DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
Alpha-glucosidase
Inhibitors
Acarbose
Miglitol
< 1.0% Negligible risk
as
monotherapy
• Allows for flexible meal dosing
• Dose taken with first bite of each
main meal
• If patient misses or adds a meal,
omit or add a dose respectively
• Use not recommended if serum
creatinine > 2.0mg/dl
• GI symptoms
(diarrhea, abdominal
pain, flatulence)
which can limit
adherence to therapy
• AST/ALT elevation
• Contraindicated in the presence of
intestinal complications (e.g.,
inflammatory bowel disease,
colonic ulceration, intestinal
obstruction, digestion or
absorption disorders)
• Acarbose is contraindicated in
patients with cirrhosis (miglitol
pharmacokinetics are not altered
in cirrhosis and may be used)
• Weight neutral
• Serum transaminase should be
checked every 3 months during
first year of treatment and
periodically thereafter
• To reverse hypoglycemia (usually
only in setting of combination
therapy),treat with oral glucose,
not sucrose
• Moderately expensive
Meglitinides
Repaglinide
Nateglinide
1.0-2.0%
(repaglinide
)
< 1.0%
(nateglinide
)
Minimalmoderate
risk
(although less
so than SU in
context of
missed
meals)
• Allows for flexible meal dosing
• Taken 1-30 minutes before a meal
• Unknown long-term outcomes
• If patient misses or adds a meal,
omit or add a dose respectively
• Do not use in patients who have
failed sulfonylurea therapy or
combine with sulfonylurea
• Weight gain
• Hypoglycemia
• Co-administration of repaglinide
with gemfibrozil is
contraindicated
• Use repaglinide cautiously in
hepatic impairment or severe renal
impairment
• Use nateglinide cautiously in
moderate to severe hepatic
impairment
• Expensive
Module G: Glycemic Control: Appendices Page 83