Diabetes Mellitus: Non-Insulin Treatment Options

Q: Medications for type 2 diabetes target multiple sites throughout the body to lower blood glucose levels. Which of the following medication is known for highest average reduction in HbA1c?

 


 

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This post will focus on non-insulin treatment options for diabetes management. The following table will summarize this in following topics:

 

  1. Mechanism of action.

  2. HbA1c reduction.

  3. Adverse effects.

  4. Precautions

  5. Monthly cost.

 

 


 

MEDICATIONS

(DOSE/ MONTHLY COST)

MECHANISM OF ACTION

A1c REDUCTION

ADVERSE EFFECTS

PRECAUTIONS

Alpha-glucosidase inhibitor

1.Acarbose (Precose)

25-100 mg TID

($80-105)

 

2.Miglitol (Glyset)

25-100 mg TID

($160-210)

Inhibits enzyme at intestinal brush border, slow carb absorption

0.5- 0.8%

Diarrhea, abd bloating, flatulence

– Avoid Cr Cl<25

– Effective with starchy high fiber diet

Biguanides

Metformin

500-1000 mg BID

($4-35)

Decrease intestinal absorption of carb and hepatic glucose formation, increase insulin sensitivity

1-1.3%

Abd bloating, diarrhea, nausea.

ER tablets have less GI side effects

– Review in GFR<30-44

– Discontinue in GFR<30

– Discontinue in acute illness (can lead to lactic acidosis)

Dipeptidy-peptidase-4 inhibitors

1.Alogliptin (Nesina)

25 mg qd

($340)

 

2.Linagliptin (Tradjenta)

5 mg qd

($400)

 

3.Saxagliptin (Onglyza)

2.5 to 5 mg qd

($350)

 

4.Sitagliptin (Januvia)

50-100 mg qd

($360)

Increase insulin secretion from Beta cells and GLP-1;

decrease glucagon secretion form alpha cells.

0.5-0.9%

Headache, pancreatitis

– Saxagliptin dose adjustment if given with CYP3A4 inhibitors.

Glucagon like peptides -1 receptor agonist

1.Albiglutide (Tanzeum)

30-50 mg SC qwk

($650)

 

2.Dulaglutide (Trulicity)

0.75-1.5 mg qwk

($700)

 

3.Exenatide

Byetta 5-10 mg BID

($500)

Bydureon 2 mg qwk

($520)

 

4.Liraglutide (Victoza)

1.2 -1.8 mg qd

($705)

Increase insulin secretion from Beta cells & decrease glucagon secretion form alpha cells, decrease hepatic glucose formation.

0.8-2%

Nausea, vomiting, weight loss, pancreatitis(rare)

– Avoid exenatide in CrCl<30

– Box warning in medullary thyroid cancer and MEN type 2 personal or family hx.

Meglitinides

1.Nateglinide (Starlix)

120 mg TID

($155)

 

2.Repaglinide (Prandin)

0.5-4 mg TID

($300-660)

Close K channel in beta cell, causing release of insulin

0.5-1%

Hypoglycemia

– Metabolized in liver (CYP3A4 & CYP2C9).

Na- glucose cotransporter 2 inhibitor

1.Canagliflozin (Invokana)

100-300 mg TID

($375)

 

2.Dapagliflozin (Farxiga)

5-10 mg qd

($375)

 

3.Empagliflozin(Jardiance)

10-25 mg qd

($410)

Inhibits renal Na-glucose channel causing urinary glucose excretion

0.5-0.9%

Increased UTI & genital infections, increase LDL, weight loss

– Dose adjustment in renal impairement.

– Avoid if GFR <45

Sulfonylureas

1.Glimepiride(Amaryl)

1-8 mg qd

($10-70)

 

2.Glipizide (Glucotrol)

5-15 mg qd

($10-30)

 

3.Glyburide (Glynase)

1.25-20 mg

($10-90)

Attaches to K channel and increases release of insulin from Beta cell of pancreas.

0.4-1.2%

Hypoglycemia, weight gain

– Dose adjustment required in renal impairment.

– Give medication with food.

Thiazolidinediones

1.Pioglitazone (Actos)

15-45 mg qd

($210-350)

 

2.Rosiglitazone(Avandia)

4-8 mg qd

($140-255)

Increase hepatic glucose uptake, decrease hepatic glucose production, increase insulin sensitivity in muscle, adipose tissue

0.5-1.4%

Weight gain, edema

Contraindicated in CHF, decrease concomitant insulin dose at initiation

Source: Am Fam Physician. 2015 Jul 1;92(1):27-34.


Post by Dr. Satinderpal Kaur, M.D.

 


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