Old School Cool
I work to lower blood sugars by decreasing hepatic gluconeogenesis, improving insulin sensitivity, and blocking the absorption of carbohydrates
Metformin
Guidelines recommend to start SGLT2is or GLP1s for patients with high ASCVD risk and indicators of risk. Define that risk.
Defined differently across CVOTs but all included individuals with established CVS (e.g., Mi, stroke, and arterial re-vascularization procedure) and variably included conditions such as transient ischemic attack, unstable angina, amputation, and symptomatic or asymptomatic coronary artery disease. Indicators of high risk: While definitions vary, most comprise >= 55 years of age with two or more additional risk factors (including obesity, hypertension, smoking, dyslipidemia, or albuminuria)
"I've heard metformin harms my kidneys." eGFR 40 ml/min. Name a safe dose.
DO NOT start metformin
I am a GLP-1 and need a prescription for pen needles.
Liraglutide (Victoza)
I'm the only GLP1 FDA approved for MASH.
semaglutide (Wegovy) 2.4mg SC once weekly.
Other GLP1-RAs have shown potential benefit but not FDA approved, includes GIP/GLP1-RA tirzepetide (Mounjaro)
GLP1s get all the buzz but I came first and work on the same incretin pathway.
DPP4 inhibitor: sitagliptin, linagliptin, alogliptin
We all work the same. We are the odd flozins out who don't reduce CV risk reduction.
No CV risk reduction: dapagliflozin (Farxiga), ertugliflozin (Steglatro).
YES, reduction in MACE (major adverse cardiovascular events): canagliflozin (Invokana), empagliflozin (Jardiance)
Pick me, pick me, I'm the only DPP4i that doesn't need to be renally dose adjusted. Hint: sitagliptin (Januvia), linagliptin (Tradjenta) or alogliptin (Nesina)
linagliptin (Tradjenta)
sitagliptin (Januvia)- Always start at maximum dose and then renally dose adjust to lower doses as appropriate.
Cannot tolerate semaglutide injectable
Try other GLP-1 that might be tolerated better such as Semaglutide tablets, Delaglutide, Liraglutide, Tirzepetide. [SPELL CHECK -same as other question RW case --could we sub a question related to delivery or injectables like AR is a 36 yo with cerepral palsy, A1C xyc, challenges putting need on injectable...answer Trulicity or Mounjaro]
I'm the only oral medication that has show benefit in diabetes and MASLD F0-F3.
pioglitazone (Actos)
Give me a chance, I can decrease A1c by 2% (but I might burn some beta cells out in the process).
Sulfonylurea: glipizide, glimeperide, glyburide
HFrEF - let's go! At first, everyone thought it was just about diuresis but we do so much more.
SGLT2s - all have shown benefit in HFrEF
No renal dose adjustments needed and I slow the progression of CKD. I am available as an injection or tablet.
Any GLP1. Findings driven by outcomes in CVOT trials for albuminuria.
Specifically for this question, what is semaglutide (Ozempic injection and tablets).
These are the recommendations when starting a SGLT-2 Inhibitor. -->What are some counseling points when starting an SGTL2i? similar to MASH and side of pearls question $400
Good hydration and good hygiene after urination.
You start dulaglutide (Trulicity) 0.75mg SC weekly. Four weeks later, pt is back and BG at goal. Other strengths available: 1.5mg, 3mg, 4.5mg. I'm the strength that has been shown to have glycemic and weight loss benefits.
dulaglutide (Trulicity) 1.5mg, need to get to step 2 or second strength of GLP1-RA and GIP/GLP1-RA. These were the doses studied in trials that demonstrated glycemic benefit and weight loss.
I take about 8 weeks to have an effect on blood sugars since I work to change gene expression of the PPAR‑γ receptor.
Thiazolidinedione: pioglitazone
RW 45 y.o male returns to the ER for evaluation of his recent stroke and (CAD). Reports dizziness, nocturia, and blurry vision. New labs show A1C 8%, eGFR 50 mL/min, BMI 40. Currently on insulin glargine 20 units bid and insulin lispro 4 units TID before meals. POCT Glucose 250 mg/dL, has a CGM with time in target at 40%. Declines an additional injection.
Oral semaglutide (Rybelsus --> Ozempic tablets)
Bonus: should you avoid GLP1-RA in patients with blurry vision?
Hx of ischemic stroke, A1c 8.6%, let's start empagliflozin, but wait, eGFR 22 ml/min. To continue or discontinue?
Ok to continue for renal protection but SGLT2i don't work as well for glycemic control when eGFR <45 ml/min.
72 yo recently admitted for UTI and found to have DM type II. A1C 13.8%. Discharged on basal-prandial insulin. Has hx of HFrEF, HTN. She asks about starting canagliflozin (Invokana) right now. You say...and explain...
Recent UTI
Weigh risk/benefit right now of eDKA
I lower blood sugar when it is elevated by increasing glucosuria which lowers sugar but also can increase risk for GU infections. Write an rx including instructions.
SGLT2i 1 tablet every morning before food, qty, refills.
Jardiance 10mg 1 tab po qAM before breakfast. Qty #30, Refills 11.
I hit the scene in 2005 but really gained popularity more recently. Compared to other non-insulin agents, I lower A1c the most.
GLP1-RA: liraglutide (Victoza), dulaglutide (Trulicity), semaglutide (Ozempic)
Provides cardiovascular and kidney risk reduction.
MS is a 57 yo male with hx of CVA, stable angina, CAD, HLD, type 2 DM, s/p CABG x4 and a BMI 35, present for DM follow-up today.
On Metformin 1000 mg BID, Ozempic 2 mg weekly, Aspirin 81 mg daily, Losartan 50 mg daily, Atorvastatin 80 mg daily.
Most recent A1C 8.5%, eGFR >60 mL/min, triglycerides 248 mg/dL.
Empagliflozin 10mg 1 tab po qAM
This medication increased the risk for hypoglycemia on patients with low eGFR.
Glipizide
Gained 5 lbs in the last month since started this medication.
Glipizide and/or pioglitazone
I am the most affordable medication in the algorithm
"OLD School" metformin, glipizide