30 min

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13–24 h

Long-acting

Glargine

3–4 h

No peak

24 h

U-300 insulin glargine

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No peak

24 h

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1–2 h

No peak

14–24 h

Degludec

1–2 h

No peak

>40 for 1 last update 12 Jul 2020 h>40 h

Premixed

70% NPH/30% regular

30–60 the 1 last update 12 Jul 2020 min30–60 min

Dual (NPH & R)

10–16 h

50% NPL/50% lispro

30–60 min

Dual (NPL & lispro)

10–16 for 1 last update 12 Jul 2020 h10–16 h

the 1 last update 12 Jul 2020 75% NPL/25% lispro75% NPL/25% lispro

5–15 min

Dual (NPL & lispro)

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70% NPA/30% aspart

5–15 min

Dual (NPA & aspart)

10–16 h

70% Degludec/30% aspart

15 min

Dual (degludec/ aspart)

> 40 h

*Times are approximate, assume subcutaneous administration, and may vary with injection technique and factors influencing absorption.

Lispro and aspart are also available in premixed forms for 1 last update 12 Jul 2020 with intermediate-acting insulins.Lispro and aspart are also available in premixed forms with intermediate-acting insulins.

NPH also exists in premixed form (NPH/regular).

NPA = neutral protamine aspart; NPH = neutral protamine Hagedorn; NPL = neutral protamine lispro.

Rapid-acting insulins, including lispro and aspart, are rapidly absorbed because reversal of an amino acid pair prevents the the 1 last update 12 Jul 2020 insulin insulin molecule from associating into dimers and polymers. They begin to reduce plasma glucose often within 15 min but have short duration of action ( the 1 last update 12 Jul 2020 << 4 h). These insulins are best used at mealtime to control postprandial spikes in plasma glucose. Inhaled regular insulin is a newer rapid acting insulin that is taken with meals.

Regular insulin is slightly slower in onset (30 to 60 min) than lispro and aspart but lasts longer (6 to 8 h). It is the only insulin form for IV use.

Neutral protamine Hagedorn (NPH, or insulin isophane) is intermediate-acting; onset of action is about 2 h after injection, peak effect is 4 to 12 h after injection, and duration of action is 18 to 26 h. Concentrated regular for 1 last update 12 Jul 2020 insulin insulin U-500 has a similar peak and duration of action (peak 4 to 8 h; duration 13 to 24 h) and can be dosed 2 to 3 times per day.

Long-acting insulins, insulin glargine, insulin detemir, and U-300 insulin glargine, unlike NPH, have no discernible peak of action and provide a steady basal effect over 24 h. Insulin degludec (another long-acting insulin) has an even longer duration of action of over 40 h. It is dosed daily, and although it requires 3 days to achieve steady state, the timing of dosing is less rigid.

Combinations of NPH and regular for 1 last update 12 Jul 2020 insulin insulin and of insulin lispro and NPL (neutral protamine lispro or a form of lispro modified to act like NPH) are commercially available in premixed preparations (see table Onset, Peak, and Duration of Action of Human Insulin Preparations). Other premixed formulations include NPA (neutral protamine aspart or a form of aspart modified to act like NPH) with insulin aspart and a formulation of premixed degludec and aspart.

Different insulin types can be drawn into the same syringe for injection but should not be premixed in bottles except by a manufacturer. On occasion, mixing insulins may affect rates of the 1 last update 12 Jul 2020 insulin insulin absorption, producing variability of effect and making glycemic control less predictable, especially if mixed > 1 h before use. Insulin glargine should never be mixed with any other the 1 last update 12 Jul 2020 insulin insulin.

Many prefilled insulin pen devices are available as an alternative to the conventional vial and syringe method. Insulin pens may be more convenient for use away from home and may be preferable for patients with limited vision or manual dexterity. Spring-loaded self-injection devices (for use with a syringe) may be useful for the occasional patient who for 1 last update 12 Jul 2020 is fearful of injection, and syringe magnifiers are available for patients with low vision.Many prefilled insulin pen devices are available as an alternative to the conventional vial and syringe method. Insulin pens may be more convenient for use away from home and may be preferable for patients with limited vision or manual dexterity. Spring-loaded self-injection devices (for use with a syringe) may be useful for the occasional patient who is fearful of injection, and syringe magnifiers are available for patients with low vision.

Insulin pumps

Lispro, aspart, or regular insulin can also be given continuously using an insulin pump (1). Continuous subcutaneous insulin infusion pumps can eliminate the need for multiple daily injections, provide maximal flexibility in the timing of meals, and substantially reduce variability in glucose levels. Disadvantages include cost, mechanical failures leading to interruptions in insulin supply, and the inconvenience of wearing an external device. Frequent and meticulous self-monitoring and close attention to pump function are necessary for safe and effective use of the insulin pump.

The first hybrid, closed-loop insulin delivery system is now available. A closed loop system or "artificial pancreas" is one in which an algorithm is used to calculate and automatically deliver insulin doses through an insulin pump, based on input from a continuous glucose monitor. The approved system still requires input from the user for bolus doses.

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  • Peters AL, Ahmann AJ, Battelino T, et al: Diabetes technologyβ€”Continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab.  101(11):3922-3937, 2016.

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Complications of insulin treatment

The most common complication is

  • diabetes type 2 cost need insulin (πŸ”₯ symptoms men) | diabetes type 2 cost sodahow to diabetes type 2 cost for Hypoglycemia

Uncommon complications include

  • Local allergic reactions

  • Generalized allergic reaction

  • Local fat atrophy or hypertrophy

  • Circulating anti- insulin antibodies

Hypoglycemia is the most common complication of insulin treatment, occurring more often as patients try to achieve strict glucose control and approach near-normoglycemia. Symptoms of mild or moderate hypoglycemia include headache, diaphoresis, palpitations, light-headedness, blurred vision, agitation, and confusion. Symptoms of more severe hypoglycemia include seizures and loss of consciousness. In older patients, hypoglycemia may cause strokelike symptoms of aphasia or hemiparesis and is more likely to precipitate stroke, myocardial infarction, and sudden death. Patients with type 1 diabetes mellitus of long duration may be unaware of hypoglycemic episodes because they no longer experience autonomic symptoms (hypoglycemia unawareness).

Patients should be taught to recognize symptoms of hypoglycemia, which usually respond rapidly to the ingestion of sugar, including candy, juice, and glucose tablets. Typically, 15 g of glucose or sucrose should be ingested. Patients should check their glucose levels 15 min after glucose or sucrose ingestion and ingest an additional 15 g if their glucose level is not > 80 mg/dL (4.4 mmol/L). For patients who are unconscious or unable to swallow, hypoglycemia can be treated immediately with glucagon 1 mg sc or IM or a 50% dextrose solution 50 mL IV (25 g) followed, if necessary, by IV infusion of a 5% or 10% dextrose solution to maintain adequate plasma glucose levels.

Hyperglycemia may follow hypoglycemia either because too much sugar was ingested or because hypoglycemia caused a surge in counter-regulatory hormones (diabetes type 2 cost is characterized by (⭐️ definition) | diabetes type 2 cost childrenhow to diabetes type 2 cost for glucagon, epinephrine, cortisol, growth hormone). Too high a bedtime insulin dose can drive glucose down and stimulate a counter-regulatory response, leading to morning hyperglycemia (Somogyi phenomenon). A more common cause of unexplained morning hyperglycemia, however, is a rise in early morning growth hormone (dawn phenomenon). In this case, the evening insulin dose should be increased, changed to a longer-acting preparation, or injected later.

Hypokalemia may be caused by intracellular shifts of potassium due to insulin-induced stimulation of the sodium-potassium pump, but it is uncommon. Hypokalemia more commonly occurs in acute care settings when body stores may be depleted and IV insulin is used.

Local allergic reactions at the site of insulin injections are rare, especially with the use of human insulins, but they may still occur in patients with latex allergy because of the natural rubber latex contained in vial stoppers. They can cause immediate pain or burning followed by erythema, pruritus, and indurationβ€”the latter sometimes persisting for days. Most reactions spontaneously disappear after weeks of continued injection and require no specific treatment, although antihistamines may provide symptomatic relief.

Generalized allergic reaction is extremely rare with human insulins but can occur when insulin is restarted after a lapse in treatment. Symptoms develop 30 min to 2 h after injection and include urticaria, angioedema, pruritus, bronchospasm, and anaphylaxis. Treatment with antihistamines often suffices, but epinephrine and IV glucocorticoids may be needed. If the 1 last update 12 Jul 2020 insulin insulin treatment is needed after a generalized allergic reaction, skin testing with a panel of purified insulin preparations and desensitization should be done.

Local fat atrophy or hypertrophy at injection sites is relatively rare and is thought to result from an immune reaction to a component of the insulin preparation. Either may resolve by rotation of injection sites.

Circulating anti-insulin antibodies are a very rare cause of the 1 last update 12 Jul 2020 insulin insulin resistance. This type of insulin resistance can sometimes be treated by changing insulin preparations (eg, from animal to human diabetes type 2 cost remission (πŸ‘ nursing diagnosis) | diabetes type 2 cost variationhow to diabetes type 2 cost for insulin) and by administering corticosteroids if necessary.

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Regimens range from twice/day split-mixed (eg, split doses of rapid- and intermediate-acting insulins) to more physiologic basal-bolus regimens using multiple daily injections (eg, single fixed [basal] dose of long-acting and variable prandial [bolus] doses of rapid-acting insulin) or an insulin pump. Intensive treatment, defined as glucose monitoring β‰₯ 4 times/day and β‰₯ 3 injections/day or continuous diabetes type 2 cost insulin (πŸ”₯ vitamin d) | diabetes type 2 cost songhow to diabetes type 2 cost for insulin infusion, is more effective than conventional treatment (1 to 2 the 1 last update 12 Jul 2020 insulin insulin injections daily with or without monitoring) for preventing diabetic retinopathy, nephropathy, and neuropathy. However, intensive therapy may result in more frequent episodes of hypoglycemia and weight gain and is more effective in patients who are able and willing to take an active role in their self-care.

In general, most patients with type 1 diabetes mellitus can start with a total dose of 0.2 to 0.8 units of insulin/kg/day. Obese patients may require higher doses. Physiologic replacement involves giving 40 to 60% of the daily diabetes type 2 cost autoimmune (πŸ”΄ qualify for fmla) | diabetes type 2 cost good foods to eathow to diabetes type 2 cost for insulin dose as an intermediate- or long-acting preparation to cover basal needs, with the remainder given as a rapid- or short-acting preparation to cover postprandial increases. This approach is most effective when the dose of rapid- or short-acting the 1 last update 12 Jul 2020 insulin insulin is adjusted for preprandial blood glucose level and anticipated meal content. A correction factor, also known as the the 1 last update 12 Jul 2020 insulin insulin sensitivity factor, is the amount that 1 unit of diabetes type 2 cost treatment side effect (πŸ‘ lifestyle) | diabetes type 2 cost treathow to diabetes type 2 cost for insulin will lower a patient's blood glucose level over 2 to 4 hours; this factor is often calculated using the "1800 rule" when rapid-acting insulin is used for correction (1800/total daily dose of the 1 last update 12 Jul 2020 insulin insulin). For regular insulin, a "1500 rule" can be used. A correction dose (current glucose level - target glucose level/ correction factor) is the dose of diabetes type 2 cost facts (πŸ‘ patho) | diabetes type 2 cost youth statisticshow to diabetes type 2 cost for insulin that will lower the blood glucose level into the target range. This correction dose can be added to the prandial diabetes type 2 cost gene (⭐️ urine) | diabetes type 2 cost insulin pumphow to diabetes type 2 cost for insulin dose that is calculated for the number of carbohydrates in a meal, using the carbohydrate-to- insulin ratio (CIR). The CIR is often calculated using the "500 rule" (500/total daily dose).

To illustrate calculation of a lunchtime dose, assume the following:

  • Preprandial fingerstick glucose: 240 mg/dL (13.3 mmol/L)

  • diabetes type 2 cost yeast infections (πŸ”΄ obese) | diabetes type 2 cost glucose levelshow to diabetes type 2 cost for Total daily dose of insulin: 30 units basal insulin + 10 units bolus insulin per meal = 60 units total, daily

  • Correction factor ( insulin sensitivity factor): 1800/60 = 30 mg/dL/unit (1.7 mEq/L/unit, or 1.7 mmol/L)

  • Estimated carbohydrate content of upcoming meal: 50 g

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  • Target glucose: 120 mg/dL (6.7 mmol/L)

Prandial insulin dose = 50 g carbohydrate divided by 8 g/unit insulin = 6 units

Correction dose = (240 mg/dL - 120 mg/dL)/30 correction factor = 4 units ([13.3 mmol/L - 6.7 mmol/L]/1.7 = 4)

Total dose prior to this meal = prandial dose + correction dose = 6 + 4 = 10 units rapid-acting insulin

Such physiologic regimens allow greater freedom of lifestyle because patients can skip or time-shift meals and maintain normoglycemia. these recommendations are for initiation of therapy; thereafter, choice of regimens generally rests on physiologic response and patient and physician preferences. The carbohydrate-to- insulin ratio (CIR) and sensitivity factors need to be fine-tuned and changed according to how the patient responds to insulin doses. This adjustment requires working closely with a diabetes specialist.

Insulin regimens for type 2 diabetes

Regimens for type 2 diabetes mellitus also vary. In many patients, glucose levels are adequately controlled with lifestyle changes and non- insulin antihyperglycemic drugs, but insulin should be added when glucose remains inadequately controlled by β‰₯ 3 drugs. Although uncommon, adult-onset type 1 DM may be the cause. Insulin should replace non- insulin antihyperglycemic drugs in women who become pregnant. The rationale for combination therapy is strongest for use of insulin with oral biguanides and insulin sensitizers. Regimens vary from a single daily injection of long- or intermediate-acting insulin (usually at bedtime) to the multiple-injection regimen used by patients with type 1 DM. In general, the simplest effective regimen is preferred. Because of insulin resistance, some patients with type 2 DM require very large doses (> 2 units/kg/day). A common complication is weight gain, which is mostly attributable to reduction in loss of glucose in urine and improved metabolic efficiency.

Oral Antihyperglycemic Drugs

Oral antihyperglycemic drugs (see tables Characteristics of Oral Antihyperglycemics and Some Combination Oral Antihyperglycemics by Class) are a mainstay of treatment for type 2 diabetes mellitus, along with glucagon-like peptide-1 (GLP-1) receptor agonists. Insulin is often added when β‰₯ 3 drugs fail to provide adequate glycemic control. Oral antihyperglycemic drugs may

  • Enhance pancreatic insulin secretion (secretagogues)

  • Sensitize peripheral tissues to insulin (sensitizers)Sensitize peripheral tissues to insulin (sensitizers)

  • Impair GI absorption of glucose

  • Increase glycosuria

Drugs with different mechanisms of action may be synergistic.

Table

Characteristics of Oral Antihyperglycemics

Generic Name

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Duration of Action

Comments

Acetohexamide*

250 mg once/day–750 mg bid

12–24 h

No longer available in US

the 1 last update 12 Jul 2020 ChlorpropamideChlorpropamide*

100 mg once/day–750 mg once/day

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Chlorpropamide: May cause hyponatremia and flushing after alcohol ingestion

Tolazamide*

100 mg once/day–500 mg bid

14–16 h

No longer available in US

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250 mg once/day–1500 mg bid

12 h

β€”

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12–24 h

Glipizide and the 1 last update 12 Jul 2020 glyburideglyburide: No evidence of increased effectiveness of doses above 10 mg/day

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0.75 mg once/day–6 mg bid

12–24 h

Glipizide, regular-releaseGlipizide, regular-release

2.5 mg once/day–20 mg bid

12–24 h

the 1 last update 12 Jul 2020 GlipizideGlipizide, extended-release

2.5–20 mg once/day

24 h

Glimepiride for 1 last update 12 Jul 2020

1–8 mg once/day

24 h

β€”

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Can be used alone or in combination with other oral drugs and diabetes type 2 cost and alcohol (⭐️ young adults early death) | diabetes type 2 cost weight loss injectionshow to diabetes type 2 cost for insulin

Nateglinide

60–120 for 1 last update 12 Jul 2020 mg tid with meals60–120 mg tid with meals

3–4 h

Repaglinide

0.5–4 mg tid with meals

3–4 h

Insulin sensitizers: Biguanides

Augment suppression of hepatic glucose production by for 1 last update 12 Jul 2020 insulin insulin

Can be used alone or in combination with other oral drugs and insulin

Major adverse effects: Lactic acidosis (rare)

Contraindicated in at-risk patients, including those with renal insufficiency, metabolic acidosis, hypoxia, alcoholism, or dehydration

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Other adverse effects: GI distress (diarrhea, nausea, pain), vitamin B12 malabsorption

Potentiates weight loss

Metformin, regular-releaseMetformin, regular-release

500 mg once/day–1250 mg bid

6–10 for 1 last update 12 Jul 2020 h6–10 h

Metformin, extended-releaseMetformin, extended-release

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24 h

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diabetes type 2 cost januvia (β˜‘ nursing diagnosis) | diabetes type 2 cost childrenhow to diabetes type 2 cost for Augment suppression of hepatic glucose production by insulin

Can be used alone or in combination with other oral drugs and insulin

Major the 1 last update 12 Jul 2020 adverse effects: Weight gain, fluid retention, anemia (mild)Major adverse effects: Weight gain, fluid retention, anemia (mild)

Hepatotoxicity rare, but liver function monitoring required

Pioglitazone

15–45 mg once/day

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Pioglitazone: May increase risk the 1 last update 12 Jul 2020 of bladder cancer, heart failure, and fractures Pioglitazone: May increase risk of bladder cancer, heart failure, and fractures

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24 h

Rosiglitazone: May increase low-density lipoprotein cholesterol and may increase risk of heart failure, angina, myocardial infarction, stroke, and fractures

Alpha-glucosidase inhibitors

Intestinal enzyme inhibitors

Used as monotherapy or combination therapy with other oral drugs or for 1 last update 12 Jul 2020 insulin insulin to decrease postprandial plasma glucose levels

Must be taken with the first bite of meal

GI adverse effects (flatulence, diarrhea, bloating) common but may decrease over time

Started with small dose (25 mg/day) and gradually titrated over several weeks

Acarbose

25–100 mg tid with meals

6–10 h

Miglitol

25–100 mg tid with meals

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Dipeptidyl peptidase-4 (DPP4) inhibitors

Alogliptin

6.25–25 the 1 last update 12 Jul 2020 mg once/day6.25–25 mg once/day

24 h

All DPP-4 inhibitors can be used in moderate to severe renal insufficiency. All, except linagliptin require dose adjustment for eGFR.

Well-tolerated but the 1 last update 12 Jul 2020 cause only modest improvements in hemoglobin A1CWell-tolerated but cause only modest improvements in hemoglobin A1C

A slight increase in risk of pancreatitis seen in several studies

Linagliptin

5 mg once/day

24 h

the 1 last update 12 Jul 2020 SaxagliptinSaxagliptin

2.5–5 mg once/day

24 h

Sitagliptin

25–100 mg once/day

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Sodium-glucose co-transporter 2 (SGLT2) inhibitors

Canagliflozin

100 or 300 mg once/ day

24 h

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Use cautiously in the elderly and in patients with renal impairment.

Possible increase in risk of diabetic ketoacidosis

Canagliflozin is associated with a higher rate the 1 last update 12 Jul 2020 of limb amputations. Canagliflozin is associated with a higher rate of limb amputations.

Empagliflozin may have cardiovascular benefits.

Dapagliflozin

5–10 mg the 1 last update 12 Jul 2020 once/day5–10 mg once/day

24 h

for 1 last update 12 Jul 2020 EmpagliflozinEmpagliflozin

10–25 mg daily

24 for 1 last update 12 Jul 2020 h24 h

Ertugliflozin

5–15 mg daily

24 h

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2nd-generation sulfonylureas.

Table

Some Combination Oral Antihyperglycemics by Class

Drugs

Available Strengths (mg/mg)

Sulfonylurea/biguanide

Glipizide/metformin

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Glyburide/metformin

1.25/250, 2.5/500, 5/500

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1/500, 2/500

Thiazolidinedione/biguanide

Pioglitazone/ the 1 last update 12 Jul 2020 metforminmetformin

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Rosiglitazone/metformin

1/500, 2/500, 4/500, 2/1000, 4/1000

Thiazolidinedione/sulfonylurea

Pioglitazone/glimepiride

30/2, 30/4

Rosiglitazone/glimepiride

4/1, 4/2, 4/4

Dipeptidyl peptidase-4 inhibitor/biguanide

Linagliptin/metforminLinagliptin/metformin

2.5/500, 2.5/850, 2.5/1000

Saxagliptin/metformin, extended-release

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Sitagliptin/metformin

50/500, 50/1000

Sitagliptin/ metformin extended release

50/500, 50/1000, 100/1000

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Metformin/ SGLT-2 in inhibitor

Canagliflozin/metformin

50/500, 50/1000, 150/500, 150/1000

Dapagliflozin/ the 1 last update 12 Jul 2020 metforminmetformin, extended release

5/500, 5/1000, 12.5/500, 12.5/1000

Empagliflozin/metformin

5/500, 5/1000, 12.5/500 12.5/1000

Ertugliflozin/metformin

2.5/ 500, 2.5/1000, 7.5/500, 7.5/1000

DPP-4 inhibitor/ SGLT-2 inhibitor

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10/5, 25/5

Ertugliflozin/sitagliptin

5/100, 15/100

Sulfonylureas

Sulfonylureas are insulin secretagogues. They lower plasma glucose by stimulating pancreatic beta-cell insulin secretion and may secondarily improve peripheral and hepatic insulin sensitivity by reducing glucose toxicity. First-generation drugs (see table Some Combination Oral Antihyperglycemics by Class) are more likely to cause adverse effects and are used infrequently. All sulfonylureas promote hyperinsulinemia and weight gain of 2 to 5 kg, which over time may potentiate diabetes type 2 cost vitamin d (β˜‘ for dummies) | diabetes type 2 cost veteranhow to diabetes type 2 cost for for 1 last update 12 Jul 2020 insulin insulin resistance and limit their usefulness. All also can cause hypoglycemia. Risk factors include age > 65, use of long-acting drugs (especially chlorpropamide, glyburide, or diabetes type 2 cost statistics uk (⭐️ yeast infections) | diabetes type 2 cost glucose levels charthow to diabetes type 2 cost for glipizide), erratic eating and exercise, and renal or hepatic insufficiency.

Hypoglycemia caused by long-acting drugs may last for days after treatment cessation, occasionally causes permanent neurologic disability, and can be fatal. For these reasons, some physicians hospitalize hypoglycemic patients, especially older ones. Chlorpropamide also causes the syndrome of inappropriate ADH secretion. Most patients taking sulfonylureas alone eventually require additional drugs to achieve normoglycemia, suggesting that sulfonylureas may exhaust beta-cell function. However, worsening of insulin secretion and insulin resistance is probably more a feature of diabetes mellitus itself than of drugs used to treat it.

Short-acting insulin secretagogues

Short-acting insulin secretagogues (repaglinide, nateglinide) stimulate insulin secretion in a manner similar to sulfonylureas. They are faster acting, however, and may stimulate insulin secretion more during meals than at other times. Thus, they may be especially effective for reducing postprandial hyperglycemia and appear to have lower risk of hypoglycemia. There may be some weight gain, although apparently less than with sulfonylureas. Patients who have not responded to other oral drug classes (eg, sulfonylureas, metformin) are not likely to respond to these drugs.

Biguanides

diabetes type 2 cost medicine which aetna pays for (πŸ”₯ feet) | diabetes type 2 cost rashhow to diabetes type 2 cost for Biguanides lower plasma glucose by decreasing hepatic glucose production (gluconeogenesis and glycogenolysis). They are considered peripheral insulin sensitizers, but their stimulation of peripheral glucose uptake may simply be a result of reductions in glucose from their hepatic effects. Biguanides also lower lipid levels and may also decrease GI nutrient absorption, increase beta-cell sensitivity to circulating glucose, and decrease levels of plasminogen activator inhibitor 1, thereby exerting an antithrombotic effect. the 1 last update 12 Jul 2020 MetforminMetformin is the only biguanide commercially available in the US. It is at least as effective as sulfonylureas in reducing plasma glucose, rarely causes hypoglycemia, and can be safely used with other drugs and insulin. In addition, metformin does not cause weight gain and may even promote weight loss by suppressing appetite. However, the drug commonly causes GI adverse effects (eg, dyspepsia, diarrhea), which for most people recede with time. Less commonly, metformin causes vitamin B12 malabsorption, but clinically significant anemia is rare.

Contribution of for 1 last update 12 Jul 2020 metforminmetformin to life-threatening lactic acidosis is very rare, but the drug is contraindicated in patients at risk of acidemia (including those with significant renal insufficiency, hypoxia or severe respiratory disease, alcoholism, other forms of metabolic acidosis, or dehydration). The drug should be withheld during surgery, administration of IV contrast, and any serious illness. Many people receiving metformin monotherapy eventually require an additional drug.

ThiazolidinedionesThiazolidinediones

Thiazolidinediones (TZDs) decrease peripheral insulin resistance ( for 1 last update 12 Jul 2020 insulin insulin sensitizers), but their specific mechanisms of action are not well understood. The drugs bind a nuclear receptor primarily present in fat cells (peroxisome-proliferator-activated receptor-gamma [PPAR-Ξ³]) that is involved in the transcription of genes that regulate glucose and lipid metabolism. TZDs also increase HDL levels, lower triglycerides, and may have anti-inflammatory and anti-atherosclerotic effects. TZDs are as effective as sulfonylureas and metformin in reducing HbA1C. TZDs may be beneficial in treatment of nonalcoholic fatty liver disease (NAFLD).

Though one TZD (troglitazone) caused acute liver failure, currently available drugs have not proven hepatotoxic. Nevertheless, periodic monitoring of liver function is recommended. TZDs may cause peripheral edema, especially in patients taking insulin, and may worsen heart failure in susceptible patients. Weight gain, due to fluid retention and increased adipose tissue mass, is common and may be substantial (> 10 kg) in some patients. Rosiglitazone may increase risk of heart failure, angina, myocardial infarction, stroke, and fracture. Pioglitazone may increase the risk of bladder cancer (although data are conflicting), heart failure, and fractures.

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diabetes type 2 cost characteristics (πŸ”΄ diagnostic procedures) | diabetes type 2 cost expected findingshow to diabetes type 2 cost for Alpha-glucosidase inhibitors

Alpha-glucosidase inhibitors competitively inhibit intestinal enzymes that hydrolyze dietary carbohydrates; carbohydrates are digested and absorbed more slowly, thereby lowering postprandial plasma glucose. Alpha-glucosidase inhibitors are less effective than other oral drugs in reducing plasma glucose, and patients often stop the drugs because they may cause dyspepsia, flatulence, and diarrhea. But the drugs are otherwise safe and can be used in combination with all other oral drugs and with insulin.

Dipeptidyl peptidase-4 inhibitors

Dipeptidyl peptidase-4 inhibitors (eg, alogliptin, linagliptin, saxagliptin, sitagliptin) prolong the action of endogenous diabetes type 2 cost webmd (πŸ”΄ treatments and preventions) | diabetes type 2 cost wikihow to diabetes type 2 cost for glucagon-like peptide-1 (GLP-1) by inhibiting the enzyme dipeptidyl peptidase-4 (DPP-4), which is involved in the breakdown of GLP-1. There is a slight increase in risk for pancreatitis with DPP-4 inhibitors, but they are otherwise considered safe and well-tolerated. The HbA1C decrease is modest with DPP-4 inhibitors.

Sodium-glucose co-transporter 2 inhibitors

Sodium-glucose co-transporter 2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, empagliflozin) inhibit SGLT2 in the proximal tubule of the kidney, which blocks glucose reabsorption, thus causing glycosuria and lowering plasma glucose. SGLT2 inhibitors may also cause modest weight loss and lowering of blood pressure. Empagliflozin was shown to decrease cardiovascular events in diabetic patients at high risk for cardiovascular disease.

The most common side effects are genitourinary infections, especially mycotic infections. Orthostatic symptoms can also occur. There have been reports of diabetic ketoacidosis in patients with both type 1 DM and the 1 last update 12 Jul 2020 type 2 DM.The most common side effects are genitourinary infections, especially mycotic infections. Orthostatic symptoms can also occur. There have been reports of diabetic ketoacidosis in patients with both type 1 DM and type 2 DM.

Dopamine agonist

Bromocriptine is a dopamine agonist that lowers HbA1C about 0.5% by an unknown mechanism. Although approved for type 2 diabetes, it is not commonly used because of potential adverse effects.

Injectable Antihyperglycemic Drugs

Injectable antihyperglycemic drugs other than diabetes type 2 cost expected findings (β˜‘ home remedies) | diabetes type 2 cost examplehow to diabetes type 2 cost for insulin are the glucagon-like peptide-1 (GLP-1) receptor agonists and the amylin analog, pramlintide (see table Characteristics of Injectable Non-Insulin Antihyperglycemic Drugs). These drugs are used in combination with other antihyperglycemics.

Glucagon-like peptide-1 (GLP-1) receptor agonists

diabetes type 2 cost symptoms women (β˜‘ list) | diabetes type 2 cost vinegarhow to diabetes type 2 cost for GLP-1 agonists (exenatide [an incretin hormone], the 1 last update 12 Jul 2020 liraglutideliraglutide, dulaglutide, albiglutide) enhance glucose-dependent insulin secretion and slow gastric emptying. GLP-1 agonists may also reduce appetite and promote weight loss and stimulate beta-cell proliferation. Formulations are available for dosing twice/day, once/day, and weekly. The most common adverse effects of GLP-1 agonists are gastrointestinal, especially nausea and vomiting. GLP-1 agonists also cause a slight increase in the risk of pancreatitis. They are contraindicated in patients with a personal or family history of medullary thyroid cancer because an increased risk of this cancer has occurred in tested rodents.

Amylin analog

The amylin analog pramlintide mimics amylin, a pancreatic beta-cell hormone that helps regulate postprandial glucose levels. diabetes type 2 cost insulin (πŸ‘ reddit) | diabetes type 2 cost vaccinehow to diabetes type 2 cost for Pramlintide suppresses postprandial glucagon secretion, slows gastric emptying, and promotes satiety. It is given by injection and is used in combination with mealtime insulin. Patients with type 1 diabetes are given 30 to 60 mcg sc before meals, and those with type 2 diabetes are given 120 mcg.

Table

Characteristics of Injectable Non-Insulin Antihyperglycemic Drugs

diabetes type 2 cost underweight (β˜‘ glucagon) | diabetes type 2 cost wikihow to diabetes type 2 cost for Generic Name

Daily Dosage

Duration of Action

the 1 last update 12 Jul 2020 CommentsComments

Glucagon-like peptide-1 (GLP-1) agonists

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30 mg or 50 mg sc once/wk

7 days

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Increased risk of pancreatitis

Thyroid C-cell tumors (medullary carcinoma) noted in rodents

Weekly preparations may cause fewer GI adverse effects. When given once/day or bid, lowest starting dose may minimize nausea

diabetes type 2 cost ketoacidosis (⭐️ type 1) | diabetes type 2 cost explainedhow to diabetes type 2 cost for Liraglutide also comes as a combination pen with insulin degludec.

Lixisenatide is also available in a combination pen with insulin glargine.

Semaglutide is associated with increased progression of diabetic retinopathy.

Dulaglutide

0.75 mg or 1.5 mg sc once/wk

7 days

diabetes type 2 cost can drink alcohol (πŸ”₯ lecture) | diabetes type 2 cost home remediehow to diabetes type 2 cost for Exenatide

5 mcg or 10 mcg sc bid the 1 last update 12 Jul 2020 before meals5 mcg or 10 mcg sc bid before meals

4–6 h

Exenatide, once/wkExenatide, once/wk

2 mg sc once/wk

7 the 1 last update 12 Jul 2020 days7 days

LiraglutideLiraglutide

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24 h

Lixisenatide

10 mcg or 20 mcg sc once/day

24 h

Semaglutide

0.25 the 1 last update 12 Jul 2020 mg, 0.5 mg, or 1 mg once/wk0.25 mg, 0.5 mg, or 1 mg once/wk

7 days

Amylin analog

Amylin analog

diabetes type 2 cost australia (πŸ‘ management) | diabetes type 2 cost weight gainhow to diabetes type 2 cost for Pramlintide

For type 1 diabetes mellitus: 30–60 mcg sc before meals

For type 2 diabetes mellitus: 120 mcg sc before meals

2–4 h

For use in combination with diabetes type 2 cost term (πŸ”₯ your guide to getting started) | diabetes type 2 cost is characterized byhow to diabetes type 2 cost for for 1 last update 12 Jul 2020 insulin insulin, but injected using a separate syringe

diabetes type 2 cost journal (⭐️ how do you get it) | diabetes type 2 cost kidney failurehow to diabetes type 2 cost for May need to adjust insulin dose to avoid hypoglycemia

Nausea common but for 1 last update 12 Jul 2020 declining with timeNausea common but declining with time

May promote modest weight loss

Adjunctive Drug Therapy for Diabetes

Pharmacologic measures to prevent or treat complications of diabetes mellitus (1) are critical, including

  • ACE inhibitors or angiotensin II receptor blockers (ARBs)

  • Aspirin

  • Statins

ACE inhibitors or ARBs are indicated for patients with evidence of early diabetic nephropathy (albuminuria), even in the absence of hypertension, and are a good choice for treating hypertension in patients who have diabetes mellitus and who have not yet shown renal impairment.

ACE inhibitors also help prevent cardiovascular events in patients with diabetes mellitus.

Aspirin 81 to 325 mg once/day provides cardiovascular protection. In particular, aspirin should be used the 1 last update 12 Jul 2020 in diabetic patients with β‰₯ 10% 10-yr risk for atherosclerotic cardiovascular disease (ASCVD) and in some patients with diabetes with intermediate (5 to 10%) 10-yr risk for ASCVD.Aspirin 81 to 325 mg once/day provides cardiovascular protection. In particular, aspirin should be used in diabetic patients with β‰₯ 10% 10-yr risk for atherosclerotic cardiovascular disease (ASCVD) and in some patients with diabetes with intermediate (5 to 10%) 10-yr risk for ASCVD.

Statins are currently recommended by the American Heart Association/American College of Cardiology guidelines for all diabetic patients 40 to 75 yr of age. Moderate- to high-intensity treatment is used, and there are no target lipid levels (see table Statins for ASCVD Prevention in Dyslipidemia). For patients < 40 or > 75, statins are given based upon individual assessment of the risk:benefit ratio and patient preference. Patients with type 2 diabetes mellitus tend to have high levels of triglycerides and small, dense low-density lipoproteins (LDL) and low levels of HDL; they should receive aggressive treatment.

Adjunctive drug therapy reference

  • 1. Fox CS, Golden SH, Anderson C, et al: AHA/ ADA Scientific Statement: Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence. diabetes type 2 cost experience (β˜‘ and coronavirus) | diabetes type 2 cost optionshow to diabetes type 2 cost for Circulation 132: 691–718, 2015.

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