Mount Carmel Health Partners Clinical Guidelines Diabetes Type II | Page 6

Table 4: Properties of available glucose-lowering agents in the U.S. and Europe that may guide individualized
treatment choices in patients with type 2 diabetes. (continued)
Class
Compounds
(Brand Names)
Cellular
Mechanisms
Primary Physiological
Action(s)
Advantages
Disadvantages Cost
High
Amylin
mimetics Pramlintide§ (Symlin) Activates amylin
receptors • ↓Glucagon secretion
• ↓Postprandial glucose
• Slows gastric emptying
excursions
• ↑Satiety
• ↓Weight • Generally modest A1C efficacy
• Gastrointestinal side effects
(nausea/vomiting)
• Hypoglycemia unless
insulin dose is
simultaneously reduced
• Injectable
• Frequent dosing schedule
• Training requirements
Insulins • Rapid-acting analogs
- Lispro (HumaLog)
-Aspart (NovoLog)
-Glulisine (Apidra, Apidra
SoloStar)
• Short-acting
-Human Regular
• Intermediate-acting
-Human NPH
• Basal insulin Analogs
-Glargine (BASAGLAR,
Lantus, Lantus SoloStar,
Toujeo SoloStar)
-Detemir (Levemir)
-Degludec (Tresiba)
• Premixed (several types) Activates insulin
receptors • ↑Glucose disposal
• ↓Hepatic glucose
production
• Suppresses
ketogenesis • Hypoglycemia
• Weight gain
• ?Mitogenic effects
• Injectable
• Patient reluctance
• Training requirements
• Nearly universal
response
• Theoretically unlimited
efficacy
• ↓Microvascular risk
(UKPDS)
Variable#
CKD: chronic kidney disease; ASCVD: atherosclerotic cardiovascular disease; GIP: glucose-dependent insulinotropic peptide; HDL-C:
HDL cholesterol; LDL-
C: LDL cholesterol; MI: myocardial infarction; PPAR-g: peroxisome proliferator–activated receptor g; PROactive: Prospective Pioglitazone Clinical Trial in Macrovas-
cular Events (30); STOP-NIDDM: Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (31); TZD: thiazolidinedione; T2DM,: type 2 diabetes mellitus; UKPDS:
UK Prospective Diabetes Study (32,33). Cycloset trial of quick-release bromocriptine (34). *Cost is based on lowest-priced member of the class. ‡Initial concerns
regarding bladder cancer risk are decreasing after subsequent study. §Not licensed in Europe for type 2 diabetes. #Cost is highly dependent on type/brand
(analogs > human insulins) and dosage.
References:
1. http://www.nhlbi.nih.gov
2. http://care.diabetesjournals.org/contents/22/Supplement1/S4.full.pdf+html (2012, Volume 35, with 1/2014 Supplement)
3. Executive summary: “Standards of care in diabetes--2010.” Diabetes Care, vol. 33, supplement 1, January 2010.
See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.
4. American Diabetes Association. Standards of medical care in diabetes. 2017.
6. UpToDate. Clinical presentation and diagnosis of diabetes mellitus in adults. 2017. Retrieved from: www.uptodate.com
7. UpToDate. Initial management of blood glucose in adults with type 2 diabetes mellitus. 2017. Retrieved from: www.uptodate.com
8. UpToDate. Management of persistent hyperglycemia in type 2 diabetes mellitus. 2017. Retrieved from: www.uptodate.com
9. UpToDate. Overview if medical care in adults with diabetes mellitus. 2017. Retrieved from: www.uptodate.com
10. “Diabetes Care.” The Journal of Clinical and Applied Research and Education, volume 38, supplement 1, January 2015.
11. American Diabetes Association. Standard of medical care in diabetes 2017. Diabetes Care vol 40, suppl 1.
12. FDA MedWatch Safety Information and Adverse Event Reporting Program. Metformin-containing drugs: drug safety
communication−revised warnings for certain patients with reduced kidney function. Food and Drug Administration website. http://
www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm494829.htm. Published April 8, 2016.
This clinical guideline outlines the recommendations of Mount Carmel Health Partners for this medical condition and is based upon the referenced best practices. It is
not intended to serve as a substitute for professional medical judgment in the diagnosis and treatment of a particular patient. Decisions regarding care are subject to
individual consideration and should be made by the patient and treating physician in concert.
Original Issue Date: November 2010
Revision Dates: November 2011, February 2013, December 2014, May 2015., May 2017
Diabetes Type II - 6