9. The long-acting basal dose is titrated to regulate overnight, fasting glucose. The optimal time to administer prandial insulin varies, based on the pharmacokinetics of the formulation (regular, RAA, inhaled), the premeal blood glucose level, and carbohydrate consumption. 2021 Highlights Webcast. E. The American Diabetes Association/European Association for the Study of Diabetes consensus report “Management of Hyperglycemia in Type 2 Diabetes, 2018” and the 2019 update (33,34) recommend a patient-centered approach to choosing appropriate pharmacologic treatment of blood glucose (Fig. It is common practice to initiate insulin therapy for patients who present with blood glucose levels ≥300 mg/dL (16.7 mmol/L) or A1C >10% (86 mmol/mol) or if the patient has symptoms of hyperglycemia (i.e., polyuria or polydipsia) or evidence of catabolism (weight loss) (Fig. This synopsis focuses on guidance relating to the pharmacologic treatment of adults with type 2 diabetes. If basal insulin has been titrated to an acceptable fasting blood glucose level (or if the dose is >0.5 units/kg/day) and A1C remains above target, consider advancing to combination injectable therapy (Fig. At the time of a diagnosis of type 2 diabetes, the ADA recommends prompt initiation of lifestyle management, determination of appropriate glycemic targets (inclusive of A1C goals), and initiation of pharmacologic therapy ().Figure 1 provides a summary of general recommendations from the ADA’s Standards of Medical Care in … Human regular insulin, NPH, and 70/30 NPH/regular products can be purchased for considerably less than the AWP and NADAC prices listed in Table 9.3 at select pharmacies. 1):S98–S110 - August 01, 2020, http://www.diabetesjournals.org/content/license, http://www.fda.gov/Drugs/DrugSafety/ucm493244.htm, http://www.micromedexsolutions.com/micromedex2/4.34.0/WebHelp/RED_BOOK/Introduction_to_REDB_BOOK_Online.htm, https://data.medicaid.gov/Drug-Pricing-and-Payment/NADAC-National-Average-Drug-Acquisition-Cost-/a4y5-998d, 9. For appropriate context, see Fig. However, there is evidence that patients with uncontrolled hyperglycemia associated with type 2 diabetes can also be effectively treated with a sulfonylurea (41). A, 9.6 Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure. However, GLP-1 RAs in these trials had a lower risk of hypoglycemia and beneficial effects on body weight compared with insulin, albeit with greater gastrointestinal side effects. With the advent of improved continuous glucose monitors, closed-loop pump-sensor systems, and devices that offer alternative approaches for patients with hypoglycemia unawareness, the role of pancreas transplantation alone, as well as islet transplant, will need to be reconsidered. Rather, drug choice is based on avoidance of side effects, particularly hypoglycemia and weight gain, cost, and patient preferences (48). 2017 Oct 3;167(7):493-498. doi: 10.7326/M17-1259. Management of hyperglycaemia in type 2 diabetes, 2018. Additional large randomized trials of other agents in these classes are ongoing. Because insulin absorption from IM sites differs according to the activity of the muscle, inadvertent IM injection can lead to unpredictable insulin absorption and variable effects on glucose, with IM injection being associated with frequent and unexplained hypoglycemia in several reports. Metformin should be started at the time type 2 diabetes is diagnosed unless there are contraindications; for many patients this will be monotherapy in combination with lifestyle modifications. Recommendations have been published elsewhere outlining best practices for insulin injection (23). However, there is no consensus to guide the choice of injection or pump therapy in a given patient, and research to guide this decision-making is needed (12). The subjects enrolled in the cardiovascular outcome trials using empagliflozin, canagliflozin, liraglutide, and semaglutide had A1C ≥7%, and more than 70% were taking metformin at baseline. For patients without established ASCVD, indicators of high ASCVD risk, HF, or CKD, the choice of a second agent to add to metformin is not yet guided by empiric evidence. For patients with established ASCVD or indicators of high ASCVD risk (such as patients ≥55 years of age with coronary, carotid, or lower-extremity artery stenosis >50% or left ventricular hypertrophy), established kidney disease, or heart failure, an SGLT-2 inhibitor or GLP-1 RA with demonstrated CVD benefit (Table 9.1, Table 10.3B, Table 10.3C) is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors (Figure 9.1). Titration can be based on home glucose monitoring or A1C. Pharmacologic Approaches to Glycemic Treatment Pharmacologic Therapy for Type 1 … •Review 2020 ADA Standards of Medical Care in Diabetes ... PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT 9.4 Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. Thus, it is important that insulin be delivered into the proper tissue in the right way. In this landmark trial, lower A1C with intensive control (7%) led to ∼50% reductions in microvascular complications over 6 years of treatment. © 2019 by the American Diabetes Association. Cardiovascular Disease and Risk Management Hypertension/Blood Pressure Control Lipid Management Antiplatelet Agents Cardiovascular Disease S124 11. 9.1). As glucose toxicity resolves, simplifying the regimen and/or changing to oral agents is often possible. Pharmacologic Approaches to Glycemic Treatment: NCI CPTC Antibody Characterization Program. More information is available at http://www.diabetesjournals.org/content/license. The prandial insulin regimen can then be intensified based on patient needs (see Figure 9.2). Diabetes can be classified … These concentrated preparations may be more convenient and comfortable for patients to inject and may improve adherence in those with insulin resistance who require large doses of insulin. With significant additions to the prandial insulin dose, particularly with the evening meal, consideration should be given to decreasing basal insulin. Many patients with type 2 diabetes eventually require and benefit from insulin therapy (Fig. Similar considerations are applied in patients who require a third agent to achieve glycemic goals; there is very little trial-based evidence to guide this choice. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes. Thus, education of patients on how to adjust prandial insulin to account for carbohydrate intake, premeal glucose levels, and anticipated activity can be effective and should be offered to most patients (20,21). Intensive insulin management using a version of CSII and continuous glucose monitoring should be considered in most patients. | U-300 glargine has a longer duration of action than U-100 glargine but modestly lower efficacy per unit administered (81,82). In addition to hyperglycemia, insulinopenia can contribute to other metabolic disturbances like hypertriglyceridemia and ketoacidosis as well as tissue catabolism that can be life threatening. 1): S64-S74 Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Pharmacologic Approaches to Glycemic Treatment–2020 and 10. Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes. Practical Strategies to Help Reduce Added Sugars Consumption to Support Glycemic and Weight Management Goals Hope Warshaw and Steven V. Edelman Clinical Diabetes 2021 Jan; 39 … As noted in Table 4.1, examination of insulin injection sites for the presence of lipohypertrophy, as well as assessment of injection device use and injection technique, are key components of a comprehensive diabetes medical evaluation and treatment plan. Successful pancreas and islet transplantation can normalize glucose levels and mitigate microvascular complications of type 1 diabetes. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Intensification of insulin treatment can be done by adding doses of prandial to basal insulin. Cardiovascular Disease and Risk Management–2020. The cost of insulin has been rising steadily over the past two decades, at a pace several fold that of other medical expenditures (76). In the VERIFY trial, participants receiving the initial combination of metformin and the dipeptidyl peptidase 4 (DPP-4) inhibitor vildagliptin had a slower decline of glycemic control compared with metformin alone and to vildagliptin added sequentially to metformin. Sign In to Email Alerts with your Email Address. The ADA has developed and provided diabetes care stand-ards, guidelines and related doc-uments since 1989, and its clini-cal practice recommendations are integral resources for health care professionals. | Results of recent large trials with cardiovascular and renal outcomes are emphasized. The ongoing Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE) will compare four drug classes (sulfonylurea, DPP-4 inhibitor, GLP-1 receptor agonist, and basal insulin) when added to metformin therapy over 4 years on glycemic control and other medical, psychosocial, and health economic outcomes (28). Over the last 25 years, rapid-acting and long-acting insulin analogs have been developed that have distinct pharmacokinetics compared with recombinant human insulins: basal insulin analogs have longer duration of action with flatter, more constant plasma concentrations and activity profiles than NPH insulin; rapid-acting analogs (RAA) have a quicker onset and peak and shorter duration of action than regular human insulin. Epub 2017 Mar 14. Would you like email updates of new search results? Similarly, the addition of a sodium–glucose cotransporter 2 (SGLT2) inhibitor to insulin therapy has been associated with improvements in A1C and body weight when compared with insulin alone (30,31); however, SGLT2 inhibitor use in type 1 diabetes is associated with a two- to fourfold increase in ketoacidosis. Members of the [ADA Professional Practice Committee][1], a multidisciplinary expert … Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2020 Diabetes Care . Once a basal/bolus insulin regimen is initiated, dose titration is important, with adjustments made in both mealtime and basal insulins based on the blood glucose levels and an understanding of the pharmacodynamic profile of each formulation (pattern control). Description: 9. Reduction of nocturnal hypoglycemia in people with type 1 diabetes using insulin pumps with glucose sensors is improved by automatic suspension of insulin delivery at a preset glucose level (12–14). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020 American Diabetes Association Diabetes Care 2020 Jan; 43 … care.diabetesjournals.org Pharmacologic Approaches to Glycemic Treatment S101 ©2019 ... Current pharmacologic treatment op-tions for youth-onset type 2 diabetes are limited to three approved drugsd ... January 2020 ©2019 American Diabetes Association. U-500 regular insulin is, by definition, five times more concentrated than U-100 regular insulin. Ensuring that patients and/or caregivers understand correct insulin injection technique is important to optimize glucose control and insulin use safety. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. A, 9.10 In patients with type 2 diabetes who need greater glucose lowering than can be obtained with oral agents, glucagon-like peptide 1 receptor agonists are preferred to insulin when possible. A, 9.7 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. Comprehensive education regarding self-monitoring of blood glucose, diet, and the avoidance and appropriate treatment of hypoglycemia are critically important in any patient using insulin. Adapted from Davies et al. For example, instruction of patients in self-titration of insulin doses based on self-monitoring of blood glucose improves glycemic control in patients with type 2 diabetes initiating insulin (58). On the other hand, two doses of premixed insulin is a simple, convenient means of spreading insulin across the day. Diabetes Care 19 December 2019 [Epub ahead of print].DOI: 10.2337/dci19-0066, 10-year follow-up of intensive glucose control in type 2 diabetes, Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systematic review and meta-analysis, FDA Drug Safety Communication: FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function, Long-term treatment with metformin in type 2 diabetes and methylmalonic acid: post hoc analysis of a randomized controlled 4.3year trial, Diabetes Prevention Program Research Group, Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study, Dapagliflozin, metformin XR, or both: initial pharmacotherapy for type 2 diabetes, a randomised controlled trial, Safe and simple emergency department discharge therapy for patients with type 2 diabetes mellitus and severe hyperglycemia, Clinical considerations for use of initial combination therapy in type 2 diabetes, Initial combination therapy with metformin, pioglitazone and exenatide is more effective than sequential add-on therapy in subjects with new-onset diabetes. Pramlintide is based on the naturally occurring β-cell peptide amylin and is approved for use in adults with type 1 diabetes. Adapted from Davies and colleagues (33,34). NLM Recommended sites for insulin injection include the abdomen, thigh, buttock, and upper arm. Recommended starting dose is 500mg daily with the evening meal, increasing as needed to achieve goals to a total dose of 2000mg per day (ADA, 2020). This is compatible with a recent report from the Diabetes Prevention Program Outcomes Study (DPPOS) suggesting periodic testing of vitamin B12 (39).
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