Diabetes

Insulin

Decreased insulin sensitivity

Organ and nerve damage

Hemoglobin A1C (AlC)

eAG = AlC + 28

126 mg/dL

Oral glucose tolerance test (OGTT)

Gemfibrozil

DPP-4

Saxagliptin

Thiazolidinediones

Metformin

Canagliflozin

Saxenda

1,000 mg BID

Ozempic

Bydureon

Ozempic

Byetta

Metformin

Aspirin 75-162 mg/day

Ezetimibe

Icosapent ethyl (Vascepa)

Bromocriptine (Cycloset)

Pramlintide (Symlin)

Pramlintide (Symlin)

False

True

False

True

True

False

True

True

True

True

False

True

True

True

True

False

True

True

True

True

True

True

True

True

True

True

Cardiovascular disease

Aspirin + low-dose rivaroxaban

Metformin is first-line treatment for T2D and can be used in prediabetes.

ACE inhibitor or ARB, and refer to podiatrist

The central problem in all types of diabetes is that blood glucose (BG) remains high (hyperglycemia) due to decreased insulin secretion from the pancreas, decreased insulin sensitivity, or both.

Insulin is responsible for moving glucose out of the blood and into body cells to be used as energy.

Glucagon is produced by alpha-cells in the pancreas and works when blood glucose is low. Glucagon pulls glucose back into the circulation by releasing glucose from glycogen. If glycogen is depleted, glucagon will signal fat cells to make ketones as an alternative energy source.

Pramlintide (Symlin) helps control postprandial glucose by slowing gastric emptying and suppressing glucagon secretion following a meal.

Bromocriptine (Cycloset) is contraindicated in patients with syncopal migraines and those who are breastfeeding.

The possible side effects of Pramlintide (Symlin) include vomiting, anorexia, and weight loss.

Alpha-glucosidase inhibitors inhibit the metabolism of intestinal sucrose, which delays glucose absorption.

Saxagliptin is a major substrate of CYP450 3A4 and P-gp.

Diabetes is the primary cause of cardiovascular disease.

The eAG is calculated using the formula: eAG (mg/dL) = (28.7 × A1C) - 46.7.

0.75 mg SC once weekly

Risk of thyroid C-cell carcinomas; do not use if personal or family history of medullary thyroid carcinoma (MTC) or with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)

5 mg daily, titrate to a max dose of 40 mg/day

Bydureon, Bydureon BCise

The three types of tests used to identify if prediabetes or diabetes is present are Hemoglobin AlC, Fasting plasma glucose (FPG), and the OGTT.

An AlC of 6% is equivalent to an eAG of 126 mg/dL.

The criteria for diagnosing diabetes are an AlC of 6.5% or higher, a fasting plasma glucose (FPG) level of 126 mg/dL or higher, or a 2-hour BG level of 200 mg/dL or higher during an oral glucose tolerance test (OGTT).

The treatment goals for AlC, preprandial glucose, and postprandial glucose are as follows: AlC goal < 6.5%, preprandial glucose goal 80-130 mg/dL, and postprandial glucose goal < 180 mg/dL.

1,000 mg

500 mg

1,000 mg BID

eGFR < 30, acute or chronic metabolic acidosis (includes DKA)

GI effects: diarrhea, nausea, flatulence, cramping; usually transient (resolve over time)

By inhibiting SGLT2, these drugs reduce reabsorption of glucose and increase urinary glucose excretion, which lowers blood glucose concentrations.

eGFR < 30, unless albuminuria > 300 mg/day

eGFR < 30

eGFR < 30

Ketoacidosis (can occur with BG < 250 mg/dL), genital mycotic infections, urosepsis and pyelonephritis, necrotizing fasciitis of the perineum, hypotension, AKI and renal impairment

Weight loss, polyuria, polydipsia, hypoglycemia, increased risk of urinary tract infections and genital mycotic infections

Increased risk of intravascular volume depletion if used in combination with diuretics, RAAS inhibitors or NSAIDs; uridine diphosphate glucuronosyltransferase (UGT) inducers can decrease levels of canagliflozin

Liraglutide (Victoza), Dulaglutide (Trulicity), Exenatide (Byetta)

Starting: 0.6 mg SC once daily for 1 week, then increase to 1.2 mg SC once daily; Maintenance: 1.2 mg SC once daily

Starting: 0.75 mg SC once weekly for 1 month, then increase to 1.5 mg SC once weekly; Maintenance: 1.5 mg SC once weekly

Starting: 5 mcg SC twice daily within 60 minutes before morning and evening meals; Maintenance: 10 mcg SC twice daily

History of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)

Nausea, vomiting, diarrhea, constipation, headache, dizziness, injection site reactions

May delay absorption of other drugs; may affect the absorption of oral contraceptives; may decrease the absorption of drugs that require rapid onset of action

Chronic hyperglycemia can lead to microvascular complications (retinopathy, nephropathy, and neuropathy) and macrovascular complications (coronary artery disease, peripheral artery disease, and stroke)

Insulin = Moves glucose out of the blood and into body cells to be used as energy Glucagon = Pulls glucose back into the circulation by releasing glucose from glycogen Adiponectin = Increases insulin sensitivity and fatty acid oxidation Epinephrine = Increases blood glucose levels during times of stress

Type 1 Diabetes = Decreased insulin production due to destruction of beta-cells Type 2 Diabetes = Decreased insulin sensitivity and/or decreased insulin production Cushing's Syndrome = Excess cortisol production Addison's Disease = Insufficient cortisol production

Hyperglycemia = High blood glucose levels Glycogen = Stored form of glucose in the liver Ketones = Produced by fat cells as an alternative energy source when glucose is not available AlC = Measure of average blood glucose level over the past 3 months

Ezetimibe = If ASCVD 10-yr risk> 20% Atorvastatin = 40-80 mg daily Clopidogrel = 75 mg/day Rivaroxaban = Low-dose added to aspirin for Diabetes + ASCVD CAD/PAD

Peripheral neuropathy = Loss of sensation, risk of foot infections and amputations Diabetic Retinopathy = Macrovascular Retinopathy Diabetic kidney disease = Top cause of lower-extremity amputations, kidney failure and blindness ASCVD = Primary cause of death, which occurs at a 2 - 4 times higher incidence than in the general population

Age 50-75 years with multiple ASCVD risk factors = High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) Diabetes + age 40- 75 years (no ASCVD) = Moderate-intensity statin Diabetes + age < 40 years + ASCVD risk factors = Moderate-intensity statin Age~ 55 with coronary, carotid or lower extremity artery stenosis > 50%, or LVH = High risk for statin treatment

Metformin = eGFR less than 30 Repaglinide = Gemfibrozil SGLT2 inhibitors = eGFR less than 30 Bromocriptine (Cycloset) = Contraindications

Metformin + SU = Metformin/glipizide Metformin + SGLT2 Inhibitor = Metformin/canagllflozin (lnvokamet, lnvokamet XR) Metformin + DPP-4 Inhibitor = Metformin/alogliptin (Kazano) Metformin + TZD = Metformin/pioglitazone (Actoplus Met)

Metformin + SU = No contraindications listed Metformin + SGLT2 Inhibitor = No contraindications listed Metformin + DPP-4 Inhibitor = No contraindications listed Metformin + TZD = No contraindications listed

Metformin/glipizide = Janumet, Janumet XR Metformin/canagllflozin = lnvokamet, lnvokamet XR Metformin/alogliptin = Kazano Metformin/pioglitazone = Actoplus Met

Hemoglobin A1C (AlC) = Indicates the average blood glucose over approximately the past 3 months Fasting plasma glucose (FPG) = Gives the blood glucose at that moment, and is taken after fasting for at least 8 hours Oral glucose tolerance test (OGTT) = Determines how well glucose is tolerated by measuring the blood glucose level 2 hours after drinking a liquid that is high in sugar (glucose) Estimated average glucose (eAG) = An interpretation of the AlC value that makes it appear similar to a glucose meter value

Weight loss = Goal waist circumference is < 35 inches for females and < 40 inches for males. Overweight or obese patients should be encouraged to lose > 5% of their body weight Carbohydrate consumption = Patients with TlD should use carbohydrate-counting, where the prandial (mealtime) insulin dose is adjusted to the carbohydrate intake. A carbohydrate serving is measured as 15 grams, which is approximately one small piece of fruit, 1 slice of bread or 1/, cup of cooked rice/pasta Physical activity = Perform at least 150 minutes of moderate-intensity aerobic activity per week spread over at least 3 days. Reduce sedentary (long hours of sitting) habits by standing every 30 minutes, at a minimum Smoking cessation = Encourage all patients who smoke to quit

Microvascular complications = Affect small blood vessels and include autonomic neuropathy, gastroparesis, loss of bladder control, and erectile dysfunction Macrovascular complications = Affect large blood vessels and include coronary artery disease (CAD), cerebrovascular disease, and peripheral artery disease (PAD)

AlC = An AlC goal of < 6.5% may be acceptable, if it can be reached without significant hypoglycemia. A less-stringent goal of < 8% may be appropriate (e.g., if severe hypoglycemia, or with a limited life-expectancy) Preprandial glucose (before meals) = Not specified in the given text Postprandial glucose (after eating) = Not specified in the given text

Dipeptidyl peptidase 4 (DPP-4) inhibitors = Prevent the enzyme DPP-4 from breaking down incretin hormones Thiazolidinediones (TZDs) = Peroxisome proliferator-activated receptor gamma (PPARy) agonists that increase peripheral insulin sensitivity Alpha-Glucosida Inhibitors = Inhibit the metabolism of intestinal sucrose, which delays glucose absorption SGLT2 inhibitors = Reduce reabsorption of filtered glucose in the kidneys, leading to increased urinary glucose excretion

Saxagliptin (Onglyza) = Limit the dose to 2.5 mg with strong CYP3A4 inhibitors Linagliptin (Tradjenta) = Linagliptin levels are increased by strong CYP3A4 inducers Alogliptin (Nesina) = No renal dose adjustments Sitagliptin (Januvia) = No specific dose limitations mentioned

Saxagliptin (Onglyza) = Risk of heart failure Alogliptin (Nesina) = Hepatotoxicity Linagliptin (Tradjenta) = Pancreatitis, severe arthralgia Pioglitazone (Actos) = Can cause or exacerbate heart failure

Saxagliptin (Onglyza) = Can cause nasopharyngitis, upper respiratory tract infections, urinary tract infections, peripheral edema, rash Linagliptin (Tradjenta) = Interacts with strong CYP3A4 inducers Pioglitazone (Actos) = Increased risk of bladder cancer Acarbose (Precose) = GI side effects are common

Exenatide ER (Bydureon, Bydureon BCise) = $0.75$ mg SC once weekly Lixisenatide (Adlyxin) = $5$ mcg SC once daily for 1 month Semaglutide (Ozempic - SC, Rybelsus - oral) = $10$ mcg SC daily for 14 days, then $20$ mcg SC daily Dulaglutide (Trulicity) = $1.5$ mg SC once weekly

Exenatide ER (Bydureon, Bydureon BCise) = Not recommended in patients with severe GI disease, including gastroparesis Lixisenatide (Adlyxin) = Do not use if personal or family history of medullary thyroid carcinoma (MTC) or with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) Semaglutide (Ozempic - SC, Rybelsus - oral) = CrCI $<$ 30: not recommended Dulaglutide (Trulicity) = Pancreatitis (can be fatal, risk factors: gallstones, alcoholism or CrCI $<$ 30: not recommended

Glipizide = $5$ mg daily, titrate to a max dose of $40$ mg/day Glyburide = $2.5-5$ mg daily, titrate to a max dose of $20$ mg/day Glimepiride = $1-2$ mg daily, titrate to a max dose of $8$ mg/day Glynase = $1.5-3$ mg daily, titrate to a max dose of $12$ mg/day

Repaglinide = $0.5-2$ mg TIO AC, Max dose: $16$ mg daily Nateglinide (Starlix) = $60-120$ mg TIO AC

Liraglutide (Victoza) = 0.6 mg SC~ x 1 week Dulaglutide (Trulicity) = 0.75 mg subcutaneously once weekly Exenatide (Byetta) = 5 mcg SC BID within 60 minutes before the morning and evening meals Semaglutide (Ozempic) = 0.25 mg SC once weekly for 4 weeks, then increase to 0.5 mg SC once weekly

Canagliflozin (lnvokanal) = $eGFR < 30$: not recommended, unless albuminuria > 300 mg/day Dapagliflozin (Farxisal) = $eGFR < 30$: contraindicated Empagliflozln (Jardiancel) = $eGFR < 30$: contraindicated Ertugliflozin (Steglatro) = Dialysis

Canagliflozin (lnvokanal) = i risk of leg and foot amputations, higher risk with history of amputation, PAD, peripheral neuropathy and/or diabetic foot ulcers; hyperkalemfa risk when used with other drugs that increase potassium Dapagliflozin (Farxisal) = Ketoacidosis (can occur with BG < 250 mg/dl., D/C prior to surgery due to risk) Empagliflozln (Jardiancel) = Ketoacidosis (can occur with BG < 250 mg/dl., D/C prior to surgery due to risk) Ertugliflozin (Steglatro) = Ketoacidosis (can occur with BG < 250 mg/dl., D/C prior to surgery due to risk)

Liraglutide (Victoza) = Weight loss, T urination, 1' t hirst, hypoglycemia, i Mg/PO4 Dulaglutide (Trulicity) = Weight loss, T urination, 1' t hirst, hypoglycemia, i Mg/PO4 Exenatide (Byetta) = Weight loss, T urination, 1' t hirst, hypoglycemia, i Mg/PO4 Semaglutide (Ozempic) = Weight loss, T urination, 1' t hirst, hypoglycemia, i Mg/PO4

It mainly impacts fasting glucose

Subcutaneous

All of the above

1-2 hours

4-12 hours

14-24 hours

Aspart-protamine

Lantus Solostar pen

0.8 mL

5 times

Premixed 70% NPH/30% Regular insulin

GLP-1 receptor agonist

0.5 units/kg/day

42 units

Short-Acting Insulin

500 units

24 units

Sulfonylureas

Increase the bolus insulin dose

Using the insulin to carbohydrate ratio (ICR)

Increase the basal insulin dose

ICR = 450 / TDD

19

3 units

50 units

5 units

True

False

True

True

True

False

True

True

True

True

False

False

True

False

True

False

True

True

True

True

True

True

True

True

True

False

0.5 units/kg/day

42 units

50% of the TDD

Evenly among 3 meals or more for larger meals

450

500

23 units

The Novolog dose taken prior to lunch should be increased.

0.4 mL (half the volume)

five times as concentrated

0.2 mL

1:10

1,800

3 units

18 units

Basal insulin includes glargine (red line), detemir (blue line) and ultra-long acting degludec (pink line). These insulins are "peakless" with an onset of 3 - 4 hours and duration~ 24 hours. They mainly impact fasting glucose.

Insulin can be administered as a subcutaneous injection (most common), intravenously (less often, usually for acutely high blood glucose), or inhaled (uncommon).

Insulin is considered a high-alert medication primarily due to human errors, such as misreading measurements, using the wrong insulin type, strength, dose, or frequency, and skipping meals.

NPH insulin has an onset of 1-2 hours, a peak at 4-12 hours, and a duration of action of 14-24 hours.

Rapid-acting insulin, such as aspart, lispro, and glulisine, has a fast onset of about 15 minutes, peaks in 1-2 hours, and lasts 3-5 hours.

Regular insulin has an onset of 30 minutes, peaks at 1-2 hours, and lasts 6-10 hours.

Insulin should not be shaken, frozen, or exposed to extreme heat. Unopened insulin vials and pens should be stored in the refrigerator, while opened vials and pens can be kept at room temperature. Cold insulin may be more painful to inject. Pen devices should not be shared due to the risk of blood-borne pathogen transmission. NPH and regular insulin can be mixed in the same syringe, with regular insulin drawn up first.

Short-acting (bolus) insulin works by injecting SC 30 minutes before meals to have insulin available when the glucose from the next meal is absorbed.

Humulin R U-500 insulin is five times as concentrated as regular insulin, with a concentration of 500 units/ml.

NPH insulin is typically dosed twice daily as a basal insulin, usually injected once daily; detemir may need to be given twice daily.

For a patient taking Humulin 70/30, the TDD of regular insulin is calculated by adding the regular dose in the morning (60 units x 0.3 = 18 units) and the regular dose in the evening (20 units x 0.3 = 6 units), resulting in a TDD of 24 units.

30%

18 units

6 units

24 units

Option 1 = Use the Same Insulin Dose Every Time Option 2 = Calculate an Insulin Dose at Each Meal ICR = Insulin to Carbohydrate Ratio TDD = Total Daily Dose of Insulin

Regular insulin = Rule of 450 Rapid-acting insulin = Rule of 500 Toujeo = No specific rule mentioned Novolog = No specific rule mentioned

Basal insulin = Fasting BG highs or lows, and/or similar trends that last most of the day Mealtime insulin = Postprandial BG is high or low following the same meal on most days Regular insulin = Can be used in IV infusions, including in parenteral nutrition, and is less expensive than other insulins Rapid-acting insulin = Used when different amounts of carbohydrates are eaten at each meal

Regular insulin = $ICR = \frac{450}{TDD}$ Rapid-acting insulin = $ICR = \frac{500}{TDD}$ Toujeo = No specific equation mentioned Novolog = No specific equation mentioned

Basal Insulin = Includes glargine, detemir, and degludec. They are peakless with an onset of 3-4 hours and duration of 24 hours. They mainly impact fasting glucose. Rapid-Acting Insulin = Used to control blood sugar levels during and immediately after meals. It is typically given within 15 minutes before or after a meal. Intermediate-Acting Insulin = Has a slower onset and longer duration of action compared to rapid-acting insulin. It is typically used to control blood sugar levels between meals and during the night. Long-Acting Insulin = Has a slower onset and a longer duration of action compared to rapid-acting insulin. It is typically used to maintain blood sugar levels throughout the day and night.

Onset = The time it takes for the insulin to start working after it is injected. Peak = The time when the insulin is working at its maximum level to lower blood sugar. Duration = How long the insulin continues to lower blood sugar. Action = The overall effect of the insulin on blood sugar levels, including the onset, peak, and duration.

Subcutaneous Injection = The most common method of insulin administration, where insulin is injected into the fatty tissue just below the skin. Intravenous Injection = A less common method of insulin administration, usually used for acutely high blood sugar levels. Oral Administration = Insulin cannot be given orally as it would be broken down by digestive enzymes. Inhalation = An uncommon method of insulin administration, where insulin is inhaled into the lungs.

Correction Factor = The amount by which 1 unit of insulin will lower the blood glucose level Insulin-to-Carbohydrate Ratio (ICR) = The number of grams of carbohydrate that 1 unit of insulin will cover Total Daily Dose (TDD) = The total amount of insulin a person needs in a day Correction Dose = The amount of insulin needed to return the blood glucose to the target range

1,500 Rule = Regular insulin 1,800 Rule = Rapid-acting insulin Rule of 500 = Rapid-acting insulin 1:10 = Rapid-acting insulin

Correction Factor = $\frac{1,800}{BG}$ = Calculating the correction factor Correction Dose = $\frac{BG - Target BG}{Correction Factor}$ = Calculating the correction dose Bolus Dose = $\frac{Carbohydrates}{ICR}$ = Calculating the bolus dose Total Daily Dose = $TDD$ = Calculating the total daily dose of insulin

Insulin Syringe = Used to draw up insulin from a vial Insulin Pen = Ready to inject once a needle is attached Vial = Usually contains 10 mL of insulin Pen = Contains 3 mL of insulin

NPH = Onset: 1-2 hours, Peak: 4-12 hours, Duration: 14-24 hours Lispro-Protamine = Onset, Peak, and Duration: Same as NPH Rapid-Acting Insulin = Onset: 15 minutes, Peak: 1-2 hours, Duration: 3-5 hours Regular Insulin U-100 = Onset: 30 minutes, Peak: 1-2 hours, Duration: 6-10 hours

Inhaled Insulin = Contraindicated in lung disease, including asthma and COPD; do not use in smokers NPH = Onset of 1-2 hours, peaks at 4-12 hours, which can cause hypoglycemia Protamine = Helps to delay absorption/extend the duration of effect Regular Insulin U-100 = Can be given as a bolus at mealtimes like rapid-acting insulin, but has a slower onset and lasts longer than needed for a meal

Aspart = Novolog, Fiasp Lispro = Humalog, Admelog, Lyumjev Lispro U-200 = Humalog U-200 Insulin glulisine = Apidra

NPH = Variable, unpredictable duration of action (14-24 hours) Regular Insulin U-100 = Most vials are 10 ml and most pens are 3 ml Inhaled Insulin = Requires lung monitoring with pulmonary function tests (FEV1) Protamine = Comes in premixed solutions only and are combined with standard rapid-acting insulin

Lantus Solostar pen = $100$ U/mL Tresiba FlexTouch pen = $200$ U/mL Toujeo SoloStar, Toujeo Max SoloStar pens = $300$ U/mL Humulin R U-500 KwikPen = $500$ U/mL

Tresiba FlexTouch U-100 = Dose: $80$ units, Volume: $0.8$ mL Tresiba FlexTouch U-200 = Dose: $80$ units, Volume: $0.4$ mL Toujeo SoloStar, Toujeo Max SoloStar pens (glargine) = Dose: $80$ units, Volume: $0.267$ mL Humulin R U-500 KwikPen = Dose: $80$ units, Volume: $0.16$ mL

Lantus Solostar pen = Dial the units to inject Tresiba FlexTouch pen = Dial the units to inject Toujeo SoloStar, Toujeo Max SoloStar pens = Dial the units to inject Humulin R U-500 KwikPen = Prescribed dose should always be expressed in units of insulin

Humulin R, Novolin R = Short-acting insulin, used 30 minutes before meals Humulin R U-500 = Concentrated regular insulin, recommended when patients require > 200 units of insulin per day NPH, Novolin N = Intermediate-acting insulin, typically dosed twice daily as an add-on to oral drugs Insulin degludec (Tresiba) = Ultra-long-acting insulin, useful when insulin detemir or glargine causes nocturnal hypoglycemia

Humulin 70/30 = 70% NPH and 30% regular insulin Novolog Mix 70/30 = 70% aspart protamine and 30% aspart insulin Humalog Mix 75/25 = 75% lispro protamine and 25% lispro insulin Humalog Mix 50/50 = 50% lispro protamine and 50% lispro insulin

IV infusion = Regular insulin is preferred for this method, as it is less expensive and has immediate onset SC injection = The recommended method for U-500 insulin, and the only method for some insulins Insulin pump = Not suitable for all types of insulin, including U-500 insulin Non-PVC container = Regular insulin for IV infusion should be prepared in this type of container

Lantus, Toujeo, Basaglar, Semglee = Insulin glargine, caution required with Toujeo due to its higher concentration Humulin R, Novolin R = Regular insulin, used as prandial insulin and for correction doses NPH, Novolin N = Intermediate-acting insulin, typically dosed twice daily Insulin degludec (Tresiba) = Ultra-long-acting insulin, available in vial and FlexTouch pen

Basal-Bolus Insulin Regimen in Type 1 Diabetes = 1. Calculate TDD ($0.5$ units/kg/day, using TBW) 2. Divide the TDD into $50%$ basal insulin and $50%$ bolus (rapid-acting) insulin 3. Divide the bolus insulin evenly among 3 meals (or allocate more insulin for larger meals and less for smaller meals) Starting a Regimen with NPH and Regular Insulin = 1. Calculate the TDD (same as with basal-bolus regimens) 2. % of the TDD is given as NPH and % is given as regular insulin Starting Insulin in Type 2 Diabetes = If an injectable medication is needed to reduce the AlC in T2D, a GLP-1 receptor agonist is preferred and should be considered first. If the patient is already on a GLP-1 agonist (or a GLP-1 agonist is not appropriate), insulin should be started. An exception is when using insulin initially to treat very high BG at diagnosis (AlC > 10% or BG > 300 mg/dL) or if symptoms of catabolism are present (e.g., DKA) Treatment with an Insulin Pump = All people with TlD require insulin. Most are treated with an insulin pump or multiple daily injections of insulin designed to mimic the normal pattern of insulin secretion. Rapid-acting injectable insulins and long-acting basal insulins are preferred (over short- and intermediate-acting insulins), because they have less hypoglycemia risk and better mimic the physiologic pattern of insulin made by the body. Pumps can provide excellent BG control and require less daily insulin injections.

Total Daily Dose (TDD) = The total amount of insulin needed per day, usually expressed in units Basal Insulin = Insulin that is released in small amounts continuously to provide a steady level of insulin between meals and during sleep Bolus Insulin = Insulin that is used to cover the rise in blood sugar from eating Insulin-to-Carbohydrate Ratio (ICR) = The amount of insulin needed to cover a certain amount of carbohydrates in a meal

Regular Insulin = Short-acting insulin that is typically taken just before or with meals to control the rise in blood sugar from eating NPH Insulin = Intermediate-acting insulin that starts to work within 1 to 3 hours after injection and peaks in 8 to 12 hours Rapid-Acting Insulin = Fast-acting insulin that starts to work within 15 minutes and peaks in 1 to 2 hours Basal Insulin = Long-acting insulin that is typically taken once or twice a day to provide a steady level of insulin between meals and during sleep

Insulin Pump = A device that delivers rapid-acting insulin by two complementary methods: continuous and bolus dosing Basal-Bolus Insulin Regimen = A treatment plan that involves taking a long-acting insulin to provide a steady level of insulin between meals and a rapid-acting insulin to cover the rise in blood sugar from eating NPH and Regular Insulin Regimen = A treatment plan that is not preferred due to the insulins' inability to mimic the natural insulin release from the pancreas as well as basal and rapid-acting insulin combinations GLP-1 Receptor Agonist = An injectable medication that is preferred and should be considered first if an injectable medication is needed to reduce the AlC in Type 2 Diabetes

Pioglitazone

GLP-1 agonists

SGLT2 inhibitors

Lisinopril

Elevated BUN, SCr, and eGFR

GLP1 agonist

Hypoglycemia, weight gain, and severe UTIs

False

True

True

True

True

True

True

Gastroparesis, GI disorders; Genital infection/UTI; Heart failure; Hepatotoxicity: Pioglitazone (bladder), GLP-1 agonists (thyroid, including medullary thyroid carcinoma); GLP-1 agonists, pramlintide; SGLT2 inhibitors; TZDs, alogliptin, saxagliptin; Hypoglycemia; Hypotension/dehydration; Hypokalemia; Ketoacidosis; Lactic acidosis; Osteopenia/osteoporosis; Pancreatitis; Peripheral neuropathy, PAD, foot ulcers; Sulfa allergy, severe; Renal insufficiency (eGFR or CrCl < 30); Weight gain/obesity

GLP-1 agonists, pramlintide

Avoid sulfonylureas, or use cautiously; Metformin, SGLT2 inhibitors, exenatide, glyburide; may need to start insulin at a lower dose

CS's symptoms likely describe dry mouth, weakness, dizziness, lightheadedness, and nearly fainting. These symptoms began approximately 2 months ago and are indicative of dehydration and hypotension.

The addition of lnvokana (canagliflozin) to CS's medication regimen is associated with her symptoms. Lnvokeana decreases blood glucose by excreting it in the urine, which can result in the excretion of water as well, leading to dehydration. Additionally, the use of diuretics and antihypertensive medications could be contributing to the problem due to additive effects.

CS is at risk for acute kidney injury. It is recommended to evaluate for elevated BUN (blood urea nitrogen), SCr (serum creatinine), and eGFR (estimated glomerular filtration rate). Additionally, checking an anion gap and ketones can indicate ketoacidosis, which can occur with the use of lnvokana.

Considering CS's history of atherosclerotic cardiovascular disease (ASCVD) and the side effects associated with SGLT2 inhibitors, it is recommended to switch CS to a GLP1 agonist with benefit. Options include dulaglutide, liraglutide, or semaglutide.

Pioglitazone = Hepatotoxicity (bladder) GLP-1 agonists = Thyroid issues, including medullary thyroid carcinoma SGLT2 inhibitors = Hypotension/dehydration, Ketoacidosis (can occur when BG < 250 mg/dl) Metformin = Lactic acidosis (increased risk with renal impairment, alcoholism, hypoxia)

Canagliflozin = Osteopenia/osteoporosis (BMD, fractures), Pancreatitis Sulfonylureas = Hypoglycemia GLP-1 agonists = Peripheral neuropathy, PAD, foot ulcers SGLT2 inhibitors = Renal insufficiency (eGFR or CrCI < 30)

TZDs = Hepatotoxicity, Heart failure, Hypoglycemia Meglitinides = Hypoglycemia Pramlintide = Hypoglycemia Insulin = Hypoglycemia, Weight gain/obesity

Metformin = Lactic acidosis, Pancreatitis, Diarrhea, Nausea, Renal impairment SGLT2 Inhibitors = Hypotension, Severe arthralgia, Heart failure Sulfonylureas/Meglitinides = Ketoacidosis, Hypoglycemia, Severe UTIs and genital fungal infections, Weight gain GLP-1 Receptor Agonists = Hypoglycemia, Hypokalemia, Weight gain

Byetta, Adlyxin = Give within 60 minutes of meals Trulicity, Bydureon, Bydureon BCise, Ozempic = Inject once a week Byetta, Victoza, Adlyxin = Needles need to be purchased Pramlintide = Inject before meals, do not mix with insulin

Dehydration and hypotension = lnvokana (canagliflozin) Acute kidney injury = Use of diuretics and antihypertensive medications Ketoacidosis = lnvokana Heart failure = Saxagliptin and alogliptin (DPP-4 Inhibitors), Thiazolidinediones

Regular insulin = Hypoglycemia Trulicity, Bydureon, Bydureon BCise, Ozempic = Hypokalemia Byetta, Victoza, Adlyxin = Weight gain Pramlintide = Nausea, diarrhea, decrease in appetite, weight loss