Type 2 diabetes mellitus (T2DM)

Use at a glance

• Lifestyle + weight management throughout

Practical pearls

• ASCVD: GLP-1 RA and/or SGLT2 favored
• Heart failure: prioritize SGLT2 inhibitor

Other practical pearls

• CKD: SGLT2; add GLP-1 as appropriate
• Obesity: GLP-1/GIP-GLP-1 often favored
• Otherwise metformin remains a common base

Choosing treatment

• Combine early if far above A1c target
• Catabolic/severe hyperglycemia → insulin

Key points

• Adding insulin → basal first
• Glargine/degludec: slightly less hypoglycemia than NPH
• Need more control → add mealtime regular or rapid-acting (aspart, glulisine, lispro)
• Rapid-acting analogs: slightly better A1C, possibly less hypoglycemia vs regular
• Inhaled insulin: rapid-acting; titration, pulmonary comorbidities limit use
• Premixed: fewer injections, harder titration, more hypoglycemia
• A1C goal <7% for most → ↓ microvascular complications
• Initial: metformin, especially without obesity, CV, or renal disease
• Obesity, CV, or renal comorbidity → add/substitute GLP-1 RA or SGLT2i

Nonpharmacologic therapies

• Pulmonary function testing
• Fasting glucose self-monitoring
• Diet
• Exercise
• Weight loss

Pearls

• SGLT2i beat GLP-1 RAs for preventing HF hospitalization
• DPP-4 inhibitors CV-neutral; saxagliptin, alogliptin may worsen HF
• A1c <8% reasonable for older or hypoglycemia-prone patients
• Basal insulin: raise 2 units every 3 days to fasting goal
• GLP-1 RAs: aspiration risk under anesthesia despite fasting

Self-check

• What treats catabolic/severe hyperglycemia in T2DM?
  Insulin.
• Which class is prioritized in T2DM with heart failure?
  SGLT2 inhibitors.

Drugs used for this (37)

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