table 8.1 drug-specific and patient factors to consider when selecting antihyperglycemic treatment

by Rogers Powlowski Published 2 years ago Updated 2 years ago

Which glycemic goals should be individualized in the treatment of diabetes?

* More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

What are the guidelines for antihyperglycemic therapy in adults with T2DM?

Antihyperglycemic Therapy in Adults with T2DM American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes. Diabetes Care 2018; 41 (Suppl. 1): S73-S85 In patients with T2DM and established ASCVD: • antihyperglycemic therapy should begin with lifestyle management and metformin

When should insulin be added to the treatment of hyperglycemia?

• The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol)] or blood glucose levels (≥300 mg/dL [16.7 mmol/L)] are very high.

How can we prevent hypoglycemia and hyperglycemia?

Prevention of hypoglycemia and hyperglycemia should be goals, since adverse outcomes are associated with both. Perform an A1C on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL) admitted to the hospital if not performed in the prior 3 months.

Why is special care required in prescribing and monitoring pharmacologic therapy in older adults?

The patient’s living situation must be considered because it may affect diabetes management and support. When patients are found to have a regimen beyond their self-management abilities, treatment should be deintensified (or simplified) to reduce hypoglycemia and disease-related distress while avoiding a substantial worsening of glycemic control.

What are the social determinants of diabetes?

Social determinants of health are defined as the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide. The ADA recognizes the association between social and environmental factors and risk for diabetes and its complications.

How much aerobic activity should a child with diabetes do?

Children and adolescents with type 1 or type 2 diabetes or prediabetes should engage in 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week. C

How often should you monitor for diabetes in prediabetes?

At least annual monitoring for the development of diabetes in those with prediabetes is suggested. E

How many people over 65 have diabetes?

Diabetes is an important health condition for the aging population as approximately one-quarter of people over the age of 65 years have diabetes. Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illness.

What should providers assess?

Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions. A

When should I do SMBG?

Most patients using intensive insulin regimens (a multiple daily injection [MDI] regimen or insulin pump therapy) should perform SMBG prior to meals and snacks, at bedtime, occasionally postprandially, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. B

Pharmacologic Therapy for Type 1 Diabetes

9.1 Most people with type 1 diabetes should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion. A

Surgical Treatment for Type 1 Diabetes

Successful pancreas and islet transplantation can normalize glucose levels and mitigate microvascular complications of type 1 diabetes. However, patients receiving these treatments require lifelong immunosuppression to prevent graft rejection and/or recurrence of autoimmune islet destruction.

Pharmacologic Therapy for Type 2 Diabetes

9.4 Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. A

NEUROCOGNITIVE FUNCTION

Screening for early detection of mild cognitive impairment or dementia and depression is indicated for adults 65 years of age or older at the initial visit and annually as appropriate. B

HYPOGLYCEMIA

Hypoglycemia should be avoided in older adults with diabetes. It should be assessed and managed by adjusting glycemic targets and pharmacologic interventions. B

TREATMENT GOALS

Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (A1C <7.5% [58 mmol/mol]), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals (A1C <8.0–8.5% [64–69 mmol/mol]).

PHARMACOLOGIC THERAPY

In older adults at increased risk of hypoglycemia, medication classes with low risk of hypoglycemia are preferred. B

TREATMENT IN SKILLED NURSING FACILITIES AND NURSING HOMES

Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E

END-OF-LIFE CARE

When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E

Which receptor agonists are the preferred choice for insulin?

Consensus Recommendation: In patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are the preferred choice to insulin . For patients with extreme and symptomatic hyperglycemia, insulin is recommended.

What is the first line of therapy for HBA?

FIRST-LINE Therapy is Metformin and Comprehensive Lifestyle (including weight management and physical activity) if HbA

What is Table 9.1?

Table 9.1 -Drug-specific and patient factors to consider when selecting antihyperglycemic treatment in adults with type 2 diabetes

When to stop TZD?

Stop TZD when commencing insulin OR reduce dose

PHARMACOLOGIC THERAPY FOR TYPE 1 DIABETES