Diabetes medication table (shssr march 2013)

SHSSR Diabetes Oral and Non-Insulin Injectable Medication Overview
Revision 5.17.2013
References
OnlineTM, Pediatric Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; Facts & Comparisons. Facts & Comparisons Web site. http://online.factsandcomparisons.com.ezproxy.samford.edu/. Clinical Pharmacology Web site. http://cpip.gsm.com.ezproxy.samford.edu/. Pharmacist’s Letter. Drugs for Type 2 Diabetes. Therapeutic Research Center: June 2012 Initial Dose
Titration Schedule
(Brand Name)
Monitoring Considerations
Take with food to decrease GI upset (breakfast and dinner); this intolerance may improve over time Recent studies suggest vitamin B12 and/or folic acid Increase by 850 mg every other week given deficiency with metformin use; supplementation may be Start with 500 mg tablets, be alert of the number of tablets patient taking daily and change to 1,000 mg General y low risk of significant hypoglycemia; may help Contraindications:
Cr >1.5 males or >1.4 females); or abnormal creatinine clearance from any cause Hold 48 hours before and after surgery or IV contrast radiologic studies; institute only after renal function has returned to normal General y, clinically significant responses are not seen at doses < 1500 mg daily; Black Box Warning:
however a lower recommended starting dose and gradual dose is recommended to Lactic Acidosis is rare but serious - the risk of accumulation increases with the degree of renal impairment - suspect if If GI side effects occur as dose is advanced, Warnings:
decrease to previous lower dose and try to advance at a later time. Cautious use in patients ≥ 80 years of age unless normal renal function established Use with caution in patients with congestive heart failure requiring pharmacologic management, particularly in patients with unstable or acute heart failure; seek MD guidance Initial Dose
Titration Schedule
Monitoring Considerations
(Brand Name)
Titrate to bid with breakfast and dinner. Take 30 minutes prior to meals at same time each day; Titrate up each dose by 2.5 – 5 mg weekly give XL tablets with meal (i.e. breakfast) until glucose levels at goal or maximum of Monitor for hypoglycemia (particularly in elderly and 40 mg (total daily dose) or 15 mg (single Glipizide may be preferred in older patient with mildly For elderly or patients with mild to moderate Weight gain (~ 2kg) common following initiation of renal dysfunction, initial dose and dose Increase by 2.5 – 5 mg weekly until glucose levels at goal or maximum of 20 mg daily. Contraindications:
For elderly or patients with mild to moderate Warnings:
increments should be 50% of those above. Increase by increments no greater than 2.5 Hypoglycemia: caution with decreased calorie intake, GENERATION
prolonged exercise, alcohol, or if used with other response. If dose >10mg/day, consider BID Do not use concurrently with non-SFU secreatgogues (repaglinide/nateglinide) due to similar effect For elderly or patients with mild to moderate Sulfonamide allergy: potential for cross-reaction renal dysfunction, initial dose and dose Glipizide not recommended with CLcr < 10 ml/min) Once 2 mg reached, increase by 2 mg every Glyburide not recommended with CLcr < 50mL/min or ƒ Cases of acute pancreatitis reported with use; discontinue Mild to moderate renal dysfunction (CLcr >30 ml/min and <50 ml/min): decrease dose ƒ PG effect within 1-2 weeks of initiation ƒ No dose adjustments in renal/hepatic impairment ƒ Common AEs: headache, runny nose, diarrhea, URI, UTI (saxagliptin only) and arthralgia (linagliptin only) Contraindications:
Warnings:
ƒ Renal function impairment: adjust dose DPP-4 INHIBITOR
ƒ Drug interactions e.g. clarithromycin, itraconazole, nafazodone, protease inhibitors (saxagliptin only) ƒ Hepatic impairment (sitagliptin only) ƒ Use caution in patients with a hx of pancreatitis
Do not use GLP-1 Agonists and DPP4-inhibitors together
Initial Dose
Titration Schedule
Monitoring Considerations
(Brand Name)
maximum of 45 mg daily if FPG not <130 ƒ Favorable lipid effects, no hypoglycemia ƒ Fluid retention: may cause significant peripheral edema More prevalent when utilized with Insulin. Adding ƒ Max effect in 6 –12 weeks. Note: glycemic benefit of medication diminishes gradually after stopping. Black Box Warning:
TZDs can cause or exacerbate CHF in some patients.
Not recommended for use with HF Sx. After initiation and
dose increases monitor patients for S/Sx of heart failure
(incl. dyspnea, edema, and excessive, rapid weight gain)
Contraindications:
ƒ Heart Failure Class III or IV (initiation of treatment), Warnings:
ƒ May increase risk of fractures of long bones, especially in THIAZOLIDINEDIONES
ƒ Fluid retention may lead or exacerbate heart failure or macular edema (If so, drug should be stopped). ƒ Potential for drug interactions (e.g. OCPs) ƒ May decrease Hgb/Hct – cautious use in patients with ƒ Fluid retention may lead to or exacerbate heart failure or ƒ Use for >1 yr may be assoc. with an ↑ risk of bladder ca Titrate by 25 mg per dose every 4-8 weeks Should be given with first bite of each meal; skip dose if intervals until 1 hour post-prandial at goal Start with a low dose and increase slowly to minimize GI Max dose: 100 mg TID (if > 60kg) or 50 mg GI side effects; flatulence, diarrhea, and abd discomfort, Oral dextrose should be used in the treatment of mild to Contraindications:
Bowel disease, DKA, cirrhosis (Acarbose only), GI INHIBITIORS
Warnings:
Not recommended with significant renal impairment (S ALPHA GLUCOSIDASE
Titrate by 25 mg per dose every 4-8 weeks intervals until 1 hour post-prandial at goal or maximum of 100 mg TID Max dose: 100 mg TID Initial Dose
Titration Schedule
Monitoring Considerations
(Brand Name)
Take 15-30 minutes prior to meals; skip dose if meal not No dose adj. for renal or hepatic disease Do not use with oral sulfonylureas – similar effect Contraindications
MEGLITINIDES
Warnings:
Initial 100 mg once daily prior to first meal of Concerns related to adverse effects
Female genital fungal infections (10.4-11.4%), urinary tract infection (4.3-5.9%), and increased urination (4.6- 5.3%). Other reported reactions male genital fungal infections (3.7-4.2%), vulvovaginal pruritus (1.6-3.0%), Renal Dosing:
thirst (2.3-2.8%), constipation (1.8-2.3%) and nausea (2.2-2.3%), abdominal pain (1.8% vs. placebo 0.8%) Hypersensitivity reactions (eg: urticaria) Hypotension due to intravascular volume depletion especially in patients with renal impairment (ie, eGFR <60), elderly, patients on other antihypertensives (eg: Hyperkalemia: Patients predisposed to hyperkalemia (including patients with renal impairment or taking potassium-sparing diuretics, ACE inhibitors, and ARBs); monitor potassium in those who are predisposed. Lipid abnormality: dose-related LDL elevation approximately 4-8%; monitor LDL and treat as needed. Special populations:
Elderly: may be predisposed to developing symptoms related to intravascular volume depletion (eg, hypotension, orthostatic hypotension, dizziness, (SGLT2) INHIBITOR
syncope, and dehydration), especially 300 mg. A1C reductions may be less in patients >65 years compared Hepatic impairment: Not recommended for use in severe hepatic impairment (has not been studied). Dose adjustment is not necessary in mild or moderate hepatic SODIUM-GLUCOSE COTRANS
Renal impairment: Glycemic efficacy may be less and adverse reactions may be higher with moderate renal impairment. Incidence of hyperkalemia may be higher with the 300 mg dose. Safety and efficacy in severe renal impairment (GFR <30). ESRD, and in patients receiving dialysis are not established and canagliflozin should not be used in these patients. (Brand Name)
Initial Dose
Titration Schedule
Monitoring Considerations
Combination products are difficult to utilize When patients are stable on these classes of medications for dose titration as they do not allow for there may be a potential for cost savings (especially in flexibility of increasing individual agents. regards to co-pays) and improved adherence with combination agents - assess and change patients as needed Utilize combination products for patients on Monitoring and Contraindication information for individual COMBINATION AGENTS
Titration Schedule
Monitoring Considerations
(Brand Name)
Administer once daily at any time of day, independently of meals Pen should be discarded 30 days after initial use Common AEs: headache, nausea, and diarrhea. Nausea is most common when first starting liraglutide, but decreases over time Black Box Warning:
Dose- and duration- dependent thyroid C-cell tumors have
developed in animal studies with liraglutide therapy; relevance in
humans unknown
Contraindications:
History of or family history of medullary thyroid carcinoma (MTC); patients with multiple endocrine neoplasia syndrome type 2 (MEN2)
Warnings:
Cautious use with GI disease (gastroparesis) Acute and chronic pancreatitis: if suspected, discontinue use Use with caution with sulfonylurea; may increase risk of hypoglycemia – consider reducing dose of SFU May result in a reduction in appetite, food intake, and/or body weight Main side effects nausea/vomiting(improve over time) and weight For oral medications that have a narrow therapeutic window or require rapid absorption, (e.g. contraceptives, antibiotics) patients should be advised to take those drugs at least 1hr before BYETTA Contraindications:
Hypersensitivity; not recommended in patients with ESRD or CLcr <30 ml/min, gastroparesis, GI disease, DM1 or DKA GLP-1 RECEPTOR AGONIST
Warnings:
Acute pancreatitis has occurred after initiation of exenatide and after dose increases - observe pts carefully for S/Sx of pancreatitis (including persistent, severe abdominal pain, sometimes radiating to the back, which may or may not be accompanied by vomiting) Caution in patients with renal transplantation and with exenatide initiation or dose increases in patients with moderate renal Use with caution with sulfonylurea; may increase risk of hypoglycemia – consider reducing dose of SFU May increase INR, increase monitoring when initiating in patients on
Do not use GLP-1 Agonists and DPP4-inhibitors together
Initial Dose
Titration Schedule
Monitoring Considerations
(Brand Name)
Reduce pre-meal insulin dose by 50%; after the immediately prior to if patient is tolerating maintenance dose of pramlintide is reached, adjust insulin No dose adjustments in renal/hepatic impairment. Administer subcutaneously immediately prior to each major meal (at least 250 kcal or containing at least 30 g of Do not mix pramlintide with any type of insulin Contraindications:
Allergy, gastroparesis or hypoglycemia unawareness Warnings:
AMYLIN ANALOG
Nausea/vomiting primary side effect, tolerance develops Pramlintide may alter absorption of oral medicines; administer the agent at least 1 hour prior to or 2 hours after

Source: http://www.suttermedicalfoundation.org/spa/about/sip/forclinicians/files/table-of-diabetes-medications-5.17.2013.pdf