Diabetes Cheat Sheet So, Do You Have Diabetes? Basic Treatment Considerations Take Any of the Following Tests: A1c Goal: 6.5% (AACE) or 7% (ADA) Hemoglobin A1c Fasting Glucose Test Glucose Tolerance Test Random Glucose Test >6.5%? ≥126 mg/dL? ≥200 mg/dL? ≥200 mg/dL? Non-Insulin Dependent: Initiate with Metformin Insulin Dependent: Initiate with Insulin Any of the Above True x 2 Days? That, Son, Is How You Get Diabeetus. For A1c ≥9% (ADA) or ≥7.5% (AACE), consider multiple agents Hypoglycemia Management Drug A1c Effect Note Defined As: Blood Glucose < 70 mg/dL Metformin 1 - 1.5% Monotherapy Symptoms: Sweating, Tremor, Hunger, HA, AMS Insulin Can Take PO? Can’t Take PO? GLP-1 Agonists 1% D50% (25 mL / 12.5 gm IV Push) Glucagon 1 mg SC DDP-IV Inhibitors 0.7% Meglitinides 0.7% Wait 15 Minutes, Check Glucose Sulfonylureas 0.8% Repeat Dose Until BG > 70 mg/dL Thiazoladinediones 0.8% Diabetes Drug Interacting Drug(s) Repaglinide 2C8 Inhibitors: Gemfibrozil Fluconazole Nicardipine Delvirdine Ketoconazole Repaglinide is a 2C8 substrate (decreased metabolism, may increase concentration and hypoglycemic effect). 2C9 Inhibitors: Fluconazole Trimethoprim Amiodarone Zafirlukast Sulfonylureas and Nateglinide are 2C9 substrates (decreased metabolism, may increase concentration and hypoglycemic effect). Acarbose Mechanism 3A4 Inhibitors: Macrolides (NOT Azithromycin) Verapamil Diltiazem Itraconazole Ketoconazole Fluoxetine Fluvoxamine HIV Protease Inhibitors Delavirdine Repaglinide is a 3A4 substrate (decreased metabolism, may increase concentration and hypoglycemic effect). Digoxin Acarbose may decrease digoxin absorption, leading to decreased Digoxin levels. Sulfonylureas Alpha Glucosidase 0.6 - 0.7% Inhibitors Pramlintide Drugs with Potential Weight Gain Effect Insulin 0.7 - 1% No IV Access? Drug Interactions Repaglinide SGLT2 Inhibitors IV Access? 15 gm Carbs (3-4 Glucose Tab, 1/2 Cup Juice, Non-Diet Soda) Sulfonylureas Nateglinide 0.9 - 1.1% Varies, No Max Dose Meglitinides Thiazolidinediones* 0.36% Must Take w/ Insulin Drugs with Potential Cardiovascular Benefit SGLT-2 Inhibitors Empagliflozin GLP-1 Agonists Liraglutide Semaglutide Drugs with Potential Weight Loss Benefit Biguanides Metformin SGLT-2 Inhibitors Canagliflozin Empagliflozin Dapagliflozin Ertugliflozin GLP-1 Agonists Exenatide Liraglutide Semaglutide Drugs That May Cause Hypoglycemia Insulin (All) Sulfonylureas Chlorpropamide Glimepiride Glyburide Glipizide Meglitinides Repaglinide Nateglinide Agents Possibly Used for DM Chlorpropamide Glimepiride Repaglinide Pioglitazone Acid Sequestrants Colesevelam (All) This study source was downloaded by 100000752467928 from CourseHero.com on 09-15-2022 17:17:55 GMT Bile -05:00 Glyburide Nateglinide Rosiglitazone Glipizide Dopamine Agonist Bromocriptine *More likely due to potential fluid retention, not fat https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ Combination Agents Metformin Alogliptin Pioglitazone Actoplus Met Actoplus Met XR Oseni Linagliptin Jentadueto Rosiglitazone Avandamet Alogliptin Kazano Canagliflozin Invokamet Dapagliflozin Xigduo XR Empagliflozin Synjardy Glimepiride Amaryl M Glipizide Metaglip Glyburide Glucovance Repaglinide PrandiMet Saxagliptin Kombiglyze XR Sitagliptin Janumet Janumet XR Empagliflozin Glimepiride Sitagliptin Duetact Glyxambi Avandaryl Simvastatin Juvisync DKA vs HHS Mortality Rate DKA 2 - 5% More common in T1DM + HHS ~15% More common in T2DM + Hyperglycemia and Dehydration Presentation + Ketoacidosis (consider adding bicarbonate as part of treatment algorithm) + Rapid Onset (< 24 hrs) + Gradual Onset (days to weeks) + + Treat with IV fluids, insulin, and electrolyte (especially potassium) repletion + + Occupational Restrictions for Insulin Dependent Diabetics Occupation Eligibility for Insulin-Dependent Law Enforcement Officer Case by Case Firefighter Case by Case Commercial Divers Case by Case Pilot Class III Only Military Restricted Notes Apply for waiver from state or Diabetes Exemption Program Most branches, but does not apply for contractors http://www.diabetes.org/living-with-diabetes/know-your-rights/discrimination/employment-discrimination/getting-a-job.html Clinical Pearls SGLT-2 Inhibitors Increased Risk of Amputation Cause/Exacerbate Renal Failure Increased Risk of UTI/Yeast Infections Biguanides Lactic Acidosis (Monitor Renal Function) Sulfonylureas Glipizide is preferred sulfonylurea in renal failure Glyburide (NOT recommended, but possible use in pregnancy based on data) GLP-1 Agonists Risk of thyroid C-cell tumors DPP-4 Antagonists Warning for potential joint pain Meglitinides Major interactions with repaglinide This study source was downloaded by 100000752467928 from CourseHero.com on 09-15-2022 17:17:55 GMT -05:00 Thiazolidinediones Insulin https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ Risk of heart failure/myocardial infarction Preferred in pregnancy/breastfeeding Class Name CKD stages 3 and 4 and predialysis stage 5* Glargine Detemir NPH Insulin Consider lower dose with ESRD 10-50 mL/min: 75% of dose <10 mL/min: 50% of dose Adjust based on response Regular Aspart Lispro Glulisine eGFR 50–80: reduce dose by 50% Chlorpropamide First-generation sulfonylureas Second-generation sulfonylureas Glinides eGFR <50: Avoid Tolazamide Avoid Tolbutamide Avoid Glipizide** eGFR <30: Caution eGFR <60: Caution Glimepiride** eGFR <30: Avoid Glyburide Avoid Repaglinide** No dose adjustment, caution with eGFR <30 Nateglinide eGFR <60: Avoid (may consider on hemodialysis) Per FDA, do not use if serum Cr ≥ 1.5 mg/dL in men ≥ 1.4 mg/dL in women. Biguanides Metformin*** eGFR ≥45-59: Caution, monitor renal function eGFR ≥30-44: max dose 1000 mg/day or use 50 % dose reduction and monitor eGFR <30: Avoid Thiazolidinediones Alpha-glucosidase inhibitors Pioglitazone No dose adjustment Rosiglitazone No dose adjustment Acarbose serum Cr >2 mg/dl: Avoid Miglitol eGFR <25 or serum Cr >2 mg/dl: Avoid eGFR ≥50: 100 mg daily Sitagliptin eGFR 30–49: 50 mg daily eGFR < 30: 25 mg daily DPP-4 inhibitor Saxagliptin Linagliptin eGFR > 50: 2.5 or 5 mg daily GFR ≤ 50: 2.5 mg daily No dose adjustment eGFR >60: 25 mg daily Alogliptin eGFR 30–59: 12.5 mg daily eGFR <30: 6.25 mg daily Canagliflozin SGLT2 inhibitors eGFR 45 to < 60: max dose 100 mg once daily eGFR <45, Not recommended Dapagliflozin eGFR < 60, Contraindicated Empagliflozin eGFR < 45, Contraindicated Dopamine receptor agonist Bromocriptine No dose adjustment, caution Bile acid sequestrant Colesevelam No dose adjustment Exenatide GLP-1 Agonists Amylin analog eGFR 30–50: Caution eGFR <30: Avoid Liraglutide No dose adjustment, caution when starting or adjusting dose Albiglutide No dose adjustment Dulaglutide No dose adjustment Pramlintide No dose adjustment, not studied in ESRD This study source was downloaded by 100000752467928 from CourseHero.com on 09-15-2022 17:17:55 GMT -05:00 * Package inserts vary on term between eGFR or CrCl ** Preferred Agents in CKD https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ *** Restriction due to lactic acidosis associated with phenformin Drug Hepatic Adjustment Notes Used with caution up to 1500 mg/day Can be used in mild liver disease Reduced/avoid in patients with moderate liver disease Avoid in severe hepatic dysfunction Metformin Sulfonylureas Meglitinides Pioglitazone Alpha-glucosidase Inhibitors DPP-4 Inhibitors SGLT-2 Inhibitors GLP-1 Agonists Insulin Use with caution Use with caution Avoid when liver enzymes >3x ULN Avoid in patients with edema Can be used without dose modification Relatively safe Use with caution without dose modification (except vildagliptin) Use with caution Contraindicated in severe liver dysfunction Caution advised due to risk of dehydration and hypotension Use with caution without dose modification Titrate dose to requirements to reduce risk of hypoglycemia Newer insulin analogs may be preferred as PK is unaltered in CLD and have low risk of hypoglycemia Shelf Life (Open) Shelf Life (Open) (Refrigerator) (Room Temp) GLP-1 Agonists Child-Pugh A Child-Pugh B Child-Pugh C Lower doses Can be used Lower doses Not preferred Avoid Not preferred Can be used Avoid Avoid Safe Safe Not preferred Can be used Use with caution Safe Not preferred Use with caution Avoid Can be used Use with caution Avoid Compatible Needles Notes 56 days NovoFine Plus Pen needles included 14 days Built-in Prefilled syringes or single use devices 28 days Included Use 8 hours after reconstitution Adlyxin Lixisenatide 14 days BD/Ypsomed/Owen Mumford ≤8 mm Byetta Exenatide 30 days 29G/30G/31G Bydureon Exenatide (ER) 28 days N/A (Vial/Syringe) Bydureon Bcise Exenatide 28 days Built-in Ozempic Semaglutide 56 days Trulicity Dulaglutide Tanzeum Albiglutide* 28 days Victoza Liraglutide 30 days 30 days NovoFine, NovoFine Plus, BD Ultra-Fine Saxenda Liraglutide 30 days 30 days Novo Nordisk Single use device Used for weight loss *Discontinued by July 2018 Insulin Transition Rapid and Regular Rapid and Rapid Regular and Regular 70/30 and 70/30 75/25 and 75/25 70/30 and 75/25 Basal and Basal NPH BID and Basal Conversion Factor (Units) 1 to 1 1 to 1 1 to 1 1 to 1 1 to 1 1 to 1 1 to 1 (Except NPH BID/Toujeo) 80% of Total Daily NPH (Except Tresiba/Levemir) Toujeo and Basal 80% of Total Daily Toujeo (Except Tresiba) NPH BID and Tresiba NPH BID and Levemir 1 to 1 1 to 1 Toujeo and Tresiba 1 to 1 Converting Mealtime Rapid/Regular Injected Insulin to Inhaled Insulin Mealtime Insulin Afrezza Dose Brand Afrezza Insulin (for inhalation) Brand Apidra Insulin glulisine Humalog Insulin lispro Novolog Insulin aspart Fiasp Insulin aspart Humulin R Insulin (regular) Novolin R Insulin (regular) Humulin N Insulin NPH Novolin N Insulin NPH Mixing Insulins With NPH only Draw first, then NPH Inject immediately Do NOT mix With NPH only Draw first, then NPH Inject immediately With regular, glulisine, lispro or aspart Draw rapid/regular first, then NPH Inject immediately Other Notes Contraindicated in patients with asthma or COPD Screen for potential lung disease prior to initiation Avoid in patients with lung cancer Higher risk of DKA HumaPen Luxura HD allows 0.5 unit increments HumaPen Memoir records time/date/dose of last 16 doses U-500 should only be for patients requiring >200 units/day Naïve / ≤4 U 4U 5-8 U 8U Humalog Insulin lispro 9-12 U 12 U Humulin R Insulin (regular) 13-16 U source was downloaded 16 U by 100000752467928 This study from CourseHero.com on 09-15-2022 17:17:55 GMT -05:00 Toujeo Insulin glargine Glucose lowered 27% less with same units as Lantus 17-20 U 20 U Premixed Insulins Various https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ 21-24 U 24 U Resuspend before use Insulin Forms Available Afrezza Insulin (for inhalation) 4 U Powder Cartridge (60) 4 U Powder Cartridge (90) 4 U Cartridge (60) + 8 U Cartridge (30) 4 U Cartridge (30) + 8 U Cartridge (60) 4 U Cartridge (90) + 8 U Cartridge (90) Apidra Insulin glulisine 100 U/mL Vial, 10 mL* 100 U/mL Pen, 3 mL (5 Pens) Humalog Insulin lispro 100 U/mL Vial, 3 mL or 10 mL* 100 U/mL Cartridge, 3 mL (5 Pens) 100 U/mL KwikPen, 3 mL (5 Pens) 100 U/mL Junior KwikPen, 3 mL (5 Pens) 200 U/mL KwikPen, 3 mL (2 Pens) Novolog Insulin aspart 100 U/mL Vial, 10 mL* 100 U/mL FlexPen, 3 mL (5 Pens) 100 U/mL FlexTouch, 3 mL (5 Pens)** 100 U/mL Cartridge, 3 mL (5 Pens) Fiasp Insulin aspart 100 U/mL Vial, 10 mL* 100 U/mL FlexTouch, 3 mL (3 Pens)** Humulin R Insulin (regular) Novolin R Insulin (regular) Humulin N Insulin NPH 100 U/mL Vial, 10 mL 500 U/mL Vial, 20 mL 500 U/mL U-500 KwikPen, 3 mL (2 or 5 Pens) 100 U/mL Vial, 10 mL 100 U/mL Vial, 10 mL 100 U/mL KwikPen, 3 mL (5 Pens) Needle Compatibility All BD pen needles BD Ultra-Fine (FlexPen) NovoFine NovoTwist NovoFine NovoFine Plus NovoTwist U-500 insulin syringes (U-500) All BD pen needles Novolin N Insulin NPH 100 U/mL Vial, 10 mL Basaglar Insulin glargine Lantus Insulin glargine 100 U/mL KwikPen, 3 mL (5 Pens) 100 U/mL Vial, 10 mL 100 U/mL SoloStar, 3 mL (5 Pens) All BD pen needles Toujeo Insulin glargine 300 U/mL SoloStar, 1.5 mL (3 or 5 Pens) BD Ultra-Fine Levemir Insulin detemir 100 U/mL Vial, 10 mL 100 U/mL FlexPen, 3 mL (5 Pens) 100 U/mL FlexTouch, 3 mL (5 Pens)** BD Ultra-Fine (FlexPen) NovoFine NovoTwist Tresiba Insulin degludec 100 U/mL Pen, 3 mL (5 Pens) 200 U/mL Pen, 3 mL (3 Pens) NovoFine NovoFine Plus NovoTwist Humalog Mix 50/50 Insulin lispro protamine/lispro 50/50% Humalog Mix 75/25 Insulin lispro protamine/lispro 75/25% 100 U/mL Vial, 10 mL 100 U/mL KwikPen, 3 mL (5 Pens) All BD pen needles All BD pen needles Humulin 70/30 Insulin NPH/regular 70/30% Novolin 70/30 Insulin NPH/regular 70/30% 100 U/mL Vial, 10 mL Novolog Mix 50/50 Insulin aspart protamine/aspart 50/50% 100 U/mL Cartridge, 3 mL (5 Pens) 100 U/mL FlexPen, 3 mL (5 Pens) NovoFine NovoTwist Novolog Mix 70/30 Insulin aspart protamine/aspart 70/30% 100 U/mL Vial, 10 mL 100 U/mL FlexPen, 3 mL (5 Pens) NovoFine NovoTwist Ryzodeg 70/30 Insulin degludec/aspart 70/30% 100 U/mL FlexTouch, 3 mL (5 Pens)** NovoFine NovoTwist Soliqua Insulin glargine/lixisenatide 100 U/mL insulin glargine + 33 mcg/mL lixisenatide, 3 mL (5 Pens) Xultophy Insulin degludec/liraglutide 100 U/mL insulin degludec + 3.6 mg/mL liraglutide, 3 mL (5 Pens) This study source was downloaded by 100000752467928 from CourseHero.com on 09-15-2022 17:17:55 GMT -05:00 * Some insulin pumps https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ ** FlexTouch pen plunge is same for all doses NovoFine NovoFine Plus NovoTwist Brand Onset Duration Peak Dosing Notes Afrezza Insulin (for inhalation) 10-30 Min 2.6 Hr 53 Min Insulin naïve, 4 units premeal Apidra Insulin glulisine 10-30 Min 3-5 Hr 0.5-2 Hr Premeal (prandial) insulin, 15 minutes before or 20 minutes from start of meal Humalog Insulin lispro 10-30 Min 3-5 Hr 0.5-2 Hr Premeal (prandial) insulin, 15 minutes before or immediately after a meal Novolog Insulin aspart 10-30 Min 3-5 Hr 0.5-2 Hr Premeal (prandial) insulin, 15 minutes before or immediately after a meal Fiasp Insulin aspart 10-30 Min 3-5 Hr 0.5-2 Hr Premeal (prandial) insulin, start of meal or within 20 minutes after Humulin R Insulin (regular) 30-60 Min 6-8 Hr 2-3 Hr Premeal (prandial), up to 30 minutes before meal Novolin R Insulin (regular) 30-60 Min 6-8 Hr 2-3 Hr Premeal (prandial), up to 30 minutes before meal Humulin N Insulin NPH 2-4 Hr up to 20 Hr 4-10 Hr Basal, varies by patient Novolin N Insulin NPH 2-4 Hr up to 20 Hr 4-10 Hr Basal, varies by patient Basaglar Insulin glargine 1-3 Hr 24+ Hr No peak Basal, varies by patient Insulin naïve: Start with 10 U or 0.2 U/kg Qdaily Administer anytime Lantus Insulin glargine 1-3 Hr 24+ Hr No peak Basal, varies by patient Insulin naïve: Start with 10 U or 0.2 U/kg Qdaily Administer anytime Toujeo Insulin glargine 6 Hr 24+ Hr No peak Basal, varies by patient Insulin naïve: Start with 0.2 U/kg Qdaily Administer anytime Levemir Insulin detemir 1-3 Hr 0.1 U/kg - 6 Hr 0.2 U/kg - 12 Hr 0.4 U/kg - 20 Hr ≥0.8 U/kg - 22-24 Hr Varies Basal, varies by patient Insulin naïve: Start with 10 U or 0.1-0.2 U/kg Qdaily Administer Qdaily at bedtime or evening meal or BID Tresiba Insulin degludec 1-3 Hr 24+ Hr No peak Basal, varies by patient Insulin naïve: Start with 10 U Qdaily Administer Qdaily at bedtime or evening meal or BID Humalog Mix 50/50 Insulin lispro protamine/lispro 50/50% 10-30 Min up to 20 Hr 1-4 Hr Within 15 minutes of meal Humalog Mix 75/25 Insulin lispro protamine/lispro 75/25% 10-30 Min up to 20 Hr 1-4 Hr Within 15 minutes of meal Humulin 70/30 Insulin NPH/regular 70/30% 30-60 Min up to 20 Hr 3-12 Hr 30-45 minutes before a meal Novolin 70/30 Insulin NPH/regular 70/30% 30-60 Min up to 20 Hr 3-12 Hr 30-45 minutes before a meal Novolog Mix 50/50 Insulin aspart protamine/aspart 50/50% 30-60 Min up to 20 Hr 3-12 Hr Within 15 minutes of meal Novolog Mix 70/30 Insulin aspart protamine/aspart 70/30% 30-60 Min up to 20 Hr 3-12 Hr Within 15 minutes of meal Ryzodeg 70/30 Insulin degludec/aspart 70/30% 10-30 Min 24+ Hr 1.5-2 Hr Once or twice daily within 15 minutes of main meal Soliqua Insulin glargine/lixisenatide 1-3 Hr 24+ Hr No peak Dose on pen is for units of insulin Dose based on control with basal insulin or lixisenatide Max 60 units This study source was downloaded by 100000752467928 from CourseHero.com on 09-15-2022 17:17:55 GMT -05:00 Xultophy Insulin degludec/liraglutide 1-3 Hr 24+ Hr https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ No peak Dose on pen is for units of insulin Max 50 units If dose <16 units discontinue Brand Shelf Life (Open) (Refrigerator) Afrezza Insulin (for inhalation) Shelf Life (Unopened) (Room Temp) Shelf Life (Opened) (Room Temp) Visual 10 days 3 days Sealed foil Apidra Insulin glulisine Vial: 28 days 28 days 28 days Clear, colorless Humalog Insulin lispro Vial: 28 days 28 days 28 days Clear, colorless Novolog Insulin aspart Vial: 28 days 28 days 28 days Clear, colorless Fiasp Insulin aspart Vial: 28 days 28 days 28 days Clear, colorless Humulin R Insulin (regular) Vial: 40 days Vial: 40 days Pen: 28 days Vial: 40 days Pen: 28 days Clear, colorless Novolin R Insulin (regular) 28 days 28 days 28 days Clear, colorless Humulin N Insulin NPH Vial: 31 days Vial: 31 days Pen: 14 days Vial: 31 days Pen: 14 days Uniformly cloudy, no particularate Novolin N Insulin NPH 42 days 42 days 42 days Uniformly cloudy, no particularate 28 days 28 days Clear, colorless 28 days 28 days Clear, colorless 42 days Clear, colorless 42 days 42 days Clear, colorless 56 days 56 days Clear, colorless Basaglar Insulin glargine Lantus Insulin glargine Vial: 28 days Toujeo Insulin glargine Levemir Insulin detemir Vial: 42 days Tresiba Insulin degludec Humalog Mix 50/50 Insulin lispro protamine/lispro 50/50% Vial: 28 days Vial: 28 days Pen: 10 days Vial: 28 days Pen: 10 days Uniformly cloudy, no particularate Humalog Mix 75/25 Insulin lispro protamine/lispro 75/25% Vial: 28 days Vial: 28 days Pen: 10 days Vial: 28 days Pen: 10 days Uniformly cloudy, no particularate Humulin 70/30 Insulin NPH/regular 70/30% Vial: 31 days Vial: 31 days Pen: 10 days Vial: 31 days Pen: 10 days Uniformly cloudy, no particularate Novolin 70/30 Insulin NPH/regular 70/30% Vial: 42 days 42 days Novolog Mix 50/50 Insulin aspart protamine/aspart 50/50% Vial: 28 days Vial: 28 days Pen: 14 days Vial: 28 days Pen: 14 days Uniformly cloudy, no particularate Novolog Mix 70/30 Insulin aspart protamine/aspart 70/30% Vial: 28 days Vial: 28 days Pen: 14 days Vial: 28 days Pen: 14 days Uniformly cloudy, no particularate Ryzodeg 70/30 Insulin degludec/aspart 70/30% 28 days 28 days Clear, colorless Soliqua Insulin glargine/lixisenatide 28 days 28 days Clear, colorless/ almost colorless 21 days Clear, colorless Xultophy This study source was downloaded by 100000752467928 from CourseHero.com on 09-15-2022 21 days 21 days17:17:55 GMT -05:00 Insulin degludec/liraglutide https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ * Do not refrigerate pens once used. Powered by TCPDF (www.tcpdf.org) Uniformly cloudy, no particularate