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

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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
Version 4.0 VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus Thiazolidinediones Pioglitazone Rosiglitazone 1.0-1.5% Negligible risk as monotherapy • Contraindicated in New York Heart Association Class III and IV heart failure • Do not initiate in patients with active liver disease or ALT > 2.5 x the upper limit of normal • Slow onset of action (6-12 weeks for full effect) • May restore ovulation in premenopausal anovulatory females • Rosiglitazone not recommended in combination with insulin • Edema • Weight gain • Decrease hemoglobin/ hematocrit • Fractures in females (rare) • Exacerbate heart failure • Macular edema (rare) • Increase LDL-C • Not recommended in symptomatic heart failure • Periodic monitoring of serum transaminases • Increase HDL-C (3-5mg/dL) • Very expensive GLP-1 agonists Exenatide 1.0% Minimal - moderate risk • Weight loss • Unknown long-term outcomes • Not recommended in patients with: -Prior history of pancreatitis -Creatinine clearance less than 30 mL/min, end stage renal disease, or receiving dialysis - Gastrointestinal disease, severe (eg, gastroparesis) • Instruct patients to contact their provider if they experience persistent severe abdominal pain which may be accompanied by vomiting (may indicate pancreatitis) • Discontinue use if pancreatitis suspected • Not a substitute for insulin in insulin requiring patients. Do not use in type 1 diabetes for treatment of diabetic ketoacidosis • GI effects (nausea, vomiting, diarrhea) • In combination with a sulfonylurea, may increase the risk of hypoglycemia • Dehydration • Pancreatitis, acute, including hemorrhagic and necrotizing pancreatitis; post marketing cases, including fatalities, have been reported • Anaphylaxis, angioedema, hypersensitivity reactions • Reports of altered renal function • Use with caution in patients receiving oral medications that require rapid gastrointestinal absorption • Very expensive Module G: Glycemic Control: Appendices Page 84
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