Clinical Pearls for Diabetic Agents

efficacy of sulfonylureas

high (A1c lowering 0.8-2%)

do sulfonylureas have risk of hypoglycemia?

yes

what weight changes occur on SU?

gain

cost of SU?

low

Route of administration for SU

oral

CV effects of SU:

ASCVD: neutral

HF: neutral

kidney effects of SU

progression of CKD: neutral

Glyburide not recommended at CrCl < 50

Glimepiride not recommended at eGFR < 15

Glipizide not recommended at eGFR < 10

considerations for SU

may blunt myocardial ischemia preconditioning, low durability, glyburide and glimepiride on BEERS list

efficacy of meglitinides

low (A1c lowering 0.6-1%)

do meglitinides have risk of hypoglycemia

yes

weight changes associated with meglitinides:

gain

cost for meglitinides

intermediate

route of administration for meglitinides

oral

CV effects of meglitinides

ASCVD: neutral

HF: neutral

kidney effects for meglitinides

progression of CKD: neutral

dosing adjustments: not required

efficacy of biguanides

high (A1c lowering: 1-2%)

do biguanides have risk of hypoglycemia

no

what weight changes are associated with biguanides?

neutral, modest loss

cost of biguanides

low

route of administration for biguanides

oral

CV effects of biguanides

ASCVD: potential benefit

HF: neutral

kidney effects of biguanides

progression of CKD: neutral

contraindicated when eGFR < 30

considerations for biguanides

vitamin B12 deficiency, lactic acidosis

efficacy of TZDs

high (A1c lowering ~1%)

do TZDs have a risk of hypoglycemia

no

what is the weight change associated with TZDs

gain

cost of TZDs

low

route of administration for TZDs

oral

CV effects of TZDs

ASCVD: potential benefit (pioglitazone)

HF: increased risk

kidney effects of TZDs

progression of CKD: neutral

No dosing adjustments

considerations for TZDs

risk of bone fractures and bladder cancer (pio)

efficacy of AGIs

high (A1c lowering ~1%)

do AGIs have a risk of hypoglycemia?

no

weight change associated with AGI?

neutral

cost of AGIs

intermediate

route of administration for AGIs

oral

CV effects for AGIs

ASCVD: neutral

HF: neutral

kidney effects of AGIs

progression of CKD: neutral

dosing: not required

efficacy of DPP4i

intermediate (A1c lowering ~0.75%)

do DPP4i have risk of hypoglycemia

no

weight changes associated with DPP4is

neutral

cost of DPP4i

high

route of administration for DPP4i

oral

CV effects of DPP4is

ASCVD: neutral

HF: potential risk (saxagliptin and alogliptin)

kidney effects of DPP4is

progression of CKD: neutral

renal dosing required for all except linagliptin

considerations for DPP4is

do not use with GLP-1 RA

efficacy of SGLT2i

high (A1c lowering: 1-2%)

do SGLT2i have risk of hypoglycemia?

no

weight changes associated with SGLT2i

loss

cost of SGLT2i

high

route of administration for SGLT2i

oral

CV effects of SGLT2i

ASCVD: benefit (canagliflozin, empagliflozin, dapagliflozin)

HF: benefit (canagliflozin, empagliflozin, dapagliflozin)

Kidney effects of SGLT2i

progression of CKD: benefit (canagliflozin, empagliflozin, dapagliflozin)

kidney dosing required for all

considerations for SGLT2i

risk of eDKA, amputations, Fournier’s Gangrene, and increased LDL

which SGLT2i only have the FDA indication for adjunct to diet and exercise to improve glycemic control in adults with T2DM?

canagliflozin, ertugliflozin, and bexagliflozin

efficacy of GLP-1 RA

high (A1c lowering 1-2%)

do GLP-1 RA have risk of hypoglycemia?

no

weight change associated with GLP-1s

loss

cost of GLP-1s

high

route of administration for GLP-1s

subcutaneous injection and oral

CV benefits of GLP-1s

ASCVD: benefit (liraglutide, semaglutide SC, and dulaglutide)

HF: neutral

kidney effects of GLP-1s

improved renal outcomes (semaglutide) and renal dosing required for exenatide products

considerations for GLP-1s

FDA BBW: risk of thyroid c-cell tumor (ALL except lixisenatide)

liraglutide and semaglutide have significant data (A1c, FBG, weight) to support use in blacks

efficacy for GIP + GLP-1 RA

high (A1c lowering ~2%)

do GIP + GLP-1 RA have risk of hypoglycemia

no

what weight changes are associated with GIP + GLP-1 RA?

loss (~ 7 kg)

cost of GIP + GLP-1 RA

high

route of admin for GIP + GLP-1

subcutaneous injection

CV effects of GIP + GLP-1 RA

ASCVD: noninferior

HF: unknown

kidney effects of GIP + GLP-1 RA

improved renal outcomes: unknown

renal dosing NOT required

considerations for GIP + GLP-1 RA

FDA BBW: risk of thyroid c-cell tumor

efficacy of pramlintide

low (A1c lowering ~0.6%)

does pramlintide have risk of hypoglycemia?

yes

weight change associated with pramlintide

neutral

cost of pramlintide

high

route of administration for pramlintide

subcutaneous injection

CV effects of pramlintide

ASCVD: unknown

HF: unknown

Kidney effects of pramlintide

progression of CKD: unknown

renal dosing not required

considerations for pramlintide

FDA BBW: risk of hypoglycemia

efficacy of insulin

high (A1c lowering is unlimited)

does insulin carry risk of hypoglycemia?

yes

weight change associated with insulin resistance

gain

cost of insulin

human = low

analogs = high

route of administration of insulin

subcutaneous injection or inhaled.

CV effects of insulin

ASCVD: neutral

HF: neutral

kidney effects for insulin

progression of CKD: neutral

no renal dose adjustments but lower doses may be required