Fast Five Quiz: Type 2 Diabetes Management

Anne L. Peters, MD


April 27, 2022

When lifestyle modifications fail to improve glycemic control, the American Diabetes Association (ADA) recommends initial monotherapy with metformin in an individual without risk factors for cardiovascular disease (CVD)/established CVD/chronic kidney disease (CKD) and/or heart failure (HF). Metformin is a biguanide drug, as the initial glucose-lowering agent. Along with beneficial effects on hemoglobin A1c, metformin causes neither weight gain nor hypoglycemia. Some studies have shown that cardiovascular mortality may be lower in patients to whom metformin has been prescribed compared with sulfonylureas; however, large cardiovascular outcome trials have not been performed with either agent.

Insulin is considered for initial therapy in patients who present with blood glucose levels ≥ 300 mg/dL, A1c > 10%, symptoms of hyperglycemia (polyuria or polydipsia), or evidence of catabolism (weight loss). Switching from insulin to other antihyperglycemic agents may be possible when glucose toxicity has resolved. Some advocate early use of a GLP1-receptor agonist (RA) instead of insulin in overweight patients, for anyone where the diagnosis of adult-onset type 1 diabetes insulin should be started.

Current ADA guidelines recommend starting with a GLP-1 RA or sodium-glucose cotransporter 2 (SGLT2) inhibitor in people at high risk for CVD, established CVD, CKD, and/or HF. Metformin should not be initiated in patients with a glomerular filtration rate (GFR) < 45 mL/min/1.73 m2 . Most GLP-1 RAs can be used at any level of renal function, and SGLT-2 inhibitors can generally be used down to an estimated GFR of 30.

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