Meds for Type 2 Diabetes - ADA Standards of Care Review

Vocabulary practice flashcards covering pharmacology, clinical trial evidence, dose titrations, and management guidelines for type 2 diabetes based on the DiabetesEd Mastery Series lecture.

Metformin

A biguanide medication that decreases hepatic glucose output, lowers A1C by $1.0\% - 2.0\%$, is weight neutral, does not cause hypoglycemia as monotherapy, and requires periodic monitoring of vitamin $B_{12}$ levels.

Metformin Renal Thresholds

Clinical guidelines for biguanide safety: do not initiate if GFR is $< 45\,\text{mL/min}$, discontinue use if GFR is $< 30\,\text{mL/min}$, and assess risk versus benefit while considering dose reduction if GFR falls to $30 - 45\,\text{mL/min}$.

Sulfonylureas

A class of insulin secretagogues (including glyburide, glipizide, and glimepiride) that stimulate pancreatic beta cells to release sustained insulin, lowering A1C by $1.0\% - 2.0\%$ with primary adverse effects of hypoglycemia and weight gain.

Meglitinides

Fast-acting insulin secretagogues (repaglinide and nateglinide) taken before meals that stimulate rapid bursts of insulin release to target postprandial hyperglycemia, lowering A1C by $1.0\% - 2.0\%$.

DPP-4 Inhibitors

Incretin enhancer medications that increase meal-stimulated insulin release and suppress glucagon secretion, lowering A1C by $0.6\% - 0.8\%$ with weight neutrality and low hypoglycemia risk, but carrying warnings for severe joint pain and pancreatitis.

DPP-4 Inhibitor Heart Failure Precaution

A safety warning specific to the DPP-4 inhibitors alogliptin and saxagliptin regarding an increased risk of heart failure, warranting monitoring for dyspnea, edema, and weakness.

GLP-1 Receptor Agonists (GLP-1 RAs)

Incretin mimetic agents that increase glucose-dependent insulin secretion, slow gastric emptying, suppress glucagon, and promote satiety, lowering A1C by $0.5\% - 1.6\%$ while reducing body weight and cardiovascular events.

Tirzepatide

A dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist that lowers A1C by $1.8\% - 2.4\%$ and achieves $7\% - 14\%$ weight loss, with advice to use back-up contraception for oral contraceptive users during the first $4\,\text{weeks}$.

Thyroid C-Cell Tumor Black Box Warning

A boxed warning present on GLP-1 receptor agonists and dual GLP-1/GIP agonists mandating avoidance in patients with a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN-2).

SGLT-2 Inhibitors

Medications known as 'glucoretics' (e.g., empagliflozin, canagliflozin, dapagliflozin) that inhibit glucose reabsorption in the proximal renal tubules, lowering glucose while offering significant cardiovascular, heart failure, and renal progression benefits.

SGLT-2 Inhibitor Adverse Effects

Characteristic side effects of SGLT-2 inhibitors, which include genitourinary infections, volume depletion, increased urination, hypotension, electrolyte imbalances, and euglycemic diabetic ketoacidosis (DKA).

Thiazolidinediones (TZDs)

Insulin sensitizers such as pioglitazone that decrease insulin resistance in muscle and adipose tissue and reduce free fatty acids, taking up to $6\,\text{weeks}$ for maximum effect and carrying precautions for fluid retention, heart failure, bone fractures, and bladder cancer.

Overbasalization

A clinical state signaled by basal insulin doses exceeding $0.5\,\text{units/kg/day}$, bedtime-to-morning glucose differentials $\ge 50\,\text{mg/dL}$, high glycemic variability, or hypoglycemia, indicating the need to add prandial therapy rather than uptitrating basal insulin.

Basal Insulin Initiation Regimen

The standard protocol for initiating basal insulin in type 2 diabetes: starting at $10\,\text{units/day}$ or $0.1 - 0.2\,\text{units/kg/day}$ and titrating by $2\,\text{units}$ every $3\,\text{days}$ until the fasting plasma glucose goal is achieved.

Prandial Insulin Initiation Regimen

The intensification protocol of adding rapid-acting insulin to the largest meal at $4\,\text{units/day}$ or $10\%$ of the basal insulin dose, followed by titration increases of $1 - 2\,\text{units}$ or $10\% - 15\%$ twice weekly.

Adequate Medication Taking Behavior

The threshold defining acceptable patient medication compliance as taking doses at least $80\%$ of the time; failing this threshold contributes to uncontrolled glycemia $23\%$ of the time.

Initial Combination Therapy Threshold

The recommendation under ADA guidelines to initiate two glucose-lowering agents simultaneously when baseline A1C is $\ge 8.5\%$ to expedite attainment of glycemic goals and slow control decline.

Severe Hyperglycemia Protocol

The clinical standard to strongly consider basal insulin or a sulfonylurea when A1C is $\ge 10\%$ or blood glucose is $> 300\,\text{mg/dL}$ with symptomatic presentation.

Alpha-Glucosidase Inhibitors

Oral agents including acarbose and miglitol that slow carbohydrate digestion in the brush border of the small intestine to target postprandial glucose excursions, with minimal systemic absorption.

ABCs of Diabetes (ADA Targets)

A foundational risk reduction framework recommending A1C $< 7\%$, blood pressure $< 130/80\,\text{mmHg}$ ($< 120/80\,\text{mmHg}$ if high CV risk), and statin therapy targeted to reduce LDL by $50\%$ with levels $< 70\,\text{mg/dL}$ ($< 55\,\text{mg/dL}$ if established ASCVD).