DM treatment algorithm

what needs to be done firt before ppl are put on insulin if a1c is not met

• put on glp or dual ag

• titrated up on glp first

or CI for GLP

what insulin should ppl be started on when glp not enough for a1c? what is the dose?

basal analog or bedtime NPH

• 10 units a day or 0.1-0.2 u/kg/day

how is insulin if glp no work for a1c dosed?

FPG goal

if a1c remains above goal after basal insulin and glp, what should be started next

prandial insulin

• starting on 4 units a day (lower if a1c under 8)

• can titrate up twice weekly

what are the options if someone has still high a1c and on glp, basal, and starting prandial

• “stepwise doses” of prandial

• spread out NPH (basal) dosing

• twice dialy MIX of basal and rapid

how often should treatment be reconsidered

every 3-6 months

list agents with benefit in MASLD/MASH . what could be used in decompensated cirrhosis

GLP-1 RA, dual GIP and GLP-1 RA, pioglitazone, or combination of GLP-1 RA with pioglitazone.

• Use insulin in the setting of decompensated cirrhosis

why is insulin to be used in decompensated cirrhosis

when liver is so damanged other drugs will damage it so insulin is pref

how to determine pt has CKD or needs meds for CKD

• eGFR < 60 ml/min/1.73 m³

• albuminuria (>3 mg/mmol)

measurement must be made twice

what should DM patient be given if have CKD? what should they already be on before all this?

SGLTi— can be started as long as eGFR is over 20

OR

GLP-1ra — should add to SGLT if A1C is above goal

• before all this— should be on max tolerated ACEi or ARB!

what should DM patients be on if HF

SGLT2i

options to take for DM patients with ASCVD or indicators of high CVD risk

• GLP-ra

• SGLT2i

add the other if A1C stays above goal; and/or pioglitazone

which glp or duo are MOST effiacious for wt loss

semaglutide

tirzepatide

which glps have high effiacy but not most for wt loss? which are intermediate?

high: dulaglutide, liraglutide

intermediate: other glps, SGLT2i

what are the most efficacious for glucose lowering

dulaglutide high dose, semaglutide, tirzepatide, insuiln

• can be oral or injectable

what drugs have high but not MOST efficacious for glucose lowering

glps not dula/sem/tirz; metformin, pioglitazone, SGLT2i, sulfonylureas

what has intermediate ind for gluocse lowering

dpp-4i

What are the SGLT2is for CVD risk

empag (jardiance)

canaglif (invokana)

what are the SGLT2is for HF

dapa (farxiga)

empag (jardiance)

cana (invokana)

which SGLT2i for CKD

cana (invokana)

dapa (farxiga)

empag (jardiance)

which ONE glp-1 has some renal benefit

semaglutide

which GLPs for CVD risk

dulaglutide (primary or secondary)

semaglutide (only pri/sec IF the pill formulation)

liraglutide (pri/sec)

which glps have benefit in MASLD

• semaglutide

• tirzepatide

• exenatide