For educational purposes only.
Diabetes Medication Summary
Metformin
Mechanism of action: decreases gluconeogenesis and increases peripheral glucose
doses, interaction, contraindications and side effects in the BNF and seek professional clinical advice before making any interventions. We do not accept any
liability for loss of any type caused by reliance on the information within this document. Please only work within your clinical competency and ensure your
utilisation
judgement or replace your local clinical guidelines. The information included in this document is meant for educational purposes only. Please check drug
Every effort has been made to ensure the information within this document is accurate and correct, however this should not replace your own clinical
Metformin Advantages: Low hypoglycaemia risk, potential for weight loss, offers some
cardiovascular protection, relatively cheap medication, offers reasonable
glycaemic control
Disadvantages: Should be used with caution in renal impairment - if eGFR drops
<45 consider dose reduction. If eGFR drops <30 stop the medication. Risk of lactic
acidosis is rare but symptoms include thirst, anorexia, abdominal pain, confusion.
Dehydration or tissue hypoxia can be potential triggers.
Warnings: GI disturbances such as nausea and vomiting occur at the initiation
stages. Taste disturbances, skin reactions. Vitamin b12 deficiency - more likely to
occur with higher doses.
Usual dose: Take with meals, start low and go slow. 500mg OD for at least 1 week,
then increase in 500mg steps at weekly intervals until highest tolerated or max
dose. (check local guidelines)
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Sulphonylureas eg gliclazide
Sulphonylurea
Mechanism of action: Augments insulin secretion
Advantages: Relatively cheap medication, can achieve good glycaemic control, has
good long term safety data
Warnings: High potential risk of hypoglycaemia which can be further aggravated
with poor renal function, possibility of weight gain of a few Kg
Disadvantages: Patients should be wary of hypoglycaemmia in terms of impacting
driving. Refer patients to view the fitness to drive document. Patients who drive
cars should monitor glucose concentration at times relevant to driving to detect
hypoglycaemia. Lorry drivers are required to monitor blood glucose twice daily
and at times relevant to driving.
Usual dose: initially 40-80mg daily, adjusted according to response upto 160mg as
a single dose with breakfast. max 320mg daily. increase the dose approximately
every 4-6 weeks
SGLT2 inhibitors eg empagliflozin, dapagliflozin, canagliflozin
SGLT2 inhibitor
Mechanism of action: Inhibits the sodium glucose co-transporter-2 in the renal proximal
convoluted tubule to reduce glucose absorption and increase urinary glucose excretion
Advantages: Can achieve good glycaemia control, relativey low risk of hypoglycaemia,
potential for weight loss, can have potential cardiovascular and renal benefits
Disadvantages: Increased risk of infections eg UTIs, diabetic ketacidosis (signs include nausea,
vomiting, abdominal pain, thirst, breathing problems, confusion), rare but risk of amputation,
use with caution in renal impairment, gangrene
Warnings: increased risk of hypoglycaemia when used with insulin or sulphonylureas. Ketones
should be monitored during treatment interruption for surgical procedures or acute serious
medicall ilnesses
Usual dose: Empagliflozin (green 1st line - check local formulary) starting dose 10mg once
daily, can be increased to 25mg once daily if tighter glycaemic control is needed and renal
function is satisfactory.
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Gliptins eg alogliptin, sitagliptin, linagliptin
Mechanism of action: Inhibit dipeptidylpeptidase-4 to increase insulin
secretion and lower glucagon secretion
Advantages: Low risk of hypoglyaemia (relative), overall weight neutral
Gliptins
Disadvantages: Relatively average glycaemia control compared to other
agents, severe and/or disabling joint pain, potential risk for acute
pancreatitis, potential increased risk of heart/kidney disease
Warnings: treatment should only be continued if there is a reduction of
>5.5mmol/mol in hba1c over 6 months. avoidance of treatment in hepatic
impairment. Dose reduction may be needed in renal impairment
Usual dose: Alogliptin (green 1st line - check local formulary) 25mg once
daily. can be used as monotherapy, dual therapy or triple therapy
Pioglitazone
Mechanism of action: Reduces peripheral insulin resistance causing lower
Pioglitazone
blood glucose concentration
Advantages: Relatively good glycaemic control, low risk of hypoglycaemia
(rare), relatively safe in renal impairment, relatively cheap medication
Disadvantages: potential for weight gain, increased risk of developing heart
failure, fractures and bladder cancer
Warnings: significant oedema can occur in some patients. Cardiac failure can
occur when pioglitazone is used in combination with insulin. observe the
patient for signs of heart failure and weight gain.
Usual dose: initially 15mg to 30mg daily adjusted according to response to
45mg once daily. In elderly patients use the lowest possible dose. dose
should be reviewed every 3-6 months.
GLP1 eg liraglutide, exenatide, lixisenatide
Mechanism of action: Increases insulin secretion, suppresses glucagon
secretion, slows gastric emptying and reduces appetite
Advantages: Very effective glycaemic control, low risk of hypoglycaemia,
possible weight loss, potential cardiovascular and renal benefits
GLP-1
Disadvantages: Relatively expensive medication, risk of necrotising and
haemorrhagic pancreatitis
Warnings: to continue therapy, patients must have achieved weight
reduction >3% in those with high BMI and a significant reduction in hba1c
with stable renal function. Routine monitoring of blood glucose is
recommended if GLP1 is given with another agent likely to cause
hypoglycaemia such as sulphonylureas. This could impact driving status.
Usual dose: Liraglutide (green 1st line - check local formulary) 0.6mg once
daily for at least 7 days, then increase to 1.2mg once daily for at least 7 days
by s/c injection (check BNF or local guidelines).
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