Glycemic Control Medications

Sulfonylureas (2 nd generation) Dose Size Dose/day (mg) Peak (hrs) Dose Interval Common side effects Glyburide (Micronase®, DiaBeta®) 2.5, 5mg 1.25mg – 20mg 4QD – BIDWeight gain Low Blood Sugar Glipizide (Glucotrol®) 5, 10mg 2.5mg – 40mg 1 – 3QD – BIDWeight gain Low Blood Sugar Glimepiride (Amaryl®) 1, 2, 4mg 1 – 8mg 2 – 3QDWeight gain Low Blood Sugar

Percent of CVD Demonstration programs with unrestricted & restricted use of glycemic control medications: UnrestrictedRestrictedTotal Glyburide87.5%2.5%90% Glipizide80%2.5%82.5% Glimepiriden/a

Pearls: Sulfonylureas 1.Generally, little benefit beyond 50% of maximal dose; 2.Metabolized in the liver: caution with liver disease; 3.Cleared by the kidneys: glyburide has partially active metabolites and should be avoided in renal disease.

Biguanides Dose Size Dose/day (mg) Peak (hrs) Dose Interval Common side effects Metformin500, 850,1000mg Up to 2gms 2 – 3QD – BIDNausea, vomiting, diarrhea* Thiazolidinediones Dose Size Dose/day (mg) Peak (hrs) Dose Interval Common side effects Pioglitazone (Actos®) 15, 30, 45mg n/aQDWeight gain Pedal Edema Rosiglitazon e (Avandia®) 2, 4, 8mg 2 – 8 n/aQD – BIDWeight gain Pedal Edema * Uncommon side effect: Lactic Acidosis

Percent of CVD Demonstration programs with unrestricted & restricted use of glycemic control medications: UnrestrictedRestrictedTotal Metformin100% Pioglitazone70%15%85% Rosiglitazone57.5%5%62.7%

Pearls: Metformin Renally cleared: do not use if creatinine  1.5 in men,  1.4 in women Major Risk: LACTIC ACIDOSIS –Very rare: 1/30,000 patient-years –Contraindicated in renal insufficiency, dehydration, hemodynamic instability, alcoholism, CHF requiring medication therapy, metabolic acidosis –Check AST/ALT and creatinine every 6-12 months

Pearls: Metformin Hold for radio-contrast studies the day of procedure and restart 48 hours after procedure Optimal dose 2,000mg/day. No additional benefit at higher dose Does not cause hypoglycemia unless used with sulfonylurea or insulin

Pearls: TZDs Weight gain and pedal edema can be a problem for patients, especially at higher dose Caution in hepatic dysfunction Check LFT every 6 months Safe in renal dysfunction Delayed onset of action: may take 4 – 12 weeks to achieve peak effect

Insulin Types Human and Analog Insulins Onset*Peak*Duration* Rapid Acting Insulin aspart (Novolog®) Insulin lispro (Humalog®) 10 – 15 minutes 1 – 2 hrs3 – 5 hrs Short Acting Regular [R] 0.5 – 1 hrs2 – 4 hrs4 – 8 hrs Intermediate NPH [N] 1 – 3 hrs4 – 10 hrs10 – 18 hrs Long Acting glargine (Lantus®) 2 – 4 hrsNone24 + hrs * Pharmacokinetics of insulins are influences by dose, injection site, and other factors: as a result, certain patients may experience variable onsets, peaks and durations of insulins.

Pearls: Insulins Rapid-Acting Insulin; –May be given no more than 15 minutes before meal –Can also be given at the end of the meal. May be helpful for patients with delayed gastric emptying Long-Acting Insulin glargine: cannot be mixed with other insulins

Percent of CVD Demonstration programs with unrestricted & restricted use of insulin: TypeMedicationUnrestrictedRestricted Rapid ActingLispro Aspart 40% n/a 15% n/a Short ActingRegular100%0% Intermediate Acting NPH100%0% Long ActingGlargine62.5%30% Mixed Insulins70/30 Lispro 70/ % 20% n/a 5%

Lipid Control Medications

HMG CoA Reductase Inhibitors (Statins) Pill Size (mg) Dosing Schedule Daily dosing range (mg) simvastatin (Zocor®) 5, 10, 20, 40, 80 QD5 – 80 atrovastatin (Lipitor®) 10, 20, 40, 80 QD10 – 80 lovastatin (Mevacor®) 10, 20, 40QD pravastatin (Pravacol®) 10, 20, 40QD

Fibrates: Used to lower Triglyercides Pill size (mg)Dosing schedule Daily dosing range Gemfibrozil (Lopid®) 600BID1200 Fenofibrate (TriCor®) 48, 160QD – TID

Percent of CVD Demonstration programs with unrestricted use of lipid control medications: ClassMedication Unrestricted StatinsSimvastatin Atrovastatin 87.5% 47.5% FibratesGemfibrozil Fenofibrate 97.5% 20% Nicotinic Acid Niacin Niacin ER 42.5% 57.5%

Hypertension Control Medications

JNC-7 Algorithm for the treatment of hypertension in patients with diabetes Lifestyle Modifications: Weight reduction, diet high in fruits & vegetables, low fat dairy produces, and decreased total and saturated fats; Na+ restriction to 2gr/day; regular aerobic exercise; and moderation of alcohol intake Drug Monotherapy: Consider ACE or ARB as first line Compelling indications for individual classes: ACEs, ARBs, thiazides,  -blockers, CCBs Optimize dosing or add additional agents until BP goal achieved NOT AT BP GOAL < 130/80

Percent of CVD Demonstration programs with unrestricted use of hypertension control medications: ClassMedicationUnrestrictedRestricted ACELisinopril Captopril 95% 60% 0% 5% ARBLosartan Olmestartan 55% 20% 2.5%  -blocker Atenolol Metoprolol 97.5% 80% 0% 7.5% Ca+ Channel Blocker Diltiazem Verapamil Amlodipine 92.5% 90% n/a 0% 2.5% n/a DiureticsHTCZ Lasix n/a 100% n/a 0%

Selected References: 1.Hypertension: Konzen, S et a. Controlling Hypertension in Patients with Diabetes: American Family Physician 2002; 66: The physician reference card from the JNC 7 (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) is available at the following website: Blood cholesterol and lipids: The appendix of the At-A-Glance: Quick Desk Reference by the NCEP ADP III (National Cholesterol Education Program Adult Treatment Panel III) provides further information on the risk determination and treatment for elevated cholesterol levels. The quick reference guide, as well as the full report, are available at the following website: Blood glucose control: Luna, B. Fienglas, M: Oral Agent in the Management of Type 2 Diabetes. American Family Physician. 2001; 63: , Clear presentation on oral agents in DM care with excellent stepped approach to glycemic management. 4.CVD Risk Reduction: Garvin, J et alReducing Cardiovascular Disease Risk in Patients with Type 2 Diabetes: American Family Physician 2003; 68: ,