Microsoft word - diabetes medication guide.doc

Diabetes Medication Guide
The purpose of this guide is to provide general care information regarding management of diabetes. The guidelines are not intended to preclude more extensive evaluation and management of the patient by specialists as needed. This guideline is based on the American Diabetes Association: Standards of Medical Care in Diabetes – 2009, Diabetes Care, volume 32, Supplement 1, January 2009.

Insulin Therapy

Insulin Preparation
Onset of Action
Peak Action
Duration of Action
Short acting (regular)
Rapid acting (Lispro (Humolog))
Intermediate acting (NPH or lente)
Long acting (ultralente)
Mixtures (70/30, 50/50)
This table summarizes the typical time course of action of various insulin preparations. These values are highly variable among individuals. Even in a given patient, these values vary depending on the site and depth of injection, skin temperature, and exercise. **No pronounced peak; smal amounts of insulin are slowly released resulting in a relative constant concentration/time profile over 24
Usual starting
Maximum dose per day
Metformin (Glucophage)
Metformin (Glucophage
Increases insulin sensitivity of peripheral tissues. Decreases glucose production by the liver. Avoid using for patients with serum levels on upper limits of normal. In elderly, use lower dose, titrate careful y, and monitor renal function regularly.
Usual starting
Usual maximum
dose for elderly
clinical effective dose per day
Glimiperide (Amaryl)
Glipizide (Glucotrol)
Glipizide (Glucotrol XL)
Glyburide (Macronase,
Glyburide (Glynase
Raises serum insulin level by stimulating the beta cel s of the pancreas to insulin. Metabolized by cytochrome P450. The lower dosages should be used for initial treatment of elderly patients, those with uncertain meal schedules, and those with mild
Alpha – Glucosidase Inhibitors
Usual starting dose
Maximum dose per day
Acarbose (Precose)
Miglitol (Glyset)
Acts in the smal intestine. Inhibits alpha-glucosidase enzyme. Delays digestion and absorption of complex carbohydrates. Lowers post-prandial glucose. Titrate dose upward every 2-4 weeks depending on GI tolerance. Monitor AST every 3 months for first year. Must be taken at the beginning of meals to be ef ective. &'''( &'')( &''&( &''*( &''+( &'',( &''- Diabetes Medication Guide
Dipeptidyl Peptidase- (DPP-4) Inhibitor
Usual starting dose
Maximum dose per day
Slows the inactivation of incretins, hormones that are normal y released in the gut throughout the day and increased after meals. Incretins increase insulin release from pancreatic beta cel , and lower glucagon secretion from pancreatic alpha cel s. Can be taken

Usual starting dose
Maximum dose per
Repaglinide (Prandin)
1 or 2 mg/meal A1c >8% or on other oral Nateglinide (Starlix)
Similar to sulfonylurea, stimulates insulin secretion, short duration of action, usual y taken 15 minutes before meals, skip dose if meal is not taken. Can be used with renal function impairment, but increase cautiously. Metabolized by cytochrome P450 enzyme system and 3A4. Interaction with other drugs metabolized by the same system is possible. This includes troglitazone, rifampicin, barbiturates and carbamazepine. Ketoconazole and micronazole may inhibit metabolism.
Glucagon-like Peptide 1 (GLP-1) Agonist

Usual starting dose
Maximum dose per
Exenatide Injection
Intended for people with type 2 diabetes who are on oral medication but not achieving good blood sugar control. Stimulates glucose- dependent release of insulin and suppresses glucagons levels.
Synthetic Analog of Human Amylin

Usual starting dose
Maximum dose per
Pramlintide Acetate
Indicated as an adjunct treatment in patients with type 1 or type 2 diabetes who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy, and it is used with or without a slfonylurea and/or metformin. May decrease A1c by an average of 0.4% and may observe weight loss of less than 1kg at six months.

Usual starting dose
Maximum dose per day
Rosiglitazone (Avandia)
Pioglitazone (Actos)
Acts via PPAR-gamma receptors on membranes of the cel nucleus. Improves response of peripheral cel s. Reduces glucose production by the liver. Favorable ef ects on lipids. Initiation of therapy is not recommended in anyone with an ALT >2.5 upper limits of normal. LFT monitoring is recommended prior to initiation of therapy and every two months for the first 8 months and periodical y &'''( &'')( &''&( &''*( &''+( &'',( &''- Diabetes Medication Guide

Combination Products

Fixed Dose (mg)
Usual starting dose (mg)
Maximum dose per Formulary
TZD + metformin
TZD + metformin
TZD + sulfonylureas
TZD + sulfonylureas
Rosiglitazone/glimerpiride Not recommended as initial Sulfonylurea +
metformin (Glucovance) 1.25/250, 2.25/500, 5/500 qd or bid
Sulfonylurea +
metformin (Metaglip)
DDP-IV inhibitor +

Glycemic Control Levels

Glycemic control for diabetics
Biochemical index
Additional action suggested
The values shown in this table are by necessity generalized to the entire population of individuals with diabetes. Patients with comorbid diseases, the very young and older adults, and others with unusual conditions or circumstances may warrant dif erent treatment goals. These values are for non-pregnant adults. “Additional action suggested” depends on individual patient circumstances. Such actions may include enhanced diabetes self-management education, comanagement with a diabetes team, referral to an endocrinologist, change in pharmacological therapy, initiation of or increase in self-monitoring of blood glucose, or more frequent contact with the patient. HbA1c is referenced to a nondiabetic range of 4.0 – 6.0% (mean 5.0%, SD 0.5%). †Measurement of capil ary blood glucose.
Lipoprotein Risk Levels
Category of risk based on lipoprotein levels in adults with diabetes
LDL Cholesterol
HDL Cholesterol*
Data are given in mil igrams per deciliter. *For women, HDL cholesterol values should be increased by 10 mg/dl. &'''( &'')( &''&( &''*( &''+( &'',( &''- Diabetes Medication Guide

Abnormalities in Albumin Excretion
Definition of abnormalities in albumin excretion
24-h col ection (mg/24h)
Timed col ection ( g/min)
Spot col ection ( g/mg creatinine)
Because of variability in urinary albumin excretion, two of three specimens col ected within a 3- to 6-month period should be abnormal before considering a patient to have crossed one of these diagnostic thresholds. Exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline values. &'''( &'')( &''&( &''*( &''+( &'',( &''-


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