Drug HbA1c MOA Weight Hypo Other Side Effects Renal CV

Class Reduction Change glycaemia Impairment Effects Special Considerations

(with
metformin)

- Biguanide No increased Low risk Generally well- Need to dose- Improves CVS - can cause GI
Metformin X - E.g. diabex, diaformin weight because just torlerated adjust risk in SEs
- Decreases hepatic modulating phy - Has been - May be overweight - esp diarrhoea
glucose production, around for limiting patients (main one)
improves insuline long time factor - also nausea
sensitivity as - is dose-related
- First line in treatment Diarrhoea = most diabetic so start low
common SE s often and gradual
- Dose have up—titrate
adjustment renal - can cause b12
Lactic acidosis (rare) disease deficiency
- If develop as well (interferes
AKI need to with
withhold absorption)
but very rarely
causes
anaemia
- Also comes in
extended-
release so
don’t have big
dump of drug
in intestine
0.5-1.3% Increases pancreatic beta cell Causes weight Renal clearance
Sulfonylureas decrease insulin section gain so will build up if
renal
Significant impairment is
hypoglycaemia present
so avoid
glimepiride and
gliblibenclamide
avoid in elderly,
 renal/liver
impairment

Has potential to
hasten beta cell
failure
0.7-1% (with Inhibits DPP4 enzyme which No weight gain Hypoglycaemia Rarely – pancreatitis Needs dose Do no use saxaglipin or
DDP4 Inhibitors metformin) increases incretin hormones unlikely adjustment in alogliptin in HF!
Less than with (GLP1 and GIP) leading to l Can also cause MSK renal
sulfonylureas pain – doesn’t impairment
i.e. acts on pathways that prevent prescribing – except for
physiologically but is a Linagliptin
consideration) doesn’t need
dose
impairment in
bc is secreted in
bile
0.8-0.9% Is subcut injection Weight loss hypoglycaemia N+V in up to 50% of Dose reduction Liraglutide Liraglutide is TGA
reduction (with - May be deterrant in patients in renal reduces major approved but not
metformin) T2DM patients bc - Usually at impairment (as subusidised by PBS and
GLP1 Analogues often want to avoid start of in all is expensive
But also causes injections (eg insulin) treatment
weight loss so and likely to
potentially more Slows gastric emptying and subside
decrease suppresses appetite = weight - But is high
loss rate
- May be used in
obesity Pancreatitis
- So avoid in
pancreatic
disease,
pancreatic
malignancy
0.5-0.7% (with Inhibits sodium-glucose Weight loss Hypoglycaemia But increased risk of Not as effective Cardioprotecti Empagliflozin =
SGLT2 Inhibitors metformin) cotransporter 2 = decreased unlikely GU infections due to in renal ve decreases risk of
 Again less so reabsorption of glucose at increased glucose in impairment bc - Decre hospitalisation in
than prox convulted tubules of urine acts at kidney to ases patients with HF, CV
sulfonylureas kidney  also increased risk exert effects BP death and overall
but has si of fournier’s gangren - Cannot due mortality
use if to
Can cause CrCl<45 [mild] Need to stop 3 days
euglycaemic osmo before surgery, and
ketoacidosis tic don’t re-start until
- Initially effect eating again
described in of
drug of this gluco
glass that se in
has been urine
fremoved - Slows
from market progr
- But also essio
picked up in n of
post- kidne
marketing y
surveillance disea
- Need to se
stop 3 days
before
surgery, and
don’t re-
start until
eating again
- Is reportable
to TGA

T2DM = hyperglycaemia due to insulin resistance

Management
- Decrease glucose available
o Diet mods
o Exercise
 - Decrease glucose absorption
o Metformin
 Also
- Act on incretin hormones
o GLP1 and DPP4
 These act to increase insulin and decrease glucagon and depress appetite and inhibit gastric emptying
 GLP1 analogues
 DPP4 inhibitors (to decrease breakdown of insulin)
- ??
- Increase excretion of glucose
o SGLT2 in ???

Start with metformin

- First line treatment
- Second line drug choice is a more complex

Other oral meds that can be used (but low on list)

- Acarbose
o Delays carb digestion and glucose absorption
o Hence significant GI symptoms
o Less effective at improving glycaemic control
- Pioglitazone
o Rarely used due to significant SE profile
 Increase riks of significant ischaemia
 Increased risk fo bladder cancer
 Worsening HF
 Increased rrisk of fractures in people with osteoporosis
 Worsening of diabetic macular oedemia
o Showed good reduction in blood glucose but then significant SE profile became apparent

T2Dm Mx Guidelines
- Lifestyle mods as first action and ongoing through all stages of diabetic management
- When starting therapy, look at HbA1c
 o If hba1c <8.5 can either start metformin asap or start it after 2-3/12 of lifestyle mods and target hba1c not acheived
o if glycaemic control not achieved after 3months on optimal drug dose, add in second drug
- If HbA1c equal or >8.5% start both metformin + second drug
o Metformin alone unlikely to achieve target
- Second drug choice
o Sulfonylurea, DPP4 inhib, or SGLT2 inhibitor
 Alternatively, GLP1 analogue (unliley as first choice as is injection), insulin, acarbose
- NB if hba1c is massive like >12 will not be able to control with oral therapy so will go straight to insulin
- If glycaemic control not achieved after 3/12 then add in third drug
o Choices include sulfonylurea, DPP4 inhib, SGLT2 inhib, GLP1 agonist, or insulin
 Alt. acarbose, thiazolinediones
- Glycaemic target
o HbA1c <7%
 If using metform  target 6.5
o If hypoglycaemic risk is significant or patient is unaware of hypoglycaemia/unable to manage appropriately, target equal to <8%