Published: September 2014
After diagnosis of diabetes, the importance of protecting the body from damage caused by hyperglycemia cannot be overstated. In the United States, 57.9% of diabetic patients have one or more diabetes complications, and 14.3% have three or more.1 Strict glycemic control is the primary method of reducing the development and progression of microvascular complications, such as retinopathy, nephropathy, and neuropathy. Aggressive treatment of dyslipidemia and hypertension decreases macrovascular complications.2-4
There are two primary techniques available for physicians to assess the quality of a patient’s glycemic control: self-monitoring of blood glucose (SMBG) and interval measurement of hemoglobin A1c (HbA1c).
SMBG is an effective way to evaluate short-term glycemic control. It helps patients and physicians assess the effect of food, medications, stress, and activity on blood glucose levels. The frequency of checking depends on the type of medical therapy, risk for hypoglycemia, and need for short-term adjustment of therapy.
For patients with type 1 diabetes mellitus (T1DM) and insulin-dependent type 2 diabetes mellitus (T2DM) patients, clinical trials have demonstrated that SMBG plays a role in effective glycemic control because it helps to refine and adjust insulin doses by monitoring for and preventing asymptomatic hypoglycemia and preprandial and postprandial hyperglycemia.2,5-7 The current American Diabetes Association (ADA) guidelines recommend that T1DM patients self-monitor their glucose at least three times per day. Those who use basal–bolus regimens should self-monitor before each meal and at bedtime (four times daily). Initially some patients require more frequent monitoring, including both preprandial and postprandial readings. Patients with gestational diabetes who are taking insulin should monitor their blood glucose three or more times daily. Patients should be educated on how to use real-time blood glucose values to adjust their food intake and medical therapy.
It is commonly recommended that T2DM patients who use insulin self-monitor their blood glucose levels, but the evidence to support the effectiveness of this practice is inconclusive. Initial studies showed that SMBG in T2DM patients results in reduction in HbA1c, but the inclusion of health-improving behavior such as diet and exercise in many of the analyses made it difficult to assess the degree of contribution of SMBG alone.2,8, Follow-up studies that attempted to correct for this found there was not a significant improvement in glycemic control after 12 months.9
It is important to establish individual goals with patients regarding target blood glucose measurements. The ADA recommends preprandial blood glucose levels in nonpregnant adults to be 70 to 130 mg/dL and less than 180 mg/dL for peak postprandial levels.10,11 The ADA’s goals for gestational diabetes is preprandial blood glucose 95 mg/dL or less and either 1 hour postprandial glucose no more than 140 mg/dL or 2 hours postprandial no more than120 mg/dL. For pregnant women with preexisting T1DM or T2DM, goals are preprandial, bedtime, and overnight glucose levels of 60 to 99 mg/dL and peak postprandial levels between 100 and 129 mg/dL.11 The American Association of Clinical Endocrinologists (AACE) recommends in nonpregnant adults a fasting blood glucose level lower than 110 mg/dL and a 2-hour postprandial level lower than 140 mg/dL.12
HbA1c measures nonreversible glycosylation of the hemoglobin molecule, which is directly related to blood glucose concentrations. It reflects a mean of the patient’s blood glucose values over a 2- to 3-month period and can be used as a predictor of a patient’s risk of microvascular complications.13 Periodic testing is recommended in all patients with diabetes. The frequency of testing depends on the clinical situation and the patient’s treatment regimen. The ADA recommends that patients with stable glycemic control be tested at least twice a year. Quarterly testing is suggested for those with a recent change in therapy or not meeting glycemic goals.11
HbA1c testing does have some limitations. HbA1c is influenced by rapid red blood cell turnover and blood loss; therefore, anemia and hemoglobinopathies can result in inaccurate values. Physicians should consider these conditions when there is a discrepancy between HbA1c and SMBG values. Episodes of hypoglycemia and hyperglycemia cannot be determined with HbA1c values alone. Table 1, adapted from the ADA’s 2014 Position Statement on diabetes management, demonstrates that correlation between HbA1c and average blood glucose values.
Traditionally it has been recommended that therapy be adjusted to maintain HbA1c values near or less than 7% in nonpregnant adults. This target has been shown to reduce microvascular complications. For patients with T1DM or T2DM who become pregnant, the goal is less than 6.0%.11 The AACE recommended an HbA1c of less than 6.5% in nonpregnant adults.12 The ADA recommends that selected patients, especially those with a long life expectancy and little comorbidity, adopt glycemic targets close to normal, providing the target can be achieved without significant hypoglycemia.11
|HbA1c (%)||Mean Plasma Glucose (mg/dL)|
HbA1c, glycated hemoglobin.
When considering appropriate pharmacologic therapy, a major factor to consider is whether the patient is insulin deficient, insulin resistant, or both. Treatment options can be divided into insulin sensitizers, secretagogues, alpha glucosidase inhibitors, incretins, pramlintide, SGLT-2 inhibitors, insulin and insulin analogs. Table 2 summarizes the different noninsulin therapies available.
|Subgroup||Generic Name (Brand)||Class||Route||Comments|
|Biguanides||Metformin (Glucophage)||Sensitizer||Oral||Weight loss
|Alpha glucosidase inhibitors||Acarbose (Precose)
|Exenatide||Byetta||GLP-1 analog||Subcutaneous||Weight loss
|Liraglutide||Victoza||GLP-1 analog||Subcutaneous||Weight loss
|Extended release exenatide||Bydureon||GLP-1 analog||Subcutaneous||Weight loss
Adjunctive therapy with insulin
|Dipeptidyl peptidase-4 inhibitors (DPP-4s)||Sitagliptin (Januvia)
|DPP-4 inhibitors||Oral||No hypoglycemia
|Rapid release bromocriptine||Cycloset||Other||Oral||Taken within 2 hours of awakening|
|SGLT-2 inhibitors||Canagliflozin (Invokana)
|Renal glycosuria||Oral||Polyuria UTIs|
GI, gastrointestinal; GLP-1, glucagon-like peptide type 1; UTIs, urinary tract infections
Available since the late 1950s, metformin can trace its roots back to medieval Europe, where biguanides in the form of French lilac were used in diabetes treatment. Its primary mechanism of action is suppression of hepatic glucose output, but it also enhances insulin sensitivity of muscle and fat. It affects primarily fasting glycemia; however, some decreases in postprandial glucose concentrations, especially after the midday meal, can also be seen.
Metformin is well tolerated, with the most common side effect being gastrointestinal (GI) complaints, such as diarrhea, nausea, abdominal discomfort, and a metallic taste. All of these improve with time and dose reduction. Metformin causes a small increase in basal and postprandial lactate concentrations in the blood, leading to potential to produce very rare but life-threatening lactic acidosis (<1 in 100,000). It is best to avoid use in patients with hepatic impairment. The use of metformin is contraindicated in patients with a serum creatinine 1.5 mg/dL or higher in male patients or 1.4 mg/dL or higher in female patients.
The major benefits of metformin are that it usually does not lead to hypoglycemia when used as monotherapy. It can lead to weight loss, and it has been shown to decrease plasma triglycerides concentration (10%-20%).
Dosing is typically twice daily; however, it can be dosed three times daily or once daily (extended release). The typical starting dose is 500 mg daily. The maximum dose is 2,550 mg/day. Gradual titration of metformin, starting at 500 mg with breakfast and increasing by 500 mg in weekly intervals until a dose of 1,000 mg with breakfast and dinner is reached help to prevent GI side effects.11,14-18
Thiazolidinediones (TZDs) are agonists of peroxisome proliferator-activated receptor gamma (PPARγ) and primarily enhance sensitivity of muscle and fat, and mildly of the liver, to exogenous and endogenous insulin. TZDs lower fasting and postprandial blood glucose levels.
Major side effects include weight gain, with an increase in subcutaneous adiposity, and fluid retention which typically manifests as peripheral edema, but heart failure has been shown to occur on occasion. These agents should be avoided in patients with functional class III or IV heart failure. These effects are mostly seen at higher doses. The PROactive trial (PROspective pioglitAzone Clinical Trial In macroVascular Events) showed that compared with placebo, pioglitazone does not increase cardiovascular risks. TZDs have been shown to have an association with an increased risk of fractures, particularly in women. The TZDs do not cause hypoglycemia when used as monotherapy. Pioglitazone use leads to lowering triglycerides, increasing high-density lipoprotein cholesterol (HDL), and increasing the low-density lipoprotein cholesterol (LDL) particle size.
Dosing is once a day. It takes 2 to 12 weeks for TZDs to become fully effective. For rosiglitazone, starting dose is 4 mg/day and maximum dose is 8 mg/day. For pioglitazone, the starting dose is 7.5 mg/day and the maximum dose is 45 mg/day.11,14,17–21
Insulin secretagogues stimulate secretion of insulin from the pancreas, thereby decreasing hepatic glucose production and enhancing glucose uptake by muscles and fat.
Sulfonylureas lower fasting and postprandial glucose levels. Main adverse effects include weight gain (about 2 kg upon initiation) and hypoglycemia. The hypoglycemia episodes can be significant (leading to need for assistance, coma, or seizure) and are seen more often in the elderly. The benefits include a 25% reduction in microvascular complications with or without insulin found by a UKPDS trial. Dosing is typically once or twice daily. Caution should be used in patients with liver or kidney dysfunction or patients who often skip meals.11,17,18,20,22
Glinides work in a manner similar to sulfonylureas; however, they have a more-rapid onset of action and a short duration of action, so they are a good option for patients with erratic timing of meals. They have a lower risk of hypoglycemia than sulfonylureas; they have a similar to lower risk of weight gain with initiation of therapy. Caution must be used in patients with liver dysfunction. Dosing is before meals.11,14,20
Alpha glucosidase inhibitors competitively block the enzyme alpha glucosidase in the brush borders of the small intestine, which delays absorption of carbohydrates (absorbed in the mid and distal portions of the small intestine instead). They primarily target postprandial hyperglycemia without causing hypoglycemia. GI complaints, such as bloating, abdominal cramps, flatulence, and diarrhea are the main side effects. Use should be avoided in patients with severe hepatic or renal impairment. Dosing must be prior to carbohydrate-containing meals.11,17,18,20,23
Incretin-based therapies can be used as injections (GLP-1 analogs) or as pills (DPP-4 inhibitors). All incretin-based medications carry increased risk of acute pancreatitis. Patients must be warned about this risk and be advised to stop taking these medications and seek medical evaluation if acute abdominal pain develops.
These medications should not be given to the individuals who have a history of medullary thyroid carcinomas or have multiple endocrine neoplasia syndrome type 2. This is because increased incidence of the thyroid C-cell tumors have been observed with these medications in the mice and rats. So far, there is no increased risk in humans but the above groups of individuals should not use these medications.
Exenatide is a synthetic form of exendin 4, hormone found in the saliva of the Gila monster, that mimics glucagon-like peptide type 1 (GLP-1). GLP-1 is produced in the small intestine and stimulates insulin secretion and inhibits glucagon secretion and hepatic glucose production in a glucose-dependent manner. It also delays gastric emptying and suppresses appetite through central pathways. It primarily decreases postprandial blood glucose levels; however, a moderate reduction in fasting blood glucose levels can also be seen.
Due to its delaying effects on gastric emptying, the major side effect is GI complaints such as nausea, vomiting, and diarrhea. Hypoglycemia does not occur when exenatide is used as monotherapy or with metformin, but it does occur when exenatide is combined with a sulfonylurea. Benefits include weight loss up to 2 to 3 kg in the first 6 months and up to 5.5 kg in the first 2 years.
Dosing is twice daily by subcutaneous injection. Start with a dose of 5 µg. If this dose is tolerated, titrate after 1 month to 10 µg.11,14,20
Exenatide is currently also available as once a week injection, supplied as a kit containing the 2 mg of extended release exenatide. If a dose is missed, it should be administered as soon as noticed provided that next dose is scheduled 3 or more days later.
Liraglutide is GLP-1 analog derived from human GLP-1. It is given as an injection once a day. Timing is independent of the meals. Half-life is about 13 hours. Its effects and side effects are similar to those of exenatide but it may be slightly more powerful in its actions. It is given by subcutaneous injection from the pen device. Initial dose is 0.6 mg/day. That dose is maintained for a week and if there are no side effects the dose is increased to 1.2 mg/day (that is the dose at which clinical benefits are seen). For most patients, dose will be increased to 1.8 mg/day after another week if there are no side effects.
Dipeptidyl peptidase 4 (DPP 4) is a cell membrane protein that rapidly degrades GLP-1 and glucose-dependent insulinotropic polypeptide. Suppression of DPP 4 leads to higher levels of insulin secretion and suppression of glucagon secretion in a glucose-dependent manner.
DPP 4 inhibitors act primarily on postprandial blood glucose levels, but reductions in fasting glycemia are also seen. It is generally well tolerated, and the most common side effect is headache. An increase in nasopharyngitis has also been seen. Benefits include that it is weight neutral and does not cause hypoglycemia when used as monotherapy or in combination with metformin or TZDs.
At this time four medications are U.S. Food and Drug Administration (FDA)-approved for use in type 2 diabetes mellitus. Those are sitagliptin, saxagliptin, linagliptin and alogliptin.
Dosing of sitagliptin is 100 mg orally once daily with or without meals. Dose reduction is needed in renal impairment. In patients with a creatinine clearance 30 to 50 mL/min, dosing is 50 mg once daily. Those patients with a creatinine clearance less than 30 mL/minute, dosing is 25 mg once daily.11,14
Dosing of saxagliptin is 2.5 or 5 mg orally once daily with or without meals. The 2.5 mg daily dose is used in patients whose eGFR is less than 50 mg/ml and those using the strong inhibitors of P450 3A4/5 (ketoconazole).
Dosing of linagliptin is 5 mg orally once daily with or without meals. Dose reduction is not needed in renal impairment.
Dosing of alogliptin is 25 mg orally once daily with or without meals. Dose reduction is needed in renal impairment. In patients with a creatinine clearance 30 to 60 mL/min, dosing is 12.5 mg once daily. Those patients with a creatinine clearance less than 30 mL/minute, dosing is 6.25 mg once daily.
Pramlintide is a synthetic form of amylin, a hormone secreted by beta-cells that acts to suppress glucagon secretion, slow gastric emptying, and suppress appetite through central pathways. It acts primarily on postprandial blood glucose levels.
As with exenatide, the major side effects are GI complaints, especially nausea, and hypoglycemia. Benefits of therapy include weight loss of 1 to 1.5 kg over 6 months and up to 4.5 kg after chronic therapy.
Currently in the United States it is approved only as an adjunctive therapy with insulin, but it can be used both T1DM and T2DM. Patients can see up to a 50% reduction in their insulin requirements with the addition of pramlintide. Starting dose for T2DM is generally 60 µg subcutaneously before meals and for T1DM is 15 µg before each meal. It can be used in patients taking insulin, metformin, or sulfonyureas.11,14,20
The SGLT-2 inhibitors are the newest group of medications approved for treatment of diabetes mellitus. SGLT-2 is a protein acting as sodium-glucose co-transporter in the kidney’s proximal tubules whose main function is reabsorption of the filtered glucose from the urine back into the circulation. It is responsible for about 90% of total glucose reabsorption. Inhibition of this protein leads to the excretion of the glucose in the urine at much lower blood glucose level than normal (at approximately 120 mg/dL instead of 180 mg/dL).
At this time canagliflozin and dapagliflozin are only medications in this class approved by the FDA for the treatment of type 2 diabetes. More are being developed.
The most common side effects of SGLT-inhibitors are vaginal yeast infections and urinary tract infections. The greatest risk is seen in female patients and those men who are uncircumcised. Polyuria is also seen.
Additional benefits are weight loss (two thirds of weight loss is because of loss of fat tissue and one third is because of loss of water) and drop in the blood pressure.
These medications are not indicated in children, in patients with type 1 diabetes, patients with frequent ketones in their blood or urine, severe renal impairment. Patients should be advised to expect glucose to be in the urine and if they are using urine glucose strips that they will have a positive reading most of the time.
Canagliflozin is dosed at 100 mg/day before the first meal of the day and can be increased to 300 mg if it is tolerated. Canagliflozin should not be used in patients with eGFR less than 45 ml/min/ 1.73 m2 and should be limited to 100 mg in those with eGFR 45 to 60 ml/min/ 1.73 m2.
Dapagliflozin is dosed at 5 mg/day and can be increased to 10 mg if tolerated. It should not be used if eGFR is less than 60 ml/min/ 1.73 m2.
Insulin is the oldest therapy available for diabetes. It was discovered in 1921, and clinical testing in humans started in 1922.
To this date it remains the most effective method of reducing hyperglycemia. There is no upper limit in dosing for therapeutic effect, so it can be used to bring any HbA1c down to near normal levels. Other benefits of insulin include its effects on reducing triglycerides levels and increasing HDL.
Hypoglycemia is a concern for many, but the actual risk of severe episodes is small. Studies have shown that episodes where the patient required assistance from another due to the hypoglycemia occurred between 1 and 3 per 100,000 patient-years. Weight gain can occur after initiation and is typically about 2 to 4 kg.
|Insulin (Brand)||Onset||Peak||Effective Duration|
|Aspart (NovoLog)||5-15 min||30-90 min||<5 h|
|Lispro (Humalog)||5-15 min||30-90 min||<5 h|
|Glulisine (Apidra)||5-15 min||30-90 min||<5 h|
|Regular||30-60 min||2-3 h||5-8 h|
|Neutral protamine Hagedorn (NPH)||2-4 h||4-10 h||10-16 h|
|Insulin glargine (Lantus)||2-4 h||No peak||20-24 h|
|Insulin detemir (Levemir)||3-8 h||No peak||17-24 h|
|75% Insulin lispro protamine/25% insulin lispro (Humalog mix 75/25)||5-15 min||Dual||10-16 h|
|50% Insulin lispro protamine/50% insulin lispro (Humalog mix 50/50)||5-15 min||Dual||10-16 h|
|70% Insulin lispro protamine/30% insulin aspart (NovoLog mix 70/30)||5-15 min||Dual||10-16 h|
|70% NPH/30% regular||30-60 min||Dual||10-16 h|
Reprinted from Endocrine (Robard L, Braithwaite SS, et al; AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus [erratum appears in Endocrin Pract 2008; 14:802-803]. Endocrin Pract.2007;13[suppl1]:1-68.0, with permission from the American Association of Clinical Endocrinologists.
There are several different regimens for insulin therapy. These are summarized in Table 4. All patients with T1DM require therapies with insulin products. There are two available regimens: basal–bolus and insulin pump therapy. Patients with T2DM often require insulin, which can be combined with oral hypoglycemic agents. Regimens include basal insulin only, twice-daily premixed insulin, basal–bolus, and insulin pump therapy.
|Insulin Regimen||HbA1c (%)||Medication||Pattern||Diet History||Lifestyle||Monitoring|
|Basal-only||>7.5-10||Oral medications adequately control postprandial glucose excursions||High fasting glucose with minimal glucose rise during the day||Small, regular meals; large meals will result in postprandial hyperglycemia||Reluctance to do MDI; requires oral agents||Fasting|
|Basal–bolus (MDI)||>7.5||—||Regimen can be matched to any pattern to achieve glycemic control||Regimen can be matched to any diet to achieve glycemic control||Erratic schedule, motivated to achieve tight glycemic control||Frequent blood glucose monitoring (minimum before meals and bedtime)|
|Once- or Twice-Daily Premixed|
|Rapid-acting analogue and intermediate acting||>7.5||Oral agent failure (maximum tolerated dosages, contraindications, cost issues)||Any fasting glucose; glucose rises during the day||Large suppers, small lunches||Consistent daily routine, reluctance to do MDI||Fasting and pre-supper (if insulin is administered twice daily)|
|Regular and NPH||>7.5||Oral agent failure (maximum tolerated dosages, contraindications, cost issues)||Any fasting glucose; glucose rises during the day||Isocaloric meals or larger lunches||Consistent daily routine, reluctance to do MDI||Fasting and pre-supper (if insulin is administered twice daily)|
HbA1c, glycated hemoglobin; MDI, multiple daily injections.
The basal–bolus regimen involves combining a long-acting agent that is used once or twice daily and provides basal insulin needs and a rapid-acting agent for prandial coverage used with meals. When initiating therapy with glargine or detemir as the basal insulin, traditionally 50% of the total daily dose is given as basal insulin and the rest as prandial insulin divided equally before meals. Meal dose of insulin can be fixed, but it is better to determine the dose based on carbohydrate content of the meal. This requires learning carbohydrate counting and knowing the dose of insulin required to cover counted carbohydrates. Help of a diabetic educator is needed for this to be achieved.
Starting daily insulin dose is typically 0.3 U/kg total (divided between long acting and rapid acting) daily. Key to good control is blood glucose self-monitoring by the patient and frequent adjustment of the regimen until control is achieved.12,14
The insulin pump allows use of different basal insulin rates in different periods of the day and administration of the meal bolus as a single discrete bolus or as an extended bolus (square bolus) over a set period of time, which allows a better match between insulin delivery and glucose absorption from the meal in patients with abnormalities of gastric emptying. The use of this therapy is spreading in all diabetic populations and particularly should be considered in the following patients:
The ADA and the AACE have different algorithms for initiation and maintenance of therapy. No studies are available comparing the efficacy of either method or comparing the two. These algorithms are available online from several sources.25,26 We support the AACE’s algorithm, because the ADA’s algorithm is significantly influenced by the cost of therapy.11 Table 5 gives a summary of titration of insulin therapy. Starting daily insulin dose is typically 0.5 U/kg total (divided between long-acting and rapid-acting) daily. Therapy can be combined with oral insulin sensitizers but not secretagogues.
|Type 1 Diabetes Mellitus|
|Initial basal dose (detemir or glargine) 10 units or 0.15 units/kg (whichever is greater)||Adjustments (desired range 90-140 mg/dL): Increase/decrease by 3 units every 3 days if out of range|
|Initial basal coverage (NPH insulin): 10 units or 0.15 units/kg divided into 2 doses; 1 at breakfast and 1 at dinner||Adjustments (desired range 90-140 mg/dL): Increase/decrease by 10% every 3 days, if out of range|
|Meal coverage (regular insulin, glulisine, aspart, lispro) 4 units per or 0.15 units/kg divided among 3 meals||Adjustments (postprandial <180 mg/dL): Increase/decrease by 1 unit or 10% (whichever is greater)|
|Carbohydrate counting (1 units per 15 g of carbohydrate)||Increase to 1 unit per 10 g of carbohydrate or decrease to 1 unit per 20 g of carbohydrate|
|Type 2 Diabetes Mellitus|
|Initial basal dose (detemir or glargine) 15 units or 0.25 units/kg (whichever is greater)||Adjustments (desired range 90-140 mg/dL): Increase/decrease by 3 units or 10% (whichever is greater) every 3 days, if out of range|
|Initial basal coverage (NPH insulin) 15 units or 0.25 units/kg divided into 2 doses; 1 given at breakfast and 1 at dinner||Adjustments (desired range 90-140 mg/dL): Increase/decrease by 10% every 3 days, if out of range|
|Meal coverage (regular insulin, glulisine, aspart, lispro) 6 units per meal or 0.25 units/kg divided between 3 meals||Adjustments (postprandial <180 mg/dL): Increase/decrease by 2 units or 10% (whichever is greater)|
|Carbohydrate counting (1 unit per 10 g of carbohydrate)||Increase to 1 unit per 5 g of carbohydrate or decrease to 1 unit per 15g of carbohydrate|
NPH, neutral protamine Hagedorn
*This is only one of the titration protocols, others are available in literature.
In patients with gestational diabetes, insulin therapy is indicated when exercise and nutritional therapy are ineffective in controlling prandial and fasting blood glucose levels. Basal therapy alone may be sufficient, but often basal–bolus regimens are required.