This patient-centered case vignette offers insight into how best to choose among additional oral agents, basal insulin, or the newer GLP-1 receptor agonists.
› Turn first to metformin for pharmacologic treatment of type 2 diabetes. A
› Add a second oral agent (such as a sulfonylurea, thiazolidinedione, sodium-glucose cotransporter-2 inhibitor, or dipeptidyl peptidase 4 inhibitor), a glucagon-like peptide-1 (GLP-1) receptor agonist, or basal insulin if metformin at a maximum tolerated dose does not achieve the HbA1c target over 3 months. A
› Progress to bolus mealtime insulin or a GLP-1 agonist to cover postprandial glycemic excursions if HbA1c remains above goal despite an adequate trial of basal insulin. A
is 1000 blood sugar high treatment insulin (👍 fruit) | is 1000 blood sugar high overweighthow to is 1000 blood sugar high for Strength of the 1 last update 15 Jul 2020 recommendation (SOR)Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The "" guidelines published in 2015 by the American Diabetes Association (ADA) state that metformin is the preferred initial pharmacotherapy for managing type 2 diabetes.1 Metformin, a biguanide, enhances insulin sensitivity in muscle and fat tissue and inhibits hepatic glucose production. Advantages of metformin include the longstanding research supporting its efficacy and safety, an expected decrease in the glycated hemoglobin (HbA1c) level of 1% to 1.5%, low cost, minimal hypoglycemic risk, and potential reductions in cardiovascular (CV) events due to decreased low-density lipoprotein (LDL) cholesterol.1,2
To minimize adverse the 1 last update 15 Jul 2020 gastrointestinal effects, start metformin at 500 mg once or twice a day and titrate upward every one to 2 weeks to the target dose.3 To help guide dosing decisions, use the estimated glomerular filtration rate (eGFR) instead of the serum creatinine (SCr) level, because the SCr can translate into a variable range of eGFRs (TABLE 1).4,5To minimize adverse gastrointestinal effects, start metformin at 500 mg once or twice a day and titrate upward every one to 2 weeks to the target dose.3 To help guide dosing decisions, use the estimated glomerular filtration rate (eGFR) instead of the serum creatinine (SCr) level, because the SCr can translate into a variable range of eGFRs (TABLE 1).4,5
What if metformin alone isn''s diabetes going forward?
If metformin at a maximum tolerated dose does not achieve the HbA1c target after 3 months, add a second oral agent (a sulfonylurea [SU], thiazolidinedione [TZD], dipeptidyl peptidase 4 [DPP-4] inhibitor, or sodium-glucose cotransporter-2 [SGLT2] inhibitor), a glucagon-like peptide-1 (GLP-1) receptor agonist, or a basal insulin (TABLE 2).1
Factors that will affect the choice of the second agent include patient preference, cost, potential adverse effects, impact on weight, efficacy, and risk of hypoglycemia.
Based on cost, familiarity, and longstanding safety data, you decide to give Mr. C an SU, while cautioning him about hypoglycemia.
is 1000 blood sugar high undiagnosed (🔥 ketones in urine) | is 1000 blood sugar high feethow to is 1000 blood sugar high for CASE › Mr. C has now been taking metformin and an SU at maximum doses for 2 years and continues with lifestyle modifications. Though his HbA1c level dropped after adding the SU, over 2 years it has crept up to 8.6% and his mean blood glucose is 186 mg/dL. What are your treatment options now?
If the target HbA1c level is not achieved on dual therapy, consider triple therapy combinations (TABLE 3).1
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