1. Oral hypoglycemics
Jennifer R Marks, MD

2. Oral hypoglycemics Factors to consider: Cost Availability Side effects
Tolerability
Risk
Accessory benefits

4. metformin
Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. A
Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin. A
Long-term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy. B

5. SGLT-2 inhibitors

6. Canagliflozin (Invokana) Dapagliflozin (Farxiga)
SGLT-2 inhibitors
Canagliflozin (Invokana)
100 or 300mg daily with breakfast
Dapagliflozin (Farxiga)
5 or 10 mg daily q AM
Empagliflozin (Jardiance)
10 or 25 mg daily q AM
PDR.net

7. SGLT-2 inhibitors
Among patients with type 2 diabetes who have established ASCVD, sodium–glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists with demonstrated CVD benefit are recommended as part of the antihyperglycemic regimen. A
Among patients with ASCVD at high risk of heart failure or in whom heart failure coexists, SGLT2 inhibitors are preferred. C
For patients with type 2 diabetes and CKD, consider use of an SGLT2 inhibitor or GLP-1 receptor agonist shown to reduce risk of DKD progression, cardiovascular events, or both. C

8. SGLT-2 inhibitors
Renally dose adjust
Increased risk amputation & fracture (canagliflozin)
DKA risk
GU infection including Fournier’s gangrene

9. GLP-1 RAs

10. GLP-1 RAs Dulaglutide (Trulicity) Exenatide (Byetta)
weekly
Exenatide (Byetta)
twice daily
Exenatide extended release (Bydureon)
Liraglutide (Victoza)
daily
Lixisenatide (Adlyxin)
Semaglutide (Ozempic)

11. GLP-1 RAs
Among patients with type 2 diabetes who have established ASCVD, sodium–glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists with demonstrated CVD benefit are recommended as part of the antihyperglycemic regimen. A
For patients with type 2 diabetes and CKD, consider use of an SGLT2 inhibitor or GLP-1 receptor agonist shown to reduce risk of DKD progression, cardiovascular events, or both. C
In most patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are preferred to insulin. B

12. GLP-1 RAs
Please note that this class is NOT actually orally administered but SQ; they get lumped together with orals since they are non-insulin products
Liraglutide has best evidence for CV benefit
Risk of thyroid tumors
GI upset is common

13. DDP-4 inhibitors

14. DDP-4 inhibitors Sitagliptin (Januvia) Saxagliptin (Onglyza)
25, 50, or 100mg once daily
Saxagliptin (Onglyza)
2.5 or 5mg once daily
Linagliptin (Trajenta)
5mg once daily
Alogliptin (Nesina)
6.25, 12.5, or 25mg once daily

15. DDP-4 inhibitors
Renally dose adjust
Risk of pancreatitis

16. Rosiglitazone (Avandia)
Thiazolidinediones
Rosiglitazone (Avandia)
2, 4, or 8mg daily or divided BID
Pioglitazone (Actos)
15, 30, or 45mg once daily

17. Thiazolidinediones Weight gain CHF/fluid retention Risk of Fracture
Risk of bladder cancer

18. sulfonylureas Glyburide (DiaBeta, Glynase, or Micronase)
 1.25, 1.5, 2.5, 3, 5, 6 up to 20mg once daily with breakfast or in divided doses
Glimepiride (Amaryl)
1, 2, or 4mg up to 8mg once daily with breakfast
Glipizide (Glucotrol)
5 or 10mg up to 20mg BID with meals
Also comes in XL form (not on LAC+USC formulary)
Chlorpropamide (Diabinese)

19. sulfonylureas Risk of hypoglycemia Weight gain
In CKD, avoid glyburide (longest half-life) & use caution with others

21. Oral hypoglycemics
Consider initiating dual therapy in patients with newly diagnosed type 2 diabetes who have A1C ≥1.5% (12.5 mmol/mol) above their glycemic target. E

23. ABIM-style question
Patient is a 64 yo female who has NIDDM, htn, hld, CKD. She has recently been discharged from the hospital after a STEMI complicated by CHF with an EF of 35% as well as an AKI.
She currently feels well, has no angina, and is eulovemic.
PE is normal (except BMI of 38) including BP 122/68, pulse 68, no JVD, RRR with no gallop, CTA bilat, no edema.
Her only DM medication is MTF 500 mg BID.

24. You review her recent labs drawn several days ago prior to the office visit:
HgbA1c 8.9
Sodium 138
Potassium 4.8
Chloride 111
CO2 19
Glucose 198
Calcium 9.8
BUN 21
Creatinine 1.66 (baseline 1.35; max1.88 with recent AKI)
GFR 45
LFTs nl
WBC 7.6
RBC 3
Hgb 12
Hct 36
MCV 88
RDW 14
Platelets 299
TSH 2.43

25. ABIM-style question
Which of the following would you advise the patient in terms of managing her DM?
A) Her metformin 500mg BID must be stopped
B) Initiating canagliflozin may benefit her CV and renal status but must be renally dose adjusted
C) Exenatide should not be offered since it will cause weight gain
D) A, B, & C
E) B & C

26. ABIM-style question
Which of the following would you advise the patient in terms of managing her DM?
A) Her metformin 500mg BID must be stopped
B) Initiating canagliflozin may benefit her CV and renal status but must be dose adjusted
C) Exenatide should not be offered since it will cause weight gain
D) A, B, & C
E) B & C max dose 100 mg daily & monitor renal function closely

27. Additional references