T2DM Guidelines

How often are the ADA guidelines updated?

annually in January

How often are the AACE guidelines updated?

periodically, most recently in 2023

What is the initiation dose of basal insulin according to ADA?

0.1-0.2 units/kg per day

What is the initiation dose of prandial insulin according to the ADA?

10% of basal insulin dose

What is the initiation dose of basal insulin according to AACE?

A1C <8%: 0.1-0.2 U/kg

A1C >8%: 0.2-0.3 U/kg

What is the initial dose of prandial insulin according to AACE?

10% of basal insulin dose

What are the lifestyle changes that are essential to a T2DM therapeutic plan?

weight reduction, healthy diet, exercise, smoking cessation

What is the relative efficacy of sulfonylureas?

high

What weight change is associated with sulfonylureas?

gain

What are the CV effects of sulfonylureas?

ASCVD: neutral

HF: neutral

What are the kidney effects of sulfonylureas?

progression of CKD: neutral

glyburide: CrCl < 50

glimepiride: eGFR <15

Glipizide: eGFR <10

What additional considerations do sulfonylureas have?

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

What is the relative efficacy of meglitinides?

low

What is the weight effect of meglitinides?

gain

What are the CV effects of meglitinides?

ASCVD: neutral

HF: neutral

What are the kidney effects of meglitinides?

progression of CKD: neutral

dosing: not required

What is the relative efficacy of biguanides?

high

What is the weight effect of biguanides?

neutral, modest loss

What are the CV effects of biguanides?

ASCVD: potential benefit

HF: neutral

What are the kidney effects of biguanides?

progression of CKD: neutral

dosing: CI when eGFR <30

What additional considerations do biguanides have?

vitamin B12 deficiency, lactic acidosis

What is the relative efficacy of thiazolidinediones?

high

What is the weight effect of thiazolidinediones?

gain

What are the CV effects of TZDs?

ASCVD: potential benefit (pioglitazone)

HF: increased risk

What are the kidney effects of TZDs?

progression of CKD: neutral

dosing: no dosing adjustments

What additional considerations do TZDs have?

bone fractures, bladder cancer

What relative efficacy do AGIs have?

high

What weight effect do AGIs have?

neutral

What CV effects do AGIs have?

ASCVD: neutral

HF: neutral

What kidney effects do AGIs have?

progression of CKD: neutral

dosing: not required

What is the relative efficacy of DPP4i?

intermediate

What is the weight effect of DPP4i?

neutral

What are the CV effects of DPP4i?

ASCVD: neutral

HF: potential risk (saxagliptin, alogliptin)

What are the kidney effects of DPP4i?

progression of CKD: neutral

dosing: required for all except linagliptin

What is the relative efficacy of SGLT-2i?

high

What is the weight effect of SGLT-2i?

loss

What are the CV effects of SGLT-2i?

ASCVD: benefit (cana, empa, dapta)

HF: benefit (cana, empa, dapta)

What are the kidney effects of SGLT-2i?

progression of CKD: benefit (cana, empa, dapta)

dosing: required for all

What additional considerations do SGLT-2is have?

eDKA, amputations, fournier’s gangrene, increased LDL

What is the FDA indication for canagliflozin?

adjunct to diet and exercise to improve glycemic control in adults with T2DM

What is the FDA indication for dapagliflozin?

(1) to reduce the risk of sustained eGFR decline, end stage kidney disease, cardiovascular death, and
hospitalization for heart failure in adults with chronic kidney disease at risk of progression.
(2) to reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure
visit in adults with heart failure.
(3) to reduce the risk of hospitalization for heart failure in adults with type 2 diabetes mellitus and either
established cardiovascular disease or multiple cardiovascular risk factors.
(4) as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

What is the FDA indication for empagliflozin?

(1) to reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart
failure.
(2) to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established
cardiovascular disease.
(3) as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus

What is the FDA indication for ertugliflozin?

adjunct to diet and exercise to improve glycemic control in adults with T2DM

What is the FDA indication for bexagliflozin?

adjunct to diet and exercise to improve glycemic control in adults with T2DM

What is the relative efficacy of GLP-1s?

high

What is the weight change assoicated with ozempic?

loss

What are the CV effects of GLP-1s?

ASCVD: benefit (liraglutide, semaglutide, dulaglutide)

HF: neutral

What are the kidney effects of GLP-1s?

improved renal outcomes with semaglutide and renal dosing required for exenatide

What additional considerations doe GLP-1s have?

FDA BBW of risk of thyroid c-cell tumor (all except lixisenatide); liraglutide & semaglutide have significant data to support use in blacks

What is the FDA indication for exenatide?

adjunct to diet and exercise to improve glycemic control in adults with T2DM

What is the FDA indication for liraglutide?

(1) as an adjunct to diet and exercise to improve glycemic control in patients 10 years and older with T2DM; (2) to reduce the risk of major adverse CV events in adults with T2DM and established CVD (3)Weight management, chronic (as Saxenda®)

What is the FDA indication of dulaglutide?

(1) adjunct to diet and exercise to improve glycemic control in adults with T2DM; (2) to reduce the risk of major adverse CV events (CV death, nonfatal MI, or nonfatal stroke) in adults with T2DMwho have established CV disease or multiple CV risk factors.

What is the FDA indication for semaglutide SQ?

(1) as an adjunct to diet and exercise to improve glycemic control in patients 10 years and older with T2DM; (2) to reduce the risk of major adverse CV events in adults with T2DM and established CVD; (3) to reduce the risk of sustained eGFR decline, end-stage kidney disease and cardiovascular death in adults with type 2 diabetes mellitus and chronic kidney disease; (4)Weight management, chronic (as Wegovy®)

What is the FDA indication for semaglutide PO?

As adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus

What is the FDA indication of tirzepatide?

(1) As adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (2) Obstructive sleep apnea, moderate to severe (as Zepbound®) (3)Weight management, chronic (as Zepbound®)

What is the relative efficacy of a GIP + GLP?

high

What is the CV effect of a GIP + GLP?

ASCVD: noninferior

HF: unknown

What are the kidney effects of a GIP + GLP??

improved renal outcomes: unknown

dosing: renal dosing not required

What additional information is associated with a GIP + GLP?

FDA BBW: risk of thyroid c-cell tumor

What is the relative efficacy of pramlintide?

low

What is the weight change associated with pramlintide?

neutral

What is the CV effects of pramlintide?

ASCVD: unknown

HF: unknown

What is the kidney effect of pramlintide?

progression of CKD: unknown

dosing: renal dosing not required

What additional considerations are true about pramlintide?

FDA BBW: risk of hypoglycemia

True or False: A1C lowering is unlimited with insulin

true

Who was enrolled in the DCCT study?

patients with T1DM

What was the conclusion of the DCCT?

intensive insulin treatments showed a reduction in retinopathy and other microcomplications

What is the conclusion of the UKPDS trial

to reduce complications of diabetes it is necessary to control blood glucose and A1C levels and blood pressure

Who was enrolled in the UKPDS trial?

T2DM

Who was enrolled in the ACCORD trial?

patients with T2DM; mean age of 62.2 years and mean DM duration of 10 years

What was the conclusion of the ACCORD trial?

intensive glycemic treatment strategy was associated with a higher risk of death over 3.4 years of follow up

Who was enrolled in the ADVANCE trial?

T2DM

What was the conclusion of the ADVANCE trial?

decreased microvascular complications

What was the conclusion of the VADT trial?

decreased microvascular complications

Which SLGT-2i have heart failure benefits?

canagliflozin, dapagliflozin, and empagliflozin

Which SGLT-2i have renal benefits?

empagliflozin, canagliflozin, dapagliflozin, ertugliflozin

Which GLPs have renal benefits?

liraglutide, semaglutide, dulaglutide

Which DPP4i have renal benefits?

linagliptin, saxagliptin