Type 2 diabetes mellitus: Difference between revisions
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+ | ==Management== |
− | * |
+ | *See also [[Diabetes mellitus#Management|Diabetes mellitus]] |
− | === |
+ | ===Medical Management=== |
− | * |
+ | *At diagnosis: lifestyle changes, with nutritional therapy, weight management, and physical activity, and consider adding [[metformin]] |
− | * |
+ | *Determine A1c target (≤7% for most people) |
− | ** |
+ | **A1c <1.5% above target |
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+ | ***Reassess after 3 months of lifestyle changes |
− | *** |
+ | ***If not at target, add [[metformin]] |
− | ** |
+ | **A1c ≥1.5% above target: start [[metformin]] immediately, and consider concurrent second agent |
− | ** |
+ | **Symptomatic hyperglycemia or metabolic decompensation: start [[metformin]] and [[insulin]] |
− | * |
+ | *If not at target and has clinical CVD: add [[empagliflozin]], [[liraglutide]], or [[canagliflozin]] |
− | * |
+ | *If still not at target, add additional agents based on individualized considerations |
− | ** |
+ | **Avoidance of hypoglycemia and/or weight gain with adequate glycemic efficacy: [[DPP-4 inhibitors]], [[GLP-1 receptor agonists]], or [[SGLT2 inhibitors]] |
− | ** |
+ | **Reduced eGFR or albuminuria |
− | ** |
+ | **Clinical CVD or CV risk factors |
− | ** |
+ | **Degree of hyperglycemia |
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+ | **Other comorbidities, such as heart failure, cardiovascular disease, kidney disease, or liver disease |
− | ** |
+ | **Planning pregnancy |
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+ | **Cost to patient |
− | ** |
+ | **Patient preference |
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+ | === Target A1c === |
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+ | * ≤6.5% for adults with T2DM to reduce with risk of CKD and retinopathy, if at low risk of hypoglycemia |
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+ | * ≤7% for most adults with T1DM and T2DM |
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+ | * 7.1-8% for functionally dependent elderly |
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+ | * 7.1-8.5% for those with recurrent severe hypoglycemia or hypoglycemia unawareness |
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+ | * 7.1-8.5% for those with a limited life expectancy (stop measuring, and target euglycemia for symptom control) |
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+ | * 7.1-8.5% for those the frail elderly or those with dementia |
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[[Category:Endocrinology]] |
[[Category:Endocrinology]] |
Revision as of 07:27, 25 February 2021
Management
- See also Diabetes mellitus
Medical Management
- At diagnosis: lifestyle changes, with nutritional therapy, weight management, and physical activity, and consider adding metformin
- Determine A1c target (≤7% for most people)
- If not at target and has clinical CVD: add empagliflozin, liraglutide, or canagliflozin
- If still not at target, add additional agents based on individualized considerations
- Avoidance of hypoglycemia and/or weight gain with adequate glycemic efficacy: DPP-4 inhibitors, GLP-1 receptor agonists, or SGLT2 inhibitors
- Reduced eGFR or albuminuria
- Clinical CVD or CV risk factors
- Degree of hyperglycemia
- Other comorbidities, such as heart failure, cardiovascular disease, kidney disease, or liver disease
- Planning pregnancy
- Cost to patient
- Patient preference
Class | CVD Outcomes | Hypoglycemia | Weight | A1c Lowering | Other Considerations | Cost |
---|---|---|---|---|---|---|
GLP-1 receptor agonists | liraglutide is superior in T2DM, LAR and lixiglutide are neutral | rare | ↓↓ | ↓↓ to ↓↓↓ | GI side effects, gallstones; contraindicated in personal/family history of medullary thyroid cancer or MEN-2; given by subcutaneous injection | $$$$ |
SGLT2 inhibitors | canagliflozin and empagliflozin are superior in T2DM | rare | ↓↓ | ↓↓ to ↓↓↓ | urogenital infections, hypotension, dose-related changes in LDL; caution with renal dysfunction, loop diuretics, and the elderly; dapagliflozin contrindicated in bladder caner; rarely caused euglycemic diabetic ketoacidosis; increased risk of fractures or amputations with canagliflozin; reduced progression of nephropathy and heart failure exacerbations with canaglizflozin and empagliflozin | $$$ |
DPP-4 inhibitors | ↔ | rare | ↔ | ↓↓ | avoid saxagliptin in heart failure; rare joint pain | $$$ |
insulin | ↔ | yes | ↑↑ | ↓↓ to ↓↓↓↓ | no dose ceiling; requires subcutaneous injection | $ to $$$$ |
thiazolidinones | ↔ | rare | ↑↑ | ↓↓ | CHF, edema, fractures, rare bladder cancer with pioglitazone, cardiovascular controversy with rosiglitazone, 6-12 weeks for maximum effect | $$ |
alpha-glucosidase inhibitors | rare | ↔ | ↓ | GI side effects common; TID dosing | $$ | |
meglitinide | yes | ↑ | ↓↓ | lower glucose rapidly; reduced postprandial glycemia; TID to QID dosing | $$ | |
sulfonylureas | yes | ↑ | ↓↓ | gliclazide and glimepiride have less hypoglycemia than glyburide; poor durability | $ | |
orlistat | none | ↓ | ↓ | GI side effects; TID dosing | $$$ |
Target A1c
- ≤6.5% for adults with T2DM to reduce with risk of CKD and retinopathy, if at low risk of hypoglycemia
- ≤7% for most adults with T1DM and T2DM
- 7.1-8% for functionally dependent elderly
- 7.1-8.5% for those with recurrent severe hypoglycemia or hypoglycemia unawareness
- 7.1-8.5% for those with a limited life expectancy (stop measuring, and target euglycemia for symptom control)
- 7.1-8.5% for those the frail elderly or those with dementia