Diabetes Pre Class Reading

Diagnostic threshold for A1C

>= 6.5%

Diagnostic threshold for fasting plasma glucose

>=126ml/dl

Diagnostic 2-hr OGTT

>=200 mg/dl

Diagnostic random glucose with hyperglycemia symptoms

>= 200mg/dl

Goal A1C

<7%

Goal fasting glucose

80-130 mg/dl

Goal peak postprandial glucose

<180mg/dl

Goal time in range with CGM

>70%

Goal %time <70 with CGM

<4% (<1% in older adults)

Goal %time <54 with CGM

<1%

Some patients may have stricter A1C goals (i.e. ____ hypoglycemia risks) while others may have lenient A1C goals (ie. severe comorbidities where harms of ______ are greater than benefits)

low; hypoglycemia

Which agents have very high efficacy (1/8)

tirzepatide

Which agent have high to very high efficacy (2/8)

GLP-1 RA, insulin

Which agents have high efficacy (3/8)

metformin, pioglitazone, sulfonylurea

Which agents have intermediate to high efficacy (1/8)

SGLT2i

Which agents have intermediate efficacy (1/8)

DPP4i

Which 2 agents have a risk of hypoglycemia

sulfonylureas, insulins

Which agents are weight loss (3/8)

SGLT2i, GLP1RA, tirzepatide

Which agents are weight neutral (2/8)

metformin, DPP4i

Which agents are weight gain (3/8)

pioglitazone, sulfonylurea, insulin

Which agents have CV benefit (2/8)

SGLT2i, GLP-1RA

Which agents have potential benefit (2/8)

metformin, pioglitazone

Which agents have neutral CV benefit (3/8)

DPP-4I, sulfonylurea, insulin

Which agents have TBD CV benefit (1/8)

tirzepatide

Which agents have beneficial HF effects (3/8)

SGLT2i, GLP1RA, tirzepatide

Which agent have neutral HF effects (4/8)

metformin, DPP-4I, sulfonylurea, insulin

Which agents have increased risk HF effects (1/8)

pioglitazone

Which agents are beneficial on renal effects (2/8)

SGLT2i, GLP1RA

Which agents have possible benefit on renal effects (1/8)

tirzepatide

Which agents are neutral for renal effects (5/8)

metformin, DPP-4I, pioglitazone, sulfonylurea, insulin

Dosing considerations for metformin

CI in pts with GFR <30

Dosing considerations in SGLT2is

glucose lowering effects are minimal in pts with eGFR <45

Dosing considerations for DPP4I

individual agent adjustments should be made based on renal function

Dosing considerations for sulfonylureas

use conservatively or not at all in pts with renal impairment

Dosing considerations in insulin

reduce doses in pts with renal impairments

Which agents should be initiated in patients with ASCVD

GLP1RA or SGLT2i

Which agents should be initiated in patients with high CVD risks

GLP1RA or SGLT2i

Which agents should be initiated in patients with HF

SGLT2i

Which agents should be initiated in patients with CKD

SGLT2i or GLP1RA

Which agents should be initiated in patients for weight loss

semaglutide/tirzepatide > dulaglutide/liraglutide> other GLP1RAS or SGLT2i > metformin or DPP4-I

Which agents should be initiated in patients for glycemic control only

metformin

Which agents should be initiated before using insulin in T2DM pts

GLP1RA or GLP/GIP

What type of insulin is recommended for initial therapy in T2DM

long-acting basal (ex. glargine, degludec, NPH)

What is the starting dose for long-acting basal insulin

10 units/day (or 0.2units/kg)

When should short-acting insulin be added in T2DM

If the A1C goal isn’t met after using basal insulin

What is the starting dose for short-acting insulin in T2DM

4units before meals (or 0.1 units/kg/dose)