diabetes 4

continuing education
The Community Pharmacist’s

Role in Diabetes Treatment
By Kimberly Ference, PharmD
U pon completion of this activity,

the pharmacist should be able to
achieve these directives:
1. Describe the pathophysiology of
diabetes and how it relates to
medications used to treat diabetes.
2. Explain the diagnostic criteria and screening
recommendations related to diabetes.
3. State the goals of therapy for diabetes.
Diabetes Association (ADA), provides recommendations
relating to diabetes self-management education (DSME),
including evidence to support DSME’s importance. ADA
specifically mentions the importance of “community
health workers” providing DSME.
Diabetes is a complex, multifactorial disease that
requires involvement from various members of the health
care team, including the patient. A well-informed patient
is essential to ensure self-management and awareness.
4. Discuss the place in therapy of all antidia- In the U.S. health care system, it is often difficult for
betic agents. primary care providers to find time to educate patients
5. Describe general differences between all an- with diabetes and, in some cases, screen for diabetes
tidiabetes agents, including types of insulin. complications. It is for this reason they call upon on other
6. List the various diabetes complications and members of the health care team to provide diabetes ed-
appropriate monitoring for each. ucation and screening. Community pharmacists possess
7. Demonstrate how recent updates for diabe- the knowledge and skills to assess, screen, educate, and
tes care can be incorporated into everyday answer questions from patients with diabetes, and refer
practice. them to appropriate resources when needed.
Introduction Pathophysiology
Diabetes is prevalent in the United States, Diabetes is a chronic metabolic disorder characterized
affecting approximately 23.6 million people.
Among that number, 2 percent are unaware that Risk Factors for the Development of Diabetes
they have diabetes. It is also estimated that 57 • amily history of diabetes in first-degree relative
F
million Americans have impaired fasting glu- • Overweight or obese
cose (prediabetes), which increases their risk • Physical inactivity
of developing frank diabetes if not managed • Ethnicity: African American, Latino, Native American,
properly. Needless to say, the opportunity for Asian American, Pacific Islander
• Prediabetes
community pharmacists to intervene and inter-
• Hypertension
act with these patients is substantial. Commu- • Dyslipidemia (HDL<35 mg/dL and triglycerides
nity pharmacists have direct access to diabetes >250 mg/dL)
patients frequently, which directly enables them • History of gestational diabetes or delivery of a baby
to provide proper education and recommend weighing > 9 lbs
appropriate screening for disease and com- • History of cardiovascular disease (CVD)
• History of polycystic ovary disease
plications. “The Standards of Medical Care in
• Other conditions with insulin resistance
Diabetes— 2010,” published by the American
www.americaspharmacist.net November 2010 | america’s Pharmacist 29

by insulin deficiency. Long-term hyperglycemia has been decreased food intake. Glucagon-like peptide1
shown to increase the risk of developing diabetes-related also decreases inappropriate pancreatic alpha
complications. There are four different classifications of cell secretion of glucagon, which increases
diabetes: type 1, type 2, gestational, and secondary (as hepatic glucose production in response to low
a result of genetic conditions, medications, and various blood glucose. The enzyme dipeptidyl pepti-
other causes). A list of risk factors for the development of dase-4 (DPP-4) rapidly inactivates GLP-1. Diabe-
diabetes can be found in the box on page 29. tes medications developed in recent years have
Insulin is an endogenous hormone that is released targeted the GLP-1 pathway. These medications
from beta cells located in the pancreas in response to act by inhibiting GLP-1 enzymatic inactivation
elevated plasma glucose. In patients without diabetes, (DPP-4 inhibitors) or augmenting the effects of
insulin stimulates carbohydrate metabolism and facilitates endogenous incretin (GLP-1 agonists).
transfer of glucose into cardiac and skeletal muscle and
adipose tissue, and converts glucose into glycogen (the Screening and Diagnosis
stored form of blood sugar). An absolute insulin defi- The ADA recommends screening for diabetes
ciency arising from beta cell destruction is responsible starting at age 45 in those without risk factors.
for the adverse changes in glucose control seen in type 1 If the screening results are normal, the patient
diabetes (formally known as juvenile diabetes or insulin- should be reassessed every three years, taking
dependent diabetes mellitus). Although the source of beta into account changing risk factors and health
cell destruction is not fully understood, it is thought to be status. Earlier testing should be considered if
autoimmune in nature. the patient is overweight as classified by BMI
Elevated plasma glucose concentrations that occur and has additional risk factors as described in
in type 2 diabetes (formally known as adult onset diabetes Table 1. Diabetes screenings that take place in
or non-insulin-dependent diabetes mellitus) are caused a community pharmacy can serve as a pre-
by a combination of insulin resistance and inadequate screening and help to identify patients who
compensatory insulin secretion in response to a meal. otherwise would not have been screened.
Insulin resistance predominantly occurs when insulin- There are several different methods used
mediated glucose uptake by the liver fails. This results in to make a diagnosis of diabetes. Prior to the
a compensatory overproduction of glucose and therefore release of the 2010 Standards of Care, hemo-
increases blood glucose concentration. Impaired insulin globin A1C (A1C) was not recommended by
secretion occurs when the pancreas continuously pro- the ADA as a diagnostic criterion because of
duces insulin in an effort to maintain euglycemia (normal the lack of assay standardization, and therefore
amounts of blood glucose), resulting in hyperinsulinemia. questionable accuracy. Since the development
It is this elevated amount of insulin in the circulation that of the National Glycohemoglobin Standardiza-
negatively affects the function of the pancreatic beta cells tion Program (NGSP), the ADA now endorses
by decreasing further insulin secretion. Thus increased the use of A1C as a diagnostic option. An A1C
insulin concentrations ultimately result in loss of beta-cell of ≥ 6.5 percent is considered diagnostic and
mediated compensatory insulin secretion in response to should be confirmed by a second test on a
meals, leading to impaired glucose tolerance. subsequent day. Currently, point-of-care (POC)
Other mechanisms contribute to maintenance of gly- devices should not be used when assigning
cemic control. Under normal physiologic circumstances, A1C for diagnosis, as they are not standardized.
glucagon-like peptide 1 (GLP-1), an endogenous incretin One advantage to using A1C as a diagnostic
hormone, is released by the intestine throughout the day. marker is that testing does not require fasting.
These levels increase in response to food intake. GLP1 Other diagnostic methods include a fasting
regulates glucose homeostasis by a variety of means, in- (at least eight hours) plasma glucose of ≥ 126
cluding increasing insulin production and the release from mg/dL or an oral glucose tolerance test (OGTT)
pancreatic beta cells, and slowing of gastric emptying and with a two-hour plasma glucose of ≥ 200 mg/
30 america’s Pharmacist | November 2010 www.americaspharmacist.net

dL. The OGTT includes a 75 g glucose load
Table 1: Goals for Glycemic Control
and should be in compliance with the World
Health Organization’s standards. Both of the Test ADA Goal ACE and
AACE Goal
tests require confirmation by repeat testing on
A1C <7% <6.5%
a subsequent date. A random plasma glucose
of ≥200 mg/dL occurring in a patient displaying Estimated average glucose <154 mg/dL <140 mg/dL
classic symptoms of hyperglycemia (such as Preprandial plasma glucose 70-130 mg/dL <110 mg/dL
polyuria, polyphagia, or polydipsia) would also Postprandial plasma glucose <180 mg/dL <140 mg/dL
meet the criteria for a diagnosis of diabetes.
This test does not need to be repeated. Subse- toring reduces quality of life without improving glycemic
quently, prediabetes is considered when fasting control. Some health care providers question the cost-
plasma glucose is 100– 125 mg/dL, or a two- effectiveness and clinical significance of frequent SMBG
hour plasma glucose during an oral glucose in patients not utilizing insulin. Less stringent monitoring
tolerance test is 140– 199 mg/dL. An A1C of may be recommended for these patients, and should be
5.7– 6.4 percent is also considered prediabetes. individualized based on patient need. Goals for plasma
glucose are illustrated in Table 1.
Treatment Goals of Therapy The ADA and American Association of Clinical
Overall diabetes treatment goals include Endocrinologists (AACE)/American College of Endo-
reducing risk for development of long-term crinologists (ACE) differ slightly in their recommenda-
microvascular and macrovascular complications for A1C goals. Assessment of A1C should be
tions, decreasing diabetes related morbidity performed every three months for patients not meeting
and mortality, prevention of acute complications glycemic goals, and at least twice yearly for those who
caused by continued hyperglycemia, preven- are controlled. Several clinical trials have demonstrated
tion of hypoglycemic episodes, and improving/ that tight glycemic control reduces cardiovascular risk
maintaining quality of life. These goals should and prevents the development of microvascular com-
be incorporated into the care plan and frequent- plications. In contrast, the Action to Control Cardiovas-
ly revisited with the patient as a part of regular cular Risk in Diabetes (ACCORD) trial demonstrated
self-management sessions. an increase in mortality in patients receiving intensive
Glycemic control is assessed through the glucose lowering. It appears that tight glucose control
measurement of A1C and capillary plasma may increase or decrease risk depending on patient-
glucose, and self-monitoring blood glucose specific factors and type of therapy administered.
(SMBG) values. Of these tests, SMBG is the Maintaining an A1C of approximately 7 percent is
least accurate; however, it is more convenient appropriate, based on the conflicting data surrounding
and less invasive than the others. Self-monitor- risk, and A1C goals should be individualized. The ADA
ing blood glucose is beneficial as a means to recommends less stringent A1C goals (i.e., ≥ 7 per-
self assess glycemic control and assist in the cent) for the following patients: the elderly, those at risk
evaluation and prevention of hypoglycemia. or those with a history of severe hypoglycemia, long-
The ADA recommends testing three or more standing difficult-to-control diabetes, several comor-
times daily in patients using multiple daily in- bidities, and decreased life expectancy.
sulin injections and insulin pumps. For patients The ADA recently endorsed using a new test that is
with diabetes not using insulin, the monitoring recommended when discussing glucose control with pa-
frequency is not well defined and evidence of tients. Estimated average glucose (EAG) is used in con-
benefit is controversial. Although some stud- junction with A1C testing, and most laboratories provide
ies suggest frequent monitoring leads to lower an EAG when an A1C is ordered. It is thought to be more
A1C values and better overall outcomes, there understandable when discussing laboratory monitoring
is also evidence that suggests frequent moni- with patients, as it correlates with patient SMBG values.

Other goals of therapy include a blood pressure of Lifestyle Modifications
<130/80 mmHg and a low-density lipoprotein level of The National Diabetes Self-Management Edu-
<100 mg/dL in most (< 70 mg/dL in those with a high cation Task Force describes DSME activities
risk for cardiovascular disease). Prevention and monitor- as the assessment of the individual’s specific
ing for macrovascular complications, including hyperten- education needs, identification of the individu-
sion and dyslipidemia, are discussed later in the preven- al’s specific diabetes self-management goals,
tion and monitoring for complications section. education and behavioral intervention directed
Table 2: Available Oral Agents

Class Generic Name Brand Name Staring dose Maximum Adjustments Preg-
Daily for Renal/ nancy
Dose * Hepatic Category
Impairment
Biguanides Metformin Glucophage 500 mg once 2,550 mg Renal : Avoid B
Riomet to twice daily
or 850 mg
once daily
Metformin ER Fortamet 500– 1,000 mg 2,000 mg Hepatic: Not
Glucophage once daily recommended
XR
Gulmetza
2nd Generation Glyburide Micronase 2.5– 5 mg once 20 mg Renal: Not C
sulfonylureas (micronized) to twice daily recommended
DiaBeta 2.5– 5 mg once 20 mg
to twice daily
Glynase 1.5 to 3 mg 12 mg
daily
Glipizide Glucotrol 5 mg once to 40 mg Hepatic:
twice daily Lower doses
Glucotrol XL 5 mg daily 20 mg recommended
to avoid
Glimepiride Amaryl 1– 2 mg daily 8 mg hypoglycemia
Thiazolidinediones Rosiglitazone Avandia 2– 4 mg once 8 mg Renal: No C
or twice daily Hepatic: No
Pioglitazone Actos 15 mg daily 45 mg
Alpha-glucosidase Acarbose Precose 25 mg with 100 mg Renal: Not B
Inhibitors each meal recommended
Miglitol Glyset 25 mg with 100 mg Hepatic: No
each meal
Meglitinides Repaglinide Prandin 0.5– 1 mg 3 16 mg Renal: C
times daily Repaglinide: Yes
with each meal Nateglinide: No
Nateglinide Starlix 120 mg 3 120 mg Hepatic: No
times daily
with each meal
Dipeptidyl Sitagliptin Januvia 100 mg daily 100 mg Renal: Yes B
Peptidase-4 inhibitors Saxagliptin Onglyza 2.5– 5 mg daily 5 mg Hepatic: No
Dopamine agonists Bromocriptine Cycloset 0.8 mg daily 4.8 mg Renal: No B
Mesylate Hepatic: No

toward achieving identified goals, and evalua-
Table 3: Available Combination Products
tion of the individual’s attainment of identified
Generic Name Brand Name
goals. There is ample evidence suggesting that
DSME improves quality of life, disease-oriented Metformin/glipizide Metaglip*
outcomes, and cost savings. The ADA recom- Metformin/ glyburide Glucovance*
mends that all patients receive DSME at the ActoPlus Met
time of diagnosis and periodically thereafter. It Metformin/ pioglitazone ActoPlus Met XR – NEW
is possible for community pharmacists to ac- FORMULATION
quire advanced training to provide reimbursable Metformin/repaglinide PrandiMet
DSME services. Metformin/rosiglitazone Janumet
Medical nutrition therapy (MNT) is an inte- Metformin/sitagliptin Avandamet
gral part of diabetes management and is rec- Pioglitazone / glimepiride Duetact
ommended for all patients with diabetes. The Rosiglitazone / glimepiride Avandaryl
ADA suggests that MNT sessions be individual- *Available as both brand and generic
ized, ongoing, and performed by a registered
dietician specializing in diabetes. Topics should of life, and resources (financial, social, and emotional).
include, but are not limited to, food planning, Patients displaying potentially troublesome characteris-
portion control, calorie reduction, appropriate tics such as depression with potential for self-harm, anxi-
fat intake, carbohydrate counting, and under- ety, eating disorders, or cognitive function decline with
standing glycemic index. impaired judgment should be referred to an appropriate
As a cornerstone of nonpharmacologic mental health consultant specializing in diabetes care.
therapy, physical activity, as tolerated, is Often, nonadherence to medication therapy may result
recommended in all adults. Patients should from one of the above mentioned factors. Community
be advised to consult with their physician pharmacists should screen for and attempt to indentify
before starting an exercise program. In and address the underlying cause.
general, moderate-intensity aerobic exercise
should performed for a total of 150 minutes Oral Medications
per week. Alternatively, well-conditioned Biguanides
patients may participate in a weekly total of Metformin is the only available biguanide on the market
75 minutes of intense aerobic activity. In type in the United States. Biguanides lower blood glucose
2 patients, resistance training involving major by decreasing hepatic glucose production, decreasing
muscle groups is recommended two to three intestinal absorption of glucose, and improving insulin
times per week. For older patients (over 65), sensitivity by increasing peripheral glucose uptake and
these recommendations may not be feasible utilization. It is the most effective oral agent in terms
or safe. For these patients, recommend low- of providing glycemic control, reducing A1C by 1– 2
impact activities such as chair exercises or percent, and it is considered first-line therapy for the
water aerobics or, at a minimum, ask them to treatment of type 2 diabetes. However, greater A1C low-
maintain an active lifestyle. ering may be seen in patients with a higher initial A1C.
Physiological and social problems can Moreover, metformin has been shown to reduce overall
adversely affect a patient’s ability to properly mortality and risk of myocardial infarction in obese or
care for his or her diabetes. Therefore, patients overweight patients with type 2 diabetes, independent of
should undergo psychological and social its effects on glycemic control. Another benefit of using
screening upon diagnosis and periodically metformin is that it is not associated with weight gain, as
thereafter. Screening includes assessing at- is the case with most other diabetes medications. Met-
titudes about having diabetes, expectations of formin is classified as weight neutral and in some cases
medical management, affect and mood, quality has been associated with mild to moderate weight loss.

Available Products sensitivity. Similar to metformin, sulfonylureas
Metformin is available in both immediate release and decrease A1C by 1– 2 percent. Sulfonylureas
extended release formulations (Table 2). There are several are considered second line for the treatment of
metformin combination products available (Table 3). Im- type 2 diabetes, and are recommended after
mediate release metformin is available on the majority of failure to achieve glucose control with maximum
generic savings plans and is affordable for most patients. clinically effective doses of metformin along
with lifestyle modifications. Glimepiride and
Dosing and Dose Adjustments glipizide are the preferred agents within this
Starting doses differ based on product used, as listed class, as they produce less hypoglycemia when
in Table 4. Generally, a lower starting dose is used with compared with the other agents. More impor-
gradual titration to minimize gastrointestinal side ef- tantly, first generation agents and glyburide may
fects. Glycemic control is rarely seen with doses <1500 be associated with increased mortality, which is
mg daily and clinical maximum dose is 2000 mg daily. suspected to be dose related.
Providers may consider dose titration every 1–2 weeks
as tolerated. Available Products
Sulfonylureas are classified into two catego-
Adverse Effects ries: first generation (chlorpropamide, tolaza-
The most common side effects are gastrointestinal mide, tolbutamide) and second generation
symptoms such as diarrhea, nausea, vomiting, flatulence, (glimepiride, glipizide, glyburide). Certain
indigestion, and abdominal discomfort. Most gastroin- sulfonylureas are available in combination
testinal side effects subside after a few weeks of therapy, product formulations, listed in Table 3. Several
and patients should also be instructed to take with food sulfonylureas are available on generic savings
to minimize these effects. Lactic acidosis is an extremely plans that are affordable for most patients.
rare yet potentially severe side effect of therapy and
caused by metformin accumulation. Hypoglycemia is Dosing and Dose Adjustments
not a common side effect as metformin does not affect Starting doses differ between agents within the
insulin release. class and are listed in Table 4. A low to moder-
ate starting dose is recommended with gradual
Drug Interactions titration to minimize risk for hypoglycemia. El-
Iodinated contrast dye may cause acute renal impair- derly patients should be started at lower doses.
ment, which can potentiate metformin-induced lactic Patients should be instructed to take sulfonyl-
acidosis. ureas 30 minutes before eating, and extensively
counseled on the importance of not skipping
Contraindications/Precautions meals while taking these medications. Clinical ef-
Metformin is contraindicated in patients with renal impair- ficacy is usually seen with moderate doses. High
ments, defined as a SCr of ≥1.5 mg/dL in men and ≥1.4 to maximum dosing does not typically provide
mg/dL in women. Use metformin with caution in patients greater blood sugar lowering, and increases the
with conditions that are associated with an increased risk of hypoglycemia. Providers may consider
risk of lactic acidosis, including congestive heart failure dose titration every 1– 2 weeks as tolerated.
requiring medical management, extreme aging, chronic
alcohol use, and active liver disease. Adverse Effects
The most common side effect is hypoglycemia.
Sulfonylureas Glyburide and chlorpropamide are associ-
Sulfonylureas decrease plasma glucose by stimulating ated with an increased risk for hypoglycemia
insulin release from the pancreatic beta cells, reduc- compared with other sulfonylureas. Weight
ing glucose output from the liver and increasing insulin gain (one pound on average) is also common.

Patients may also experience headache, dizzi- Available Products
ness, and gastrointestinal upset. For the time being, there are two available products
in the United States: pioglitazone (Actos) and rosi-
Drug Interactions glitazone (Avandia). The FDA was considering the
The most common drug interactions occur withdrawal of rosiglitazone for the market, but an advi-
with other medications that potentiate hypo- sory committee voted to keep the drug on the market
glycemia. in July 2010. These agents are also available in a
combination tablet with metformin and glimepiride.
Contraindications/Precautions Currently, none of these products are available as a
Use of a sulfonylurea is contraindicated in generic, and they are quite costly for patients without
patients with type 1 diabetes and diabetic prescription insurance.
ketoacidosis. Precautions should be taken
with patients who are susceptible to hypo- Dosing and Dose Adjustments
glycemia and have hepatic or renal insuf- Pioglitazone (Actos) is dosed once daily and may be
ficiency. Patients with a sulfonamide allergy increased in increments as needed to control blood glu-
should be counseled as to the potential for cose, taking into account that it may take several weeks
cross-sensitivity, and appropriate precau- to reach full therapeutic benefit. Initial dose and maximum
tions should be employed. dose recommendations can be found in Table 4.
Thiazolidinediones Adverse Effects

Thiazolidinediones (TZDs or glitazones) reduce In clinical trials, TZDs were associated with an increased
blood glucose concentrations by enhancing risk of fluid retention, leading to peripheral edema, weight
the effects of existing insulin through improved gain, and increased risk of heart-failure exacerbations
peripheral glucose uptake, decreased hepatic and hospitalizations.
glucose production, and decreased insulin
resistance. When used as monotherapy for the Drug Interactions
treatment of type 2 diabetes, TZDs reduce A1C Due to their mechanisms of action, concurrent use
by 0.5– 1.4 percent. Unlike other oral medica- with sulfonylureas and insulin increase the risk of
tions, TZDs may take up to 12 weeks to see full hypoglycemia.
benefit. The ADA does not recommend use of
rosiglitazone due to the increased risk of myo- Contraindications/Precautions
cardial infarction. This risk does not appear to Thiazolidinediones are contraindicated in patients with
be associated with pioglitazone, and it remains established New York Heart Association (NYHA) class III
a therapeutic option as an add-on to maximum or IV heart failure. Concomitant insulin use is associated
clinical doses of metformin, along with life- with greater amounts of fluid retention. Likewise, TZDs
style modifications, for patients who have not should be used with caution in patients with a history of
achieved glycemic control. This combination is symptomatic edema. An increased risk for development
not recommended in patients with hypoglyce- of bone fractures was observed in clinical trials for both
mia, edema, CHF, or bone loss. Pioglitazone agents, and they should be used cautiously in patients
also positively affects the lipid profile by in- with a history of bone loss. These agents should be
creasing high density lipoprotein and decreas- used with caution in patients with a history of anemia, as
ing triglycerides. However, it is important to volume overload may cause hemodilution, manifested
note that pioglitazone has not been shown to as a decrease in measured hemoglobin and hematocrit.
improve clinically relevant outcomes such as Thiazolidinediones may result in resumption of ovula-
reduced mortality risk, or reduction of diabetes- tion. Premenopausal anovulatory women should be
related endpoints. counseled about this risk.

Meglitinides Contraindications/Precautions
Meglitinides (glitinides or glinides) are short-acting secre- The use of meglitinides is contraindicated
tagogues, working similarly to their longer-acting sulfonyl- in patients with type 1 diabetes or DKA, and
urea counterparts. When used for the treatment of type 2 those using gemfibrozil. Use caution in pa-
diabetes, meglitinides have been shown to reduce A1C tients with liver disease, renal disease, or
by 0.5– 1.5 percent, with nateglinide (Starlix) being slightly adrenal or pituitary insufficiency, and those
less effective than repaglinide (Prandin). Neither agent susceptible to hypoglycemia (such as elderly
has been shown to reduce clinically relative endpoints. and malnourished persons).
Meglitinides are approved for the treatment of type 2 dia-
betes, as an adjunct to diet and exercise. The ADA does Alpha-Glucosidase Inhibitors
not recommend meglitindes for routine use in the treat- Alpha-glucosidase inhibitors lower postpran-
ment of type 2 diabetes, as they have not demonstrated dial glucose levels by delaying carbohydrate
clinical or cost-effective superiority compared with routine absorption in the brush border of the small
therapies. Meglitinides may be used as adjunct therapy intestine. They have been shown to reduce A1C
in patients who are unable to take standard treatment, by 0.5– 0.8 percent but have not been shown
and may be particularly beneficial in those with elevated to improve overall or cardiovascular mortality.
postprandial glucose elevations. Alpha-glucosidase inhibitors are recommended
as adjunct therapy for the treatment of type 2
Available Products diabetes in patients who are unable to achieve
Nateglinide (Starlix) and repaglinide (Prandin) are the two glycemic control with diet alone. They are not
products available in the United States. Both products are routinely used due to their limited efficacy and
only available as brand name and are costly for patients gastrointestinal side effects, and are not recom-
without prescription insurance. mended for routine use by the ADA. They may
be used as adjunct therapy in patients that
Dosing and Dose Adjustments are unable to tolerate standard treatment or
Meglitinides have a shorter onset of action and duration those with difficult to control postprandial blood
of action when compared with sulfonylureas and there- glucose readings. Acarbose may have a role
fore require more frequent dosing. Starting and maximum in treatment of prediabetes based on results of
recommended doses differ between the two agents and a single trial in patients with impaired glucose
can be found in Table 2. They should be taken 15 minutes tolerance (IGT), in which patients receiving
before meals and are titrated weekly. To avoid hypoglyce- acarbose demonstrated a reduced risk of car-
mia, instruct patients to omit their dose if skipping a meal. diovascular events.
Adverse Effects Available Products

Common adverse effects include hypoglycemia, upper re- Acarbose (Precose) and miglitol (Glyset) are
spiratory infection, and headache. Glinides are associated the two alpha-glucosidase inhibitors available
with less hypoglycemia when compared with sulfonylureas. in the United States. Acarbose is available as
both brand and generic, whereas miglitol is
Drug Interactions only available as brand. Cost differs based on
Combination therapy with sulfonylureas is not recom- product, with acarbose (generic) being the least
mended, given their similar mechanism of action and expensive option.
risk for hypoglycemia. Repaglinide is contraindicated
with use of gemfibrozil and should be used with cau- Dosing and Dosage Adjustments
tion in combination with itraconazoles, as they can To decrease gastrointestinal side effects, initi-
potentiate its hypoglycemic effects. These three mediate therapy at low dose three times daily with
cations should never be used together. the first bite of each meal. Starting dose and

maximum recommended dose information can percent. Dipeptidyl peptidase-4 inhibitors are indicated
be found in Table 2. Titration should be based for use in type 2 diabetics as monotherapy or in combina-
on glucose control and tolerance. Patients with tion with other antidiabetic agents to improve blood glu-
high carbohydrate diets may observe a larger cose. They are not recommended for routine use by the
decrease in A1C. ADA due to their limited clinical efficacy when compared
with other anti-diabetes agents. These agents have not
Adverse Effects been shown to reduce cardiovascular or overall mortal-
The most common side effects from therapy are ity. They may be used as adjunct therapy in patients who
gastrointestinal in nature (flatulence, diarrhea, are unable to tolerate standard treatment and may have
and abdominal pain) and occur in high inci- some benefit in patients who are overweight, as they are
dences, leading to poor long-term adherence weight neutral.
rates. These adverse effects often preclude the
routine use of alpha-glucosidase inhibitors as a Available Products
treatment option. Saxagliptin (Onglyza) was approved for use by the FDA in
2009 and was released in 2010. Sitagliptin (Januvia) was
Drug Interactions the first available DDP-4 inhibitor and is available in com-
Concurrent use with sulfonylurea may potenti- bination with metformin (Janumet). Both medications are
ate hypoglycemia and should be avoided. available only as brand names and are costly for patients
Instruct patients experiencing hypoglycemia to without prescription insurance. Two additional agents in
treat symptoms with sucrose, as the alpha-glu- this class are under FDA review for approval.
cosidase inhibitors slow absorption of complex
carbohydrates. Digestive enzyme supplements Dosing and Dose Adjustments
(amylase and pancreatin) and intestinal ad- Both sitagliptin (Januvia) and saxagliptin (Onglyza) are
sorbents (charcoal) may cause a reduction of administered once daily without regard to meals. Dosing
glycemic effects, and concomitant use is not information is available in Table 2.
recommended.
Adverse Effects
Contraindications/Precautions Common side effects include headache, nasopharyn-
Alpha-glucosidase inhibitors are contraindi- gitis, and upper respiratory tract infection. Urinary tract
cated in the following situations: SCr >2 mg/dL, infections were also observed with saxagliptin therapy.
cirrhosis, diabetic ketoacidosis, colon ulcer- The use of sitagliptin alone or in combination with
ations, conditions that worsen with increased metformin has been associated with the development of
intestinal gas, digestive diseases, inflammatory acute pancreatitis in 88 cases. Instruct patients to moni-
bowel disease, partial bowel obstruction, and tor for symptoms of pancreatitis (such as upper abdomi-
predisposition to bowel obstruction. nal pain, often radiating to the back, and accompanied
by nausea, vomiting, and diarrhea) and recommend dis-
Dipeptidyl Peptidase-4 Inhibitor continuation if symptoms occur. The majority of cases
Dipeptidyl peptidase-4 inhibitors block the were resolved with discontinuation of sitagliptin. Pancre-
breakdown of the incretin hormones GLP-1 and atitis has not been observed with saxagliptin. However, it
glucose-dependent insulinotropic polypeptide has not been on the market for a long period of time.
(GIP), thus potentiating their effects, which are
responsible for increasing glucose-mediated Drug Interactions
insulin secretion and decreasing glucagon Use with caution in patients taking medications that are
secretion. When used as monotherapy for the metabolized by the CYP3A4 and CYP3A5 system. Induc-
treatment of type 2 diabetes, DPP-4 inhibitors ers of the above enzyme systems may increase metabo-
have been shown to decrease A1C by 0.6– 0.9 lism and may decrease efficacy. Drugs that inhibit these

enzyme systems may interfere with metabolism and po- operate heavy machinery if experiencing this
tentiate side effects of the drug. The risk of hypoglycemia adverse effect.
is increased when DPP-4 inhibitors are used in combina-
tion with sulfonylureas. Drug Interactions
Concomitant use of bromocriptine and do-
Contraindications/Precautions pamine receptor antagonists (such as dom-
Use caution when using sitagliptin in patients with a his- peridone) may reduce the effectiveness of
tory of pancreatitis, as safety in this population has not bromocriptine. Bromocriptine may increase
been studied. Patients with renal dysfunction require dose ergot-related adverse effects and reduce ergot
adjustments for both agents. effectiveness. Bromocriptine is extensively
metabolized by CYP3A4 and should be used
Central Acting Dopamine Agonists with caution when coadministered with strong
Bromocriptine mesylate is a dopamine receptor ago- inhibitors (such as macrolide antibiotics, azole
nist, and its exact mechanism for glucose reduction is antifungals, and HIV protease inhibitors),
unknown. It is FDA-indicated as an adjunct to diet and inducers (such as rifampin and dexametha-
exercise in adults with type 2 diabetes. It should be not sone), or substrates of CYP3A4.
be used to treat type 1 diabetes or diabetic ketoacidosis.
Limited efficacy data exists for when it is used in combi- Contraindications
nation with thiazolidinediones, and efficacy has not been The use of bromocriptine is contraindicated in
confirmed in combination with insulin. Reductions in A1C patients allergic to ergot-related drugs, those
of approximately 0.5 percent have been observed when with syncopal migraines, and nursing women.
used as monotherapy and when added to other therapy Bromocriptine use is associated with hypo-
including sulfonylureas and metformin. This is a new class tension and should be used with caution in
approved to treat type 2 diabetes and the ADA has not patients taking antihypertensive medications.
commented on its place in therapy. More clinical evidence Use with caution in patients with a history of
is needed to determine place in therapy. psychosis, as bromocriptine may exacerbate
psychotic disorders or reduce the effectiveness
Available Products of antipsychotics.
Bromocriptine mesylate (Cycloset) was approved for
use by the FDA in May 2009 and is available as an 0.8 Injectable Medications
mg tablet. Amylin Agonists
Amylin is a hormone secreted in conjunction
Dosing and Dose Adjustments with insulin from the pancreatic beta cells, It
Therapy should be initiated with a dose of 0.8 mg daily reduces postprandial blood glucose by slow-
and increased weekly by 0.8 mg until a maximum tolerated ing gastric emptying, reducing both glucagon
dose of 1.6 to 4.8 mg is achieved. Bromocriptine should secretion, and induces appetite suppression.
be taken within two hours after waking in the morning with Amylin agonists decrease A1C by 0.5– 0.7 per-
food to minimize gastrointestinal side effects. Information cent. Amylin agonists are indicated as adjunc-
about Cycloset dosing is located in Table 2. tive therapy for the treatment of type 1diabetes
in patients using mealtime insulin who have
Adverse Effects failed to achieve glucose control. They are also
Common side effects seen in clinical trials include nau- indicated for the treatment of type 2 diabetes as
sea, fatigue, dizziness, vomiting, and headache. Hypogly- an adjunctive agent for patients taking mealtime
cemia was not commonly observed when bromocriptine insulin who have failed to achieve glucose con-
was used as monotherapy. Bromocriptine may cause trol with optimal insulin therapy (with or without
somnolence, and patients should be advised not to the use of metformin and sulfonylurea). They

are not recommended for routine use by the in approximately 30 percent of patients and is often the
ADA due to their limited efficacy and poor toler- rate-limiting factor for dose titration. Although pramlintide is
ability. They may be used as adjunct therapy indicated for use in combination insulin, there is a black box
in patients who are unable to tolerate standard warning for the risk of severe hypoglycemia (usually seen
treatment or those with difficult-to-control post- within three hours) when used in combination with insulin.
prandial blood glucose readings. They could
be considered in overweight patients, as they Drug Interactions
have been proven to decrease weight by 2– 3 Anticholinergics, alpha-glucosidase inhibitors, and other
pounds. Amylin agonists have not been shown medications that alter gastrointestinal motility are not
to reduce cardiovascular or overall mortality. recommended for use in combination with amylin ago-
nists. Concurrent use with glucose-lowering medications
Available Products may increase the risk of hypoglycemia, and monitoring is
Pramlintide (Symlin) injection is the only amylin recommended when used in combination.
agonist available in the United States.
Contraindications
Dosing and Dose Adjustments Amylin agonists are contraindicated in patients with a
Dosing recommendations for the use of confirmed diagnosis of gastroparesis and hypoglycemia
pramlintide differ based on type of diabetes. unawareness. Treatment with pramlintide is not recom-
Starting doses and maximum doses are listed mended in the following patients: those with A1C >9
in Table 4. Pramlintide is administered immedi- percent, those who show poor compliance with medica-
ately prior to major meals. Prophylactic insulin tion and glucose monitoring or who have severe recurrent
dose reduction by 50 percent is recommended episodes of hypoglycemia, and pediatric patients.
upon the initiation of pramlintide to reduce the
risk of hypoglycemia. Frequent blood glucose Glucagon-like Peptide-1 Receptor Agonist
monitoring is recommended during dose initia- Incretin, or GLP-1, is an endogenous hormone that modu-
tion and titration. lates glycemic response. Glucagon-like receptor agonists
enhance glucose-dependent insulin secretion, decrease
Adverse Effects glucagon secretion, and slow gastric emptying, resulting
The most common side effects observed with in lower blood glucose levels. Decreases in A1C of 0.5– 1
pramlintide include headache, hypoglycemia, percent are observed in patients using GLP-1 agonists.
nausea, vomiting, and anorexia. Nausea occurs This class of medications is indicated for use in patient with
Table 4: Non-Insulin Injectable Agents

Drug Class Generic Type of Starting Dose Maximum Adjustment for Pregnancy
Name Diabetes Dose Renal/Hepatic Category
(Brand) Insufficiency
Amylin agonists Pramlintide 1 15 mcg before 60 mcg before Renal: No C

(Symlin) meals meals Hepatic: No
2 60 mcg before 120 mcg
meals before meals
Glucagon-like Exenatide 2 5 mcg twice 10 mcg twice Renal: Not C
Peptide-1 agonists (Byetta) daily daily before recommended
meals Hepatic: No
Liraglutide 2 0.6 mg once 1.8 mg once
(Victoza) daily daily

type 2 diabetes as an adjunct to diet and exercise. Exena- with the sulfonylurea glimepiride. Both drugs
tide is also indicated for use as adjunct therapy for patients have been associated with acute pancreatitis,
with type 2 diabetes and inadequate glycemic control with although this is rare.
metformin and/or a sulfonylurea, and/or a thiazolidinedione.
These agents may improve glycemic control but are as- Drug Interactions
sociated with more gastrointestinal side effects than other Patients receiving GLP-1 agonists are at in
agents. The ADA recommends use of GLP-1 agonists as an increased risk of hypoglycemia when added to
adjunct to lifestyle and maximum clinical effective doses of therapy with sulfonylureas, and consideration
metformin. Exenatide may reduce body weight, but neither should be given to reducing the sulfonylurea
agent has been shown to improve patient-oriented out- dose. However, no standard recommendations
comes such as cardiovascular or overall mortality. have been established at this time.
Available Products Contraindications

Exenatide (Byetta) and liraglutide (Victoza) are both solu- The use of liraglutide is contraindicated in pa-
tions for subcutaneous injection available in multidose tients with a personal history or family history
pens for daily use. Liraglutide was approved for use of medullary thyroid carcinoma, and in patients
in 2010. A once weekly injection of exenatide is under with multiple endocrine neoplasia syndrome
development. None of these products are available as a type 2 (MEN2). These risks have not been ob-
generic and they are costly for patients without prescrip- served in patients taking exenatide. Exenatide
tion insurance. is contraindicated in patients with a hypersen-
sitivity to the active drug or any component of
Dosing and Dose Adjustments the formulation.
Exenatide is administered twice daily within 60 minutes
before meals. The initial dose of liraglutide is intended to Insulin
reduce gastrointestinal symptoms and does not provide Commercially available insulin products mimic
effective glycemic control. Liraglutide should be initiated the plasma glucose regulatory actions of en-
once daily without regard to meals or time of day. Seven- dogenous insulin by stimulating carbohydrate
ty-eight post-marketing reports of altered kidney function metabolism, facilitating transfer of glucose into
in patients taking exenatide have prompted changes to cardiac and skeletal muscle and adipose tissue,
prescribing information. It is not recommended in patients and converting glucose into glycogen. Prescrip-
with a creatinine clearance less than 30 mL/min, and it tion insulin is a life-sustaining medication in
should be used with caution in those with a creatinine those with type 1 diabetes. It is also the treat-
clearance of 30– 50 mL/min. The prescribing information ment of choice for hyperglycemic emergencies
also says to monitor patients carefully for the develop- such as diabetic ketoacidosis or hyperosmolar
ment of kidney dysfunction and evaluate the continued hyperglycemic states. Insulin decreases blood
need for exenatide if kidney dysfunction is suspected sugars, A1C, and the frequency of hyperglyce-
while using the product. Liraglutide has not been exten- mic symptoms to a greater extent than any other
sively studied in the presence of renal dysfunction and agent, but it has not been shown to improve
should be avoided. cardiovascular or overall mortality. When used in
adequate doses, insulin can decrease any level
Adverse Effects of elevated A1C to, or close to, glycemic goals.
In clinical trials, the most commonly reported adverse The ADA recommends adding insulin for type 2
effects for GLP-1 agonists were dose-related gastrointes- patients receiving the maximum tolerated dose
tinal distress. Overall, in five clinical trials gastrointestinal metformin and whose A1C remains >8.5. Newer
adverse effects were reported in 41 percent of patients and more expensive analogues (such as aspart
taking liraglutide, compared with 17 percent treated and glargine) have demonstrated marginal, if

any, benefit compared with older, less expensive be added to metformin at a starting dose of 10 units or 0.2
insulins (such as regular and NPH) in terms of units/kg administered at night. Certain patients will require
glycemic control or incidence of hypoglycemia. the additional bolus insulin to provide glycemic control.
This decision is made based on the patient’s self-monitor-
Available Products ing of blood glucose values and frequency of hyperglyce-
Insulins are characterized by their onset and mic symptoms. Many insulin titration schedules exist. Most
duration of action. In general, insulins are cat- patients will achieve glycemic control by titrating an insulin
egorized as bolus (administered prior to meals) dose by two units every three days until blood glucose
or basal (administered one to two times daily) in values are consistently in the target range or hyperglyce-
nature. Bolus and basal insulin may be further mic symptoms resolve. There is no ceiling dose of insulin,
categorized as rapid- or short-acting and inter- but frequent hypoglycemia may limit dose titration. Insulin
mediate- or long-acting, respectively. Premixed properties are described in Table 5.
insulin preparations are a combination of basal
and bolus insulin. Adverse Effects
Hypoglycemia is the most common adverse effect seen
Dosing and Dose Adjustments with insulin use. Insulin doses should not be increased in
In those with type 1 diabetes, administration of the presence of frequent hypoglycemia, and a dose de-
a basal/bolus insulin replacement regimen that crease may be appropriate if an underlying cause cannot
mimics natural physiologic insulin secretion is be identified and addressed. Upon insulin administration,
initiated using a weight-based approach. In gen- or dose adjustment, patients should be educated to pre-
eral, endocrinologists or those with an advanced vent, recognize and treat hypoglycemia. Insulin is associ-
understanding of insulin initiate therapy in these ated with modest weight gain, but the benefits of glyce-
types of patients. For patients with type 2 diabe- mic control often outweigh the small increase in weight.
tes, a basal augmentation insulin regimen can Lipohyperotrophy may result from reuse of needles or
Table 5: Available Insulin Agents

Generic Name Brand Name Onset Peak (hours) Duration
Rapid-Acting Novolog 15– 30 minutes 0.5– 2.5 3– 4

Aspart Humalog 1– 3 3– 5
Lispro Apidra 1– 2 3– 4
Glulisine
Short-Acting Humulin R 30– 60 minutes 2– 3 3– 6

Regular Novolin R
Intermediate-Acting Humulin N 2– 4 hours 4– 6 8– 12
Neutral Protamine Hagedorn (NPH) Novolin N
Long-Acting Lantus 4– 5 hours No peak 22– 24
Glargine Levemir 3– 4 hours Up to 24
Detemir
Combination Products Humulin 70/30 30– 60 minutes 1.5– 16 10– 16
Regular and NPH Novolin 70/30 2– 12
Humulin 50/50 2– 5.5
Humalog Mix 75/25 15– 30 minutes 1– 6.5 15– 18

Lispro and neutral protamine lispro
Novolog Mix 70/30 15– 30 minutes 1– 4 Up to 24
Aspart and neutral protamine aspart

repeated injections in the same area. Educate patients Pregnancy Category
to rotate injection sites at each administration. Exces- Insulin is safe and effective for the treatment of
sive insulin doses may cause hypokalemia. Although not diabetes during pregnancy and is considered
conclusive, some evidence suggests insulin may cause a the drug of choice. Most insulins are con-
small increase in cancer risk. sidered pregnancy category B, with detemir,
glargine, glulisine, and Novolog Mix having a
Drug Interactions rating of category C.
Insulin use potentiates the risk of hypoglycemia when
combined with medications that increase endogenous Treatment Algorithm/Discussion
insulin secretion or peripheral utilization. Use of insulin of Treatment Progression
and thiazolidinediones result in greater increases of fluid In 2009, the ADA and the European Asso-
retention compared to either agent alone. ciation for the Study of Diabetes released a
consensus statement with recommendations
Contraindications for the treatment of type 2 diabetes, including
Insulin is contraindicated during an acute episode of hy- an algorithm (Figure 1). The treatment algo-
poglycemia and in those with a hypersensitivity to insulin rithm is broken down into tier 1 (well-validated
or any of its components. Hypersensitivity reactions to hu- therapies that represent the best-established
man recombinant insulin formulations are rare and occur and most effective and cost-effective thera-
less often than with porcine- and bovine-derived insulin peutic strategies) and tier 2 (less well-vali-
products, which are no longer commercially available. dated therapies that may be considered in
Close monitoring of serum potassium is recommended in certain clinical situations). Tier 1 recommen-
those taking insulin who are at high risk for hypokalemia dations consist of the initiation of metformin
(such as loop diuretic use). and lifestyle modifications on diagnosis,
Figure 1: Algorithm for the Treatment of Type 2 Diabetes
Tier 1: Well-validated core therapies
TLC + Metformin TLC + Metformin

+ Basal Insulin + Intensive insulin
At diagnosis:
TLC + Metformin
TLC + Metformin
+ Sulfonylurea
Step 1 Step 2 Step 3
Tier 2: Less well-validated therapies

TLC + Metformin
TLC + Metformin
+ Pioglitazone
+ Pioglitazone
+ Sulfonylurea
TLC + Metformin TLC + Metformin

+ GLP-1 agonist + Basal insulin

and sulfonylureas and basil insulin as add-
Table 6: Recommendations for Complication Screening
on therapy when further glycemic control is
Screening Recommended Interval
desired. The addition pioglitazone or a GLP-1
agonist is recommended when hypoglycemia Blood pressure At every visit
is particularly undesirable or in patients who Lipid profile Annually
are unable to tolerate or use tier 1 therapies. Annually with visual
Monofilament foot exam
Alpha-glucosidase inhibitors, meglitinides, inspection at every visit
DPP-4 inhibitors, and amylin agonists are not Diabetic eye exam Annually
listed as tier 1 or 2 agents due to their overall Urine microalbumin Annually
limited efficacy, lack of patient-oriented evi-
dence, and increased cost when compared blood pressure in patients with type 1 diabetes is a
with other therapies. Cycloset was not com- predisposition for developing nephropathy. Goal blood
mercially available during the publication of pressure for all patients with diabetes is <130/80 mmHg
the consensus statement. and should be measured at every office visit. A diagnosis
of hypertension is made by assessing office blood pres-
Prevention and Monitoring for sure above goal on two separate occasions. Therapeutic
Complications lifestyle modifications are recommended for the treat-
Morbidity and mortality associated with dia- ment of hypertension in all patients and may be used
betes is not a result of high blood sugars in first-line for blood pressures of <140/90 mmHg for up to
and of itself. Instead, it is due to the effects three months. Several antihypertensive regimens (such
hyperglycemia has on other systems of the as angiotensin-converting enzyme inhibitors, angiotensin
body. Although many believe glycemic control receptor blockers, calcium channel blockers, diuretics,
is the most important aspect of diabetes care, and beta blockers) are recommended for treatment and
addressing CVD risk factors such as hyperten- have been shown to reduce short-term effects of major
sion, dyslipidemia, and smoking provides an cardiovascular events. Thiazide diuretics or angiotensin-
overall greater benefit in terms of risk reduc- converting enzyme (ACE) inhibitors are the preferred
tion. Diabetes complications are commonly agents for the treatment of stage 1 hypertension (140–
categorized as either macrovascular or micro- 159/90– 99 mm Hg). A two-drug combination using thia-
vascular in nature. Dysfunction and damage zide diuretic plus ACE inhibitor is recommended when
of large vessels (macrovascular) contribute to treating stage 2 hypertension (>160/100 mm Hg). Newer
the development of atherosclerosis, coronary evidence calls into question the utility of beta-blockers
heart disease, stroke, and peripheral vascular for the treatment of hypertension in diabetes patients.
disease. Microvascular complications result A recent meta-analysis of eight randomized trials com-
from disease of the small blood vessels found paring atenolol versus other anthihypertensives found
in the eyes, nerves, and kidneys. The com- either no significant differences or worse outcomes with
munity pharmacist has the ability to provide atenolol for total mortality, stroke, or myocardial infarc-
education to patients relating to the monitor- tion. It remains to be seen whether or not these findings
ing and prevention of diabetes complications. hold true for other beta-blockers. For the time being, it
Recommendations for complication screening is reasonable to reserve beta-blockers for those with a
are found in Table 6. history of myocardial infarction or heart failure and utilize
other proven therapies for the treatment of hypertension.
Blood Pressure
In patients with diabetes, hypertension is as- Dyslipidemia
sociated with an increased risk for the devel- Lipid abnormalities are common in patients with diabe-
opment of macrovascular and microvascular tes. Elevated low-density-lipoprotein cholesterol (LDL-C)
complications. Long-standing, uncontrolled is associated with an increased risk for the develop-

ment of CVD. Controlling LDL-C is the primary target recommendations regarding aspirin use for pri-
of therapy unless triglycerides are >500 mg/dL due to mary prevention were revised. Consider recom-
the risk of acute pancreatitis. In this case, treatments mending aspirin for primary prevention in men
for elevated triglycerides (such as fibrates, fish oil, and over 50 and women over 60 with a 10-year CVD
niacin) should be employed. Once triglycerides are risk of >10 percent and additional risk factors
below 500 mg/dL, LDL-C becomes the target of therapy. as defined above. The recommended dose
Goal LDL-C for diabetes patients with or without overt of aspirin is 75– 162 mg daily. The benefits of
CVD is <100 mg/dL. An optional goal of <70mg/dL aspirin use for secondary prevention are well
may be considered in very high-risk patients, including established, and it should be used in diabetes
those with overt CVD and multiple or poorly controlled patients with a history of CVD. Clopidogrel may
risk factors (such as metabolic syndrome). Screening be used in patients with a history of CVD and
is conducted using a fasting lipid profile and should an aspirin allergy.
be performed annually for all diabetes patients. Less
stringent monitoring may be considered in patients who Retinopathy
have achieved their LDL-C goal. Therapeutic lifestyle Diabetic retinopathy is defined as damage to
modifications are recommended in all patients above the retina cased by long-term hyperglycemia.
goal LDL-C. Statins are considered the drug of choice Retinopathy affects both type 1 and type 2
for the treatment of dyslipidemia. In diabetes patients patients and is usually related to duration of
with cardiac risk factors but without a history of CVD, diabetes. In the United States, diabetic reti-
statin therapy reduced the risk of first major cardiovas- nopathy is the leading cause of blindness in
cular events regardless of initial LDL-C. These results adults between the ages of 20 and 74. The ADA
helped inform the ADA, which resulted in the latest recommends screening for diabetes retinopathy
recommendations that statins be considered indepen- shortly after diagnosis for people with type 2
dent of baseline lipid levels in those over the age of diabetes, and within five years of diagnosis for
40 without CVD and one or more CVD risk factors. In type 1 diabetes patients older than 10. A dilated
patients under 40 without overt CVD, therapeutic lifestyle eye examination performed by an ophthalmolo-
changes (TLC) plus a statin are recommended when gist or optometrist is recommended yearly.
LDL-C is above goal. In patients with established CVD Control of blood glucose and blood pressure
the recommendations are less ambiguous. In addition has been shown to reduce the risk of develop-
to aspirin, a beta-blocker, and an ACE inhibitor, statin ing retinopathy in type 1 and 2 diabetics.
therapy is considered the standard of care to prevent a
future event and should be offered to all patients without Nephropathy
a contraindication. Diabetic nephropathy is the most common
cause of end-stage renal disease in the United
Antiplatelet Therapy States. Albuminuria (protein in the urine) is used
In previous years, the use of aspirin for primary preven- as a marker for nephropathy. Patients with type
tion of CVD was recommended in diabetes patients at 1 diabetes in general, and patients with type 2
increased risk; defined as over 40 years old with ad- with microalbuminuria (small amounts of protein
ditional risk factors (family history of CVD, smoking, in the urine), are at increased risk for disease
hypertension, dyslipidemia, or albuminuria). Newer progression and macroalbuminuria (large
evidence questions the use of aspirin for primary preven- amounts of protein in the urine), as well as the
tion. Recently published clinical trials failed to demon- development of fulminate kidney disease. Risk
strate a reduction in cardiovascular endpoints in diabetes factors for diabetic nephropathy include hyper-
patients using aspirin for primary prevention. Based on tension, poor glucose control, and microalbu-
the results of these trials, which were included along with minuria. A diagnosis of microalbuminuria may
other trials in a meta-analysis performed by the ADA, the be a marker for increased mortality and future

nephropathy. The preferred method for screen- as peripheral neuropathy. Peripheral neuropathy presents
ing is a urine albumin-to-creatinine ratio via a as pain, numbness, and tingling in the extremities, most
random spot collection. Degrees of albumin- commonly in the legs, feet, and toes. Incidence is thought
urea are defined as follows: microalbuminuria to increase with duration of diabetes. Education about
30– 299 µg/ml and macroalbuminuria ≥300 µg/ proper foot care and assessment of sensation can re-
ml. Initial screening for type 1 diabetes patients duce risk for the development of diabetic foot ulcers. The
is recommended within five years of diagnosis. ADA recommends annual testing for loss of protective
For those with type 2 diabetes, initial sensation (LOPS) using a 10 g monofilament, plus testing
screening should occur at diagnosis. Moni- any one of the following: vibration using a 128-hertz (Hz)
toring is recommended yearly thereafter. tuning fork, pinprick sensation, ankle reflexes, or vibration
The primary intervention for prevention and perception threshold. Patients should be educated on
progression of nephropathy is blood pressure proper foot care and instructed to examine their feet daily
and blood glucose control. Treatment strate- for sores, cuts, and dryness. A comprehensive foot exam
gies to prevent worsening of nephropathy should be performed annually by a health care provider,
differ based on type of diabetes and degree to include assessment of sensation as described above,
of albuminuria. Both ACE inhibitors and ARB’s pedal pulses, and visual inspection. A visual inspection is
have been shown to slow the progression of recommended at every follow-up visit. Achieving glyce-
albuminuria in type 2 diabetes patients with mic control is considered a first-line preventive measure.
documented microalbuminuria. Reduction in Medications may be used to provide symptomatic pain
overall mortality has been seen with the use relief. These include amitriptyline, nortriptyline, imipra-
of ACE inhibitors, whereas there is limited mine, gabapentin, carbamazepine, pregabalin, dulox-
evidence suggesting a reduction in mortality etine, opioids, nonsteroidal anti inflammatory agents, and
with ARB therapy. According to the ADA, ACE capsaicin cream.
inhibitors or ARBs may be considered for use
in type 2 patients with microalbuminuria. The Vaccinations
treatment of choice for macroalbuminuria in Patients with diabetes are more susceptible to infections
type 2 diabetes is an ARB, as they have been and should be educated about the importance of stay-
shown to reduce risk for end-stage renal dis- ing up-to-date with the recommended vaccinations. The
ease in this population. ADA and Centers for Disease Control (CDC) specifically
The favored agents in those with type recommend that patients with diabetes receive seasonal
1 diabetes with any degree of albuminuria influenza and pneumococcal vaccinations, as influenza
are ACE inhibitors. The combination of ACE and pneumonia are associated with an increased risk
inhibitors and ARBs has been shown to of morbidity and mortality in the elderly and patients
reduce progression to albuminurea in certain with certain comorbidities including diabetes. A yearly
patients, but there is no data to support long- seasonal influenza vaccination starting in September is
term reduction in renal and cardiovascular recommended for all diabetes patients age 6 months
events. If combination therapy is considered, and older. The pneumococcal vaccination is also recom-
close monitoring is required due to increased mended for all patients with diabetes age 2 years and
risk of hyperkalemia. older. The pneumococcal vaccination should be admin-
istered on diagnosis. A second vaccination is recom-
Peripheral Neuropathy mended in patients age 65 and older if more than five
Nerve damage is a complication of both type 1 years have passed since their last vaccination.
and type 2 diabetes mellitus. There are several
different types of diabetic neuropathies. The Smoking Cessation
most frequent neuropathy is symmetric distal The health risks of cigarette smoking and increased risk of
polyneuropathy (DPN), commonly referred to morbidity and mortality for patients who choose to smoke

Table 7: Diabetes Update 2010 blood glucose and, if it is <70 mg/dL, should
consume 15–20 g of glucose or carbohydrate
• A
1C newly endorsed as a diagnostic test
• E
stimated average glucose now recommended in con- (equal to three glucose tablets or four ounces
junction with A1C monitoring of orange juice). Patients should be instructed
• N
ew evidence suggests A1C “close to” 7% is acceptable to check finger-stick blood glucose again in 15
for most patients (ACCORD trial) minutes to ensure resolution of hypoglycemia.
• N
ew Antidiabetic Agents This intervention may be repeated as needed if
a) O
nglyza (saxagliptin): New DPP-4 inhibitor
initial symptoms do not resolve or blood glucose
b) C
ycloset (bromocriptine mesylate):
New class (dopamine agonists)for treatment of type 2 does not rise above 70 mg/dL. Once above
diabetes blood glucose is >70 mg/dL, suggest eating
c) Victoza
(liraglutide): New GLP-1 agonist a small snack to maintain euglycemia. For a
d) A
ctoPlus Met XR: New formulation conscious patient experiencing a hypoglycemic
• R
ecommendations for the use of aspirin for primary pre- episodes with a blood glucose of <50 mg/dL,
vention have been updated
30 grams of carbohydrate or glucose consump-
Source: The Standards of Medical Care in Diabetes— 2010, published by the tion is recommended. In unconscious patients,
American Diabetes Association (ADA).
a glucagon kit should be utilized and emergency
management services activated.
are well known. All patients with diabetes should be coun- Diabetic ketoacidosis (DKA) and hyperos-
seled on the benefits of smoking cessation and advised to molar hyperglycemic state (HHS) are potentially
quit. There are several therapeutic options available to as- fatal conditions that occur in diabetes patients
sist in smoking cessation, including nicotine replacement with elevated blood glucose. They are both
therapy, bupropion (Zyban SR), and varenicline (Chantix). considered medical emergencies, and patients
The effectiveness of these commonly used medications should receive inpatient treatment. Diabetic
appears similar. The use of medication to assist with ketoacidosis is caused by insulin deficiency
smoking cessation, therefore, should be chosen based and is most common in young type1 diabetes
on individual preferences and potential contraindications patients. However, it can occur in adult type 1
to therapy. The benefits of smoking cessation counseling patients and type 2 diabetes patients. The most
in combination with pharmacologic therapy are greater common causes of DKA are alcohol abuse,
than either practice alone. Counseling provided by trained infection, and noncompliance with treatment.
community pharmacists has been shown to increase a Signs and symptoms of DKA include fruity/
patient’s likelihood of quitting. acetone breath, nausea, vomiting, dehydration,
polydipsia, polyuria, and rapid breathing. Hyper-
Acute Complications osmolar hyperglycemic states occur primarily in
Hypoglycemia is a risk for all patients with diabetes tak- older type 2 patients and result from extremely
ing medications that may predispose them to low blood elevated glucose and dehydration, which
glucose (such as insulin and sulfonylureas). Clinical increase plasma osmolality and altered mental
diagnosis of hypoglycemia is defined as a blood glucose status. A hyperosmolar hyperglycemic state is
of <50 mg/dL. However the ADA recommends treatment usually not associated with ketoacidosis. Signs
when blood glucose is <70 mg/dL. Common signs and and symptoms of HHS include weakness, visual
symptoms of hypoglycemia include fatigue, shakiness, disturbance, and leg cramps. Nausea, vomiting,
sweating, headache, hunger, and confusion. Patients with lethargy, confusion, hemiparesis, seizures, and
elevated blood glucose levels may experience hypoglyce- coma are less common symptoms of HHS. For-
mic symptoms without having a blood glucose of <70mg/ tunately, patients rarely present with these acute
dL as their blood glucose is being reduced to near-normal conditions in the community pharmacy. How-
or normal ranges. Patients experiencing hypoglyce- ever, it is important for pharmacists to recognize
mic symptoms should be advised to check finger-stick the signs and symptoms of DKA and HHS to

triage and refer patients for proper medical at- and in the evening before dinner (220– 260 mg/dL).
tention in the event a patient does present with
the described symptoms. PMH: Type 2 diabetes
Hypertension (diagnosed two years ago)
Conclusion Osteoporosis
The number of patients with diabetes in the Medications: Lisinopril 10 mg daily
United States is projected to grow significantly Risedronate 35 mg once weekly
over the next decade. Given the large number Os-Cal 500 + Extra D 1 tablet twice daily
of patients currently with diagnosed diabetes, Metformin 500 mg daily for seven days,
there is a significant opportunity for the commu- then BID (new with today’s prescription)
nity pharmacist to play a pivotal role in diabetes Allergies: Sulfa (hives and difficulty breathing)
care. The progressive, multifactorial nature of Family History: Mother (68) has type 2 diabetes
the disease requires contributions from vari- Father (70) has CHF
ous members of the health care team. With the Social History: Smokes 1 pack per day
strong supporting evidence for DSME, phar- Denies alcohol
macists can now receive reimbursement for the Caffeine: 1– 2 beverages per day
time spent counseling patients with diabetes. Weight: 180 lbs.
As the role of the pharmacist continues to prog- Height: 5’3’’
ress, community pharmacy will play an integral Blood Pressure: at physician’s office today was 120/72
role in the care of diabetes patients.… Diet: Has cut out sugar and is watching car-
bohydrate intake
Exercise: Has started walking three days per week
Kimberly Ference, PharmD, is an assistant professor at the for about 15 minutes
Wilkes University College of Pharmacy and Nursing. Framingham risk: 9%
What important metformin counseling points would you

Case Study 1A review her when starting therapy?
JD is 45-year-old Caucasian female who comes Metformin therapy is considered first-line because it
to your pharmacy counter with a new prescrip- provides a significant reduction in blood glucose. More
tion for metformin. She would also like assis- importantly, it has been shown to reduce the risk of
tance with picking an aspirin product. Her friend, premature death and other diabetes-related endpoints
who also has diabetes, told her to take aspirin in patients such as her. The most common side effects
daily, but she does not know what product to from metformin therapy are gastrointestinal in nature;
purchase. She also saw a sign in the window they usually are seen at the beginning of therapy or after
stating that the pharmacy offers diabetes educa- a dose increase, and they subside after a few weeks of
tion sessions and she would like to schedule an therapy. Patients should be instructed to take with food
appointment. to minimize these effects. Lactic acidosis is an extremely
rare yet potentially severe side effect of therapy. Pa-
HPI: Patient was diagnosed with type 2 diabetes tients should be counseled to self-monitor for symptoms
one month ago and was instructed to initiate of lactic acidosis (hyperventilation, myalgia, malaise,
lifestyle modifications. After an appointment with unusual somnolence) and notify a health care provider if
her physician today, she was started on metfor- these symptoms occur. Kidney function will be monitored
min therapy. She denies polyphagia and blurred by their physician while on this medication. Patients may
vision and admits to experiencing polydipsia begin to see a decrease in their FSBG as soon as two
and polyuria occasionally. She checks her FSBG
in the morning before eating (200– 240 mg/dL) Continued on page 38 ➥

➥ Foot Exam
weeks after starting, and they can also tell the medication The ADA recommends comprehensive foot
is working if their symptoms of hyperglycemia decrease in exams annually, which include assessment of
frequency/severity. sensation, pedal pulses, and visual inspection.
A visual inspection is recommended at every
At this time, would you recommend aspirin in JD? If so, follow-up visit. Education about proper foot care
what dose would you recommend? is also recommended.
This patient does not meet the criteria for aspirin therapy
for primary prevention as set by the ADA. She is not Smoking Cessation
more than 60 years old and her Framingham 10-year JD should be advised about the benefits of
CHD risk is under 10 percent. However, she does have smoking cessation and advised to quit. Smok-
risk factors such as smoking and hypertension. These ing cessation counseling in combination with
risk factors should be addressed as part of a compre- pharmacologic therapy may be of benefit in this
hensive care plan. You should consider reassessing patient.
the patient’s CHD risk once the patient is over 60 years
old and recommend aspirin at that time if appropriate. Vaccinations
Doses of 81 mg daily have been shown effective in pro- The ADA and CDC recommend offering pneu-
viding cardioprotection. mococcal and seasonal influenza vaccines to
all diabetes patients without a contraindica-
What complication education and screening would you tion. As it is currently flu season, the patient is
recommend at this time? due for her annual influenza vaccination. The
Blood pressure screening is recommended at every of- patient should also be advised to receive a
fice visit. Patient has hypertension and is at goal blood pneumococcal vaccination if it has not been
pressure (according to reading in office today) of under administered in the past.
130/80 mmHg. Recommend continuous assessment to
ensure goals are being met and the treatment regimen is
appropriate. Case Study 1B
JD returns to your pharmacy, three months
Dyslipidemia after her initial visit, with a prescription for
The ADA recommends screening with a fasting lipoprotein motormin 1,000 mg twice daily. Under the
profile on diagnosis. In this patient, therapy with a statin direction of her physician, she has been taking
may be considered independent of baseline lipid levels, as metformin 500 mg two tablets twice daily for
she is over 40 years old without CVD and one or more CVD the past six weeks and has not experienced
risk factors (smoking, hypertension). any side effects. She states that her FSBG
“are not quite where they should be” and that
Retinopathy her doctor is considering adding insulin to her
The ADA recommends screening for diabetic retinopa- regimen if the new dose of metformin does
thy shortly after diagnosis for type 2 diabetes patients. A not work. She states that she “is not ready for
dilated eye examination is recommended yearly. insulin” and asks if you know anything about
the two new diabetes medications that she
Nephropathy saw on television, Onglyza and Victoza. She
The ADA recommends initial screening for nephropathy wants to know if these medications can be
shortly after diagnosis for type 2 diabetes patients, using a used instead of insulin. Upon further question-
urine albumin-to-creatinine ratio via a random spot collec- ing, you uncover that she is opposed to using
tion. Monitoring is recommended annually thereafter. insulin due to fear and the association with her
mother’s worsening diabetes. Her mother was

started on insulin just prior to going on dialy- Continuing Education Quiz
sis. The patient has lost 10 pounds and quit Select the correct answer.
smoking after her smoking cessation coun-
seling session at your community pharmacy. 1. An absolute insulin deficiency arising from beta cell
Her FSBG are as follows: morning fasting: destruction best describes which type of diabetes?
160– 180 g/dL, and before dinner: 180– 200 a. T
ype 1
mg/dL. Recent A1C was 8 percent. b. T
ype 2
c. Gestational
What would you tell JD about her available d. P
rediabetes
treatment options?
According to the ADA treatment algorithm, 2. Which of the following patients would benefit most
the use of sulfonylureas or basal insulin is from a diabetes screening?
recommended as add-on therapy once pa- a. A
44-year-old woman with no risk factors
tients have reached maximum clinical dos- b. A
n overweight 40-year-old male with no other risk
es of metformin. As JD has a sulfonamide factors
allergy that resulted in difficulty breathing, c. A
n obese 35-year-old African American female
the physician is considering basal insulin. d. A
38-year-old female with a history of gestational
Given the patient’s fear of insulin, JD would diabetes and a BMI of 23
benefit from education about the advan-
tages and disadvantages of insulin therapy, 3. According to the ADA, which of the following lab val-
as well as addressing any insulin myths or ues is considered diagnostic for diabetes if confirmed
misconceptions. by a second reading on a subsequent day?
If the patient is still opposed, alterna- a. Oral glucose tolerance test (two hours postprandial)
tive options may be considered. At that ≥180 mg/dL
time, the patient would benefit from edu- b. F
asting plasma glucose ≥110 mg/dL
cation regarding the benefits and risks of c. E
stimated average glucose ≥126 mg/dL
antidiabetes medication options (such as d. H
emoglobin A1C ≥6.5 percent
tier 2 less well-validated therapies) that
may be considered in her situation. The 4. The ADA recommends a goal two-hour postprandial
tier 2 therapies include pioglitazone and plasma glucose of less than:
GLP-1 agonists. The use of pioglitazone is a. 1
30 mg/dL
not recommended in this patient given her b. 1
40 mg/dL
history of osteoporosis. Therefore, lira- c. 1
80 mg/dL
glutide (Victoza) or Exenatide (Byetta) are d. 2
00 mg/dL
therapeutic options for this patient. JD may
be unaware that GLP-1 agonists are inject- 5. Which of the following tests is recommended in
ables and she may not be interested, given conjunction with A1C monitoring, as it is thought to
her fear of insulin (an injectable). Use of be more understandable when discussing laboratory
DPP-4 inhibitors (Onglyza) are not recom- monitoring with patients because it correlates with
mended in the ADA’s treatment algorithm patient SMBG values?
due to their overall limited efficacy, lack of a. F
asting plasma glucose
patient-oriented evidence, and increased b. E
stimated average glucose
cost when compared with other therapies. c. P
ostprandial plasma glucose
Onglyza may be considered in patients d. P
reprandial plasma glucose
who are unable to take standard treatment,
which may be the case with this patient.

6. Which of the following antidiabetic medication class is 11. Which of the following statements best de-
considered first line for the treatment of type 2 diabetes? scribes the primary difference between exena-
a. Thiazolidinediones tide (Byetta) and liraglutide dosing?
b. Sulfonylureas a. L
iraglutide is dosed twice daily with meals,
c. Biguanides while exenatide is dosed once daily without
d. Dipeptidyl peptidase inhibitors regard to meals.
b. E
xenatide is dosed twice daily with meals,
7. Due to the concern for adverse cardiovascular effects, while liraglutide is dosed once daily without
which of the following medications is no longer recom- regard to meals.
mended for use by the ADA? c. T
here is no difference in dosing and both
a. Glyburide should be taken with meals.
b. Rosiglitazone d. T
here is no difference in doing and both can
c. Acarbose be taken without regard to meals.
d. Nateglinide
12. Which of the following insulins should you
8. According to the ADA treatment algorithm, pioglitazone instruct patients to administer prior to a meal?
is recommended for the treatment of type 2 diabetes in a. N
PH (Humulin N)
which of the following situations? b. Glargine (Lantus)
a. In combination with metformin as a second-line, well- c. D
etemir (Levemir)
validated treatment option d. Glulisine (Apidra)
b. In combination with metformin in patients who are un-
able to use tier 1 agents 13. All of the following medications have been
c. In combination with insulin in patients who are unable associated with an increased risk of pancreatitis
to use tier 1 agents EXCEPT:
d. In patients with CHF that are unable to use metformin a. Sitagliptin
b. Saxagliptin
9. Which of the following medications is associated with c. Exenatide
hypotension and should be cautiously in patients taking d. Liraglutide
antihypertensives?
a. Saxagliptin 14. What is the drug of choice for the treatment
b. Liraglutide of diabetes during pregnancy?
c. Bromocriptine a. Insulin
d. Rosiglitazone b. Sulfonylureas
c. Thiazolidinediones
10. All of the following medications promote weight loss d. Glucagon-like peptide inhibitors
in diabetes patients EXCEPT:
a. Glipizide 15. With type 2 diabetes, which of the following
b. Exenatide aspects of care provides the most benefit in
c. Amylin terms of risk reduction?
d. Metformin a. S
moking cessation
b. Use of ACE inhibitors
c. B
lood glucose control
d. U se of aspirin

The Community Pharmacist’s
16. Which of the following is the recommended Role in Diabetes Treatment
goal blood pressure for a diabetic patient with Nov. 1, 2010 (expires Nov. 1, 2013) • Activity Type: Application-based
hypertension?
FREE ONLINE C.E. Pharmacists now have online access to NCPA’s
a. <120/80 C.E. programs through Powered by CECity. By taking this test online—
b. <130/80 go to the Continuing Education section of the NCPA Web site (www.
ncpanet.org) by clicking on “Professional Development” under the
c. <130/85 Education heading you will receive immediate online test results and
d. 140/90 certificates of completion at no charge.
To earn continuing education credit: ACPE Program 207-000-10-011-H01-P

17. Based on recent evidence, which of the fol-
A score of 70 percent is required to successfully complete the C.E. quiz.
lowing diabetes patients is most likely to benefit If a passing score is not achieved, one free reexamination is permitted.
from the use of aspirin to reduce the risk of Statements of credit for mail-in exams will be available online for you
cardiovascular disease? to print out approximately three weeks after the date of the program
(transcript Web site: www.cecerts.ORG). If you do not have access to a
a. A 30-year-old male with hypertension and a
computer, check this box and we will make other arrangements to send
10-year CHD risk of 8 percent you a statement of credit: q
b. A 40-year-old female with hyperlipidemia and
Record your quiz answers and the following information on this form.
a 10-year CHD risk of 5 percent q NCPA Member License
NCPA Member No. ____________________ State __________ No. _____________________
c. A 50-year-old male smoker with a 10-year
q Nonmember State __________ No. _____________________
CHD risk of 11 percent
All fields below are required. Mail this form and $7 for manual processing to:
d. A 50-year-old female smoker with a 10-year NCPA C.E. Processing Ctr.; 405 Glenn Drive, Suite 4; Sterling, VA. 20164
CHD risk of 8 percent _____________________________________________________________________________________
Last 4 digits of SSN MM-DD of birth
_____________________________________________________________________________________
18. Which of the following interventions has Name
_____________________________________________________________________________________
NOT been shown to reduce the risk of worsen- Pharmacy name
_____________________________________________________________________________________
ing nephropathy in patients with diabetes? Address
_____________________________________________________________________________________
a. Use of an ACE inhibitor City State ZIP
b. Use of a beta-blocker _____________________________________________________________________________________

Phone number (store or home)
c. Control of blood pressure _____________________________________________________________________________________
Store e-mail (if avail.) Date quiz taken
d. Control of blood glucose
Quiz: Shade in your choice
a b c d e a b c d e
19. The ADA recommends annual screening 1. q q q q q 11. q q q q q
for all of the following diabetes complications 2. q q q q q 12. q q q q q
3. q q q q q 13. q q q q q
EXCEPT:
4. q q q q q 14. q q q q q
a. Urine microalbumin 5. q q q q q 15. q q q q q
b. Diabetes eye exam
6. q q q q q 16. q q q q q
c. Monofilament foot exam 7. q q q q q 17. q q q q q
d. Blood pressure 8. q q q q q 18. q q q q q
9. q q q q q 19. q q q q q
10. q q q q q 20. q q q q q
20. Which of the following interventions would
you recommend to treat symptoms of hypo- Quiz: Circle your choice
21. Is this program used to meet your mandatory C.E. requirements?
glycemia in a conscious patient receiving both
a. yes b. no
glipizide and acarbose with a blood glucose of 22. Type of pharmacist: a. owner b. manager c. employee
65 mg/dL? ge group: a. 21–30 b. 31–40 c. 41–50 d. 51–60 e. Over 60
23. A
a. Glucagon injection id this article achieve its stated objectives? a. yes b. no
24. D
b. Humulin R injection 25. H

ow much of this program can you apply in practice?
a. all b. some c. very little d. none
c. Three glucose tablets
d. A bowl of ice cream How long did it take you to complete both the reading and the quiz? ______ minutes
NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider

of continuing pharmacy education. NCPA has assigned two contact hours (0.2 CEU)
www.americaspharmacist.net of continuing educationNovember
credit to this 2010
article.|Eligibility
america’s Pharmacist
to receive 51
continuing education
credit for this article expires three years from the month published.

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continuing education

The Community Pharmacist’s

U pon completion of this activity,

www.americaspharmacist.net November 2010 | america’s Pharmacist 29

30 america’s Pharmacist | November 2010 www.americaspharmacist.net

www.americaspharmacist.net November 2010 | america’s Pharmacist 31

Table 2: Available Oral Agents

32 america’s Pharmacist | November 2010 www.americaspharmacist.net

www.americaspharmacist.net November 2010 | america’s Pharmacist 33

34 america’s Pharmacist | November 2010 www.americaspharmacist.net

Thiazolidinediones Adverse Effects

www.americaspharmacist.net November 2010 | america’s Pharmacist 35

Adverse Effects Available Products

36 america’s Pharmacist | November 2010 www.americaspharmacist.net

www.americaspharmacist.net November 2010 | america’s Pharmacist 37

38 america’s Pharmacist | November 2010 www.americaspharmacist.net

Table 4: Non-Insulin Injectable Agents

Amylin agonists Pramlintide 1 15 mcg before 60 mcg before Renal: No C

www.americaspharmacist.net November 2010 | america’s Pharmacist 39

Available Products Contraindications

40 america’s Pharmacist | November 2010 www.americaspharmacist.net

Table 5: Available Insulin Agents

Rapid-Acting Novolog 15– 30 minutes 0.5– 2.5 3– 4

Short-Acting Humulin R 30– 60 minutes 2– 3 3– 6

Humalog Mix 75/25 15– 30 minutes 1– 6.5 15– 18

www.americaspharmacist.net November 2010 | america’s Pharmacist 41

Figure 1: Algorithm for the Treatment of Type 2 Diabetes

Tier 1: Well-validated core therapies

TLC + Metformin TLC + Metformin

Step 1 Step 2 Step 3

Tier 2: Less well-validated therapies

TLC + Metformin TLC + Metformin

42 america’s Pharmacist | November 2010 www.americaspharmacist.net

www.americaspharmacist.net November 2010 | america’s Pharmacist 43

44 america’s Pharmacist | November 2010 www.americaspharmacist.net

www.americaspharmacist.net November 2010 | america’s Pharmacist 45

46 america’s Pharmacist | November 2010 www.americaspharmacist.net

What important metformin counseling points would you

www.americaspharmacist.net November 2010 | america’s Pharmacist 47

48 america’s Pharmacist | November 2010 www.americaspharmacist.net

www.americaspharmacist.net November 2010 | america’s Pharmacist 49

50 america’s Pharmacist | November 2010 www.americaspharmacist.net

To earn continuing education credit: ACPE Program 207-000-10-011-H01-P

b. Use of a beta-blocker _____________________________________________________________________________________

b. Humulin R injection 25. H

NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider

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b. Use of a beta-blocker _____________________________________________________________________________________

b. Humulin R injection 25. H