Step 3 : step up to 3 drug combination (including metformin)
Step4: more complex insulin regimen
Target values for blood glucose - answer✔70-130 mg/dL before meals; 100-140 mg/dL at bedtime
Insulin Lispro (Humalog) - answer✔Short-duration (3-5 hours), rapid acting (10-20 minutes); analog of
human insulin. Administered immediately before or after eating
Insulin Aspart (Novolog) - answer✔Short-duration (3-6 hours), rapid acting (15-30 minutes after subQ
injection). Rapid-acting analog of regular insulin. Acts faster than regular insulin but has a shorter
duration of action. Should be injected 5-10 minutes before meals.
Insulin Glulisine (Apidra) - answer✔Short-duration (3-5 hours), rapid acting (10-15 minutes). Synthetic
analog of natural human insulin. Should be administered close to the time of eating
Regular insulin (Humulin R, Novolin R) - answer✔Short-duration, slower-acting insulin. Unmodified
human insulin. Routes: subQ, subQ infusion, IM, and oral. Effects begin in 30-60 minutes; peaks in 1-5
hours; duration up to 10 hours. CLEAR solution.
NPH Insulin (Humulin N, Novolin N) - answer✔Intermediate-duration insulin. Injected 2-3 times daily to
provide glycemic control between meals and during the night. Only one suitable for mixing with short-
acting. CLOUDY suspensions. Administered subQ.
Insulin Glargine (Lantus) - answer✔Long-duration insulin. Modified human insulin. Prolonged duration of
action (up to 24 hours). Once-daily subQ. CLEAR solution - do not mix with other insulins.
Insulin detemir (Levemir) - answer✔Long-duration insulin. Human insulin analog. Slow onset and dose-
dependent duration of action. Used to provide basal glycemic control (NOT given before meals to
control post-prandial hyperglycemia). CLEAR, colorless solution. Dosing: 1-2 times daily by subQ. Do not
mix with other insulins.
Afrezza - answer✔Inhalation insulin. Used for mealtime insulin. Provides good glycemic control with
relatively low incidents of hypoglycemia. Little to no effect on the pulmonary function, but can cause
bronchospasm, so us with caution in patients with chronic lung disease.
Metformin - answer✔Drug of choice for initial therapy in most patients with T2DM. Most common side
effects: GI disturbances; lactic acidosis (be cautious in patients with CKD). Inhibits glucose production in
the liver; reduces glucose absorption in the gut; sensitizes insulin receptors in target tissues scubas fat
and skeletal muscle and increases the glucose uptake and response to whatever insulin is available. Drug
interactions: alcohol, cimetidine, iodinated radio contrast (d/c drug 2-3 days before dye)
Promote insulin release; only to be used for T2DM. Major side effects: hypoglycemia, weight gain. Drug
interactions: alcohol, NSAIDs, cimetidine, beta blockers
Meglitindies - answer✔Repaglinide and Nateglinide. Same MOA as Sulfonylureas; stimulate the
pancreatic insulin release. Adverse effect: hypoglycemia. Drug interactions: gemfibrozil
Thiazolidinediones (Glitazones) - answer✔Reduce glucose levels primarily by decreasing insulin
resistance; only indicated for T2DM (add-on to metformin). Rosiglitazone; pioglitazone. Do not give to
patients with HF.
Pioglitazone - answer✔Reduces insulin resistance and may also decrease glucose production. Adverse
effects: URI, headache, sinusitis, and myalgia. Drug interactions: insulin; drugs that induce or inhibit the
CYP2C8 system
Alpha-glucosidase inhibitors - answer✔Act in the intestine to delay the absorption of carbohydrates.
T2DM. Acarbose ADE: frequently causes flatulence, cramps, abdominal distention, borborygmus,
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