Drug Class Drug Name Dosage When to AE/ADR Clinical Considerations Monitor CV/HF/R/H Contraindication
&A1C take
Biguanide Metformin / 500-2000mg With meals GI-related Weight neutral / anorexia A1C Renal: -Metabolic acidosis
ER BID / TID (if ER, take (NVD) B12 (LT) decrease -Previous lactic acidosis
1-1.5% Start 250mg with largest Low hypo risk Hb <45 GFR -Excessive alcohol use
and titrate q3- meal) Metallic taste SCr CI <15 GFR (risk of lactic acidosis
7d. Max Lactic acidosis LT safety data CV: which can be 50% fatal)
2550mg. CI in CV -Severe stress
Flat at SADMANS Collapse / -Severe infection
2000mg Cardioresp -Severe dehydration
insufficienc
y
Hepatic:
CI if severe
dysfunction
SGLT2 Canagliflozin 100-300mg AM, before Polydipsia -Weight loss (2-3 kg, 60- Pre: GFR Renal: Amputation (Invokana),
OD first meal Polyuria 100g of glucose) Don’t start if Fracture
0.5-1% Dapagliflozin 5-10mg OD AM Genital -Lower BP (5/2 mmHg) Ongoing: GFR GFR <20, DKA (doubles risk)
preferred infection -Low hypo risk K+ at baseline, vol status
Empagliflozin 10-25mg OD AM Lightheadednes -NO LT safety data then 2-4wk, then ********MOA: SGLT2i
preferred s -SADMANS q3-6m Liver: lower renal glucose
Hypovolemia -Less effective in elderly Don’t start if threshold by 4-5 mmol/L
Postural due to GFR Vol status dysfunction (normal is 10-11; in
hypotension *Expect 4-6 ml/min T2DM is 14)
Increased DKA decrease A1C CV
risk ** if decrease <15-20%, CV benefit
Constipation lower dose or stop Changes in risk
Nausea
GLP1RA Dulaglutide 0.75-1.5mg SC GI: NVD (up to Weight loss SCr CVD History of medullary
QW 50% Low risk of hypo reduction thyroid cancer
1-1.5% Exenatide 5-10mcg BID SC, 0-60 Injection site NO LT safety data with
min BID rxn Dulaglutide MEN-2
before food *** FYI/MOA Liraglutide
Exenatide ER 2mg QW SC Acute Complement insulin Semaglutide Gastroparesis
Liraglutide 0.6-1.8mg OD SC (same pancreatitis release
(3mg for time) Can also promote
weight loss) Risk of Thyroid insulin release before
Semaglutide 0.25-1mg QW SC C-cell tumors sugar levels rise
Semaglutide 7-14mg PO 30 min before
W only
PO OD
, <120ml
DPP4i Alogliptin 6.25-25mg Before 1st Headache Weight neutral SCr Renal:
OD meal Nasopharyngitis Low risk of hypo adjust dose
0.7% Linagliptin 5mg OD Rash (rare) NO LT safety data LFT (Alogliptin except
Saxagliptin 2.5-5mg OD Acute Improved post prandial only) Linagliptin
Sitagliptin 25-100mg OD pancreatitis? control
HF? HF:
caution
Saxagliptin
TZD’s Pioglitazone 15-45 mg OD -Fluid retention 6-12 weeks for full effect SCr CV: CI: HF, CV risk
Rosiglitazone 4-8mg OD or -Edema LFTs CV risk ?
0.82% Met BID -Weight gain PROactive for PIO
-Non-fatal MI HF:
(Rosi) Nissan for ROSI CI in HF
-Bladder cancer
(Pio) Slow onset, longer duration Risk of
- lots of targets= of glycemic control fractures in
lots of ADRs elderly
(women)
Meglitinides Repaglinide 0.5-4mg with 15 min AC Headache -Flexible dosing (skip dose SCr Renal:
meals Weight gain if skip meal) LFTs Cautious if
1% mono Max 16mg Hypoglycemia -Rapid onset and short failure
0.7% Met (lower risk than duration of action
SU’s) -Useful to lower Liver:
UTRI postprandial glucose Safe
SU’s Glyburide 1.25-20mg 30 min AC Hypoglycemia Low cost SCr Renal:
OD / BID (not HS) Weight gain LT safety data LFTs lower dose
1-2% mono Gliclazide 80-320 mg NV SADMANS
0.8% Met OD / BID Hypersensitivity Stimulate insulin release. Lower dose
Gliclazide 30-120 mg Breakfast in elderly
MR OD
Glimepiride 1-8mg OD 30 min AC
(not HS)
a- Acarbose 25-100mg With first GI (flatulence, Low hypo risk (if hypo, SCr
Glucosidase divided TID bite diarrhea) titrate use glucose) LFTs
Inhibitor drug up slowly. Weight neutral
Useful for postprandial
0.6% LFT increase at control
high doses Avoid if GI disorder
&A1C take
Biguanide Metformin / 500-2000mg With meals GI-related Weight neutral / anorexia A1C Renal: -Metabolic acidosis
ER BID / TID (if ER, take (NVD) B12 (LT) decrease -Previous lactic acidosis
1-1.5% Start 250mg with largest Low hypo risk Hb <45 GFR -Excessive alcohol use
and titrate q3- meal) Metallic taste SCr CI <15 GFR (risk of lactic acidosis
7d. Max Lactic acidosis LT safety data CV: which can be 50% fatal)
2550mg. CI in CV -Severe stress
Flat at SADMANS Collapse / -Severe infection
2000mg Cardioresp -Severe dehydration
insufficienc
y
Hepatic:
CI if severe
dysfunction
SGLT2 Canagliflozin 100-300mg AM, before Polydipsia -Weight loss (2-3 kg, 60- Pre: GFR Renal: Amputation (Invokana),
OD first meal Polyuria 100g of glucose) Don’t start if Fracture
0.5-1% Dapagliflozin 5-10mg OD AM Genital -Lower BP (5/2 mmHg) Ongoing: GFR GFR <20, DKA (doubles risk)
preferred infection -Low hypo risk K+ at baseline, vol status
Empagliflozin 10-25mg OD AM Lightheadednes -NO LT safety data then 2-4wk, then ********MOA: SGLT2i
preferred s -SADMANS q3-6m Liver: lower renal glucose
Hypovolemia -Less effective in elderly Don’t start if threshold by 4-5 mmol/L
Postural due to GFR Vol status dysfunction (normal is 10-11; in
hypotension *Expect 4-6 ml/min T2DM is 14)
Increased DKA decrease A1C CV
risk ** if decrease <15-20%, CV benefit
Constipation lower dose or stop Changes in risk
Nausea
GLP1RA Dulaglutide 0.75-1.5mg SC GI: NVD (up to Weight loss SCr CVD History of medullary
QW 50% Low risk of hypo reduction thyroid cancer
1-1.5% Exenatide 5-10mcg BID SC, 0-60 Injection site NO LT safety data with
min BID rxn Dulaglutide MEN-2
before food *** FYI/MOA Liraglutide
Exenatide ER 2mg QW SC Acute Complement insulin Semaglutide Gastroparesis
Liraglutide 0.6-1.8mg OD SC (same pancreatitis release
(3mg for time) Can also promote
weight loss) Risk of Thyroid insulin release before
Semaglutide 0.25-1mg QW SC C-cell tumors sugar levels rise
Semaglutide 7-14mg PO 30 min before
W only
PO OD
, <120ml
DPP4i Alogliptin 6.25-25mg Before 1st Headache Weight neutral SCr Renal:
OD meal Nasopharyngitis Low risk of hypo adjust dose
0.7% Linagliptin 5mg OD Rash (rare) NO LT safety data LFT (Alogliptin except
Saxagliptin 2.5-5mg OD Acute Improved post prandial only) Linagliptin
Sitagliptin 25-100mg OD pancreatitis? control
HF? HF:
caution
Saxagliptin
TZD’s Pioglitazone 15-45 mg OD -Fluid retention 6-12 weeks for full effect SCr CV: CI: HF, CV risk
Rosiglitazone 4-8mg OD or -Edema LFTs CV risk ?
0.82% Met BID -Weight gain PROactive for PIO
-Non-fatal MI HF:
(Rosi) Nissan for ROSI CI in HF
-Bladder cancer
(Pio) Slow onset, longer duration Risk of
- lots of targets= of glycemic control fractures in
lots of ADRs elderly
(women)
Meglitinides Repaglinide 0.5-4mg with 15 min AC Headache -Flexible dosing (skip dose SCr Renal:
meals Weight gain if skip meal) LFTs Cautious if
1% mono Max 16mg Hypoglycemia -Rapid onset and short failure
0.7% Met (lower risk than duration of action
SU’s) -Useful to lower Liver:
UTRI postprandial glucose Safe
SU’s Glyburide 1.25-20mg 30 min AC Hypoglycemia Low cost SCr Renal:
OD / BID (not HS) Weight gain LT safety data LFTs lower dose
1-2% mono Gliclazide 80-320 mg NV SADMANS
0.8% Met OD / BID Hypersensitivity Stimulate insulin release. Lower dose
Gliclazide 30-120 mg Breakfast in elderly
MR OD
Glimepiride 1-8mg OD 30 min AC
(not HS)
a- Acarbose 25-100mg With first GI (flatulence, Low hypo risk (if hypo, SCr
Glucosidase divided TID bite diarrhea) titrate use glucose) LFTs
Inhibitor drug up slowly. Weight neutral
Useful for postprandial
0.6% LFT increase at control
high doses Avoid if GI disorder
