The document outlines various antidiabetic medications, detailing their mechanisms of action, indications, contraindications, side effects, and their impact on blood glucose levels. Key highlights include the recommendation to stop certain medications before IV contrast and their variances in safety during pregnancy, particularly with respect to categories and renal function. Additionally, it emphasizes specific choices for patients intolerant to metformin, as well as the cardiovascular benefits associated with liraglutide and empagliflozin.

1. Antidiabetic medications
-Stop prior to IV contrast &
48 hours after angiography
-CC < 30 mL/min - Do not
use
Category B in pregnancy
-B12 deficiency
Gi upset-
-No hypoglycemia
or weight gain
-Improves CKD
- lactic acidosis( Rare)
 in the liver:
1↓gluconeogenesis,
2-↓Glycogenolysis
3-↓Fatty acid
oxidation
 in skeletal muscle
1-↑ glycogenesis
2-↓Fatty acid
oxidation
 in intestine:
1-Anerobic glucose
metabolism
Biguanide Metformin
(max 2550)
▼HbA1c by 1.to 2.0 %
-Avoid Glimepiride ,
glibenclamide in elderly
-Weight gain
-hypoglycemia
Cholestasis(Chlorpropamide)-
-Retinopathy (Gliclizide)
-Stimulate pancreatic beta cells
to release insulin
Sulfonylureas
-Glipizide,
-Glyburide
(glibenclamide),
Glimepiride-
-Gliclazide
(Diamicron)
▼HbA1c by 1 to 2%
-Black Box warning for
class III or IV HF
Category C in pregancy-
-Risk of bladder, prostate,
edemapancreatic cancers ,
-Decrease bone density and
increase fractures
Weight gain-
Increases ovulation-
-Decreases insulin resistance
at muscle and fat level
Thiazolidinedion
-Pioglitazone (Actos)
Rosiglitazone (Avandia)-
.-Do not use in MEN2 and
CC below 30.
Category C in pregnancy
Weight loss-
-Pancreatitis
-Hypoglycemia with
Sulfonylureas
Thyroid C-cell T-
1- Potentiate insulin secretion
2- Suppress postprandial
glucagon secretion
3- Slow gastric emptying
4- Promote satiety
5- Increases insulin response
to postprandial rise in glucose
GLP-1
Exenatide-
-Liraglutide( Victoza )
Dose 0.6, 1.2, 1.8 mg
daily
Dulaglutide-
1-Linagliptin not renally
excreted and good choice in
elderly
2-Better insulin release and
blood sugar control,
particularly postprandial
-URI, sore throat, diarrhea,
pancreatitis-
Joint pain-
weight neutral-
Decrease breakdown-
of GLP-1
DPP-4 Inhibitors
Linagliptin 5mg daily-
Sitagliptin(Januvia)100mg
daily-
Saxagliptin
▼HbA1c by .5 to .7 %-
Lower BB-
-Improve renal F
- Decrease risk of MI,
stroke, CKD
B12 deficiency-
Weight loss-
DKA-
-Increase fractures and risk of
foot amputation
Fournier's gangrene-
Increased UTIs-
1-Block reabsorption of
glucose in the kidney
2- Increase urinary excretion of
glucose
SGLT2 Inhibitors
Canagliflozin-
Dapagliflozin-
Empagliflozin
▼HbA1c by .5 to .8 %-
Weight neutral-
no hypoglycemia-
Category B in pregnancy-Delay carbohydrate absorption
in gut
A-Glucosidase
Inhibitors
Acarbose-
Miglitol-
- May be used in
elderly, renal failure, &
cardiopulmonary
disorders
Rapid-acting-Meglitinides
-Repaglinide
-Nateglinide
++Side effectMechanism of actionMedication

2.  Types of insulins:
Side effect : Systemic : Hypoglycemia, Wight gain, Insulin resistance
Local : Hypersensitivity Infection ,Lipodystrophy
Long actingIntermediateShort actingRapid acting
,)Lantus(Glargine
)Levemir(etemirD
Neutral protamine
Hagedorn (NPH)
Regular(Humulin R),)NovoRapid(spartA
glulisine
)Humalog(),lisproApidra)
Onset 30-60 min,
Glargine No peak
Detemir dose
dependent ,
duration 16-24 hr
Onset 1-2 H,
peak 4-8 hr,
duration 8-12 hr
Onset 30 min,
peak 1-3 hr,
duration 4-8 hr
Onset 15 min,
peak 1-3 hr,
duration 2-5 hr
Administered once
daily
● Route: SubQ
injection
○ NOT for IV use
● Appearance:
Clear-
-Can NOT be mixed
with other types of
insulin
Administered once
or twice daily
● Route: SubQ
injection
NOT for emergency
IV use
● Appearance:
Cloudy
Only :insulin that
can be mixed with
short-acting
-Administered immediately
before eating a meal
● Route: May be given IV
● Appearance: Clear
 Patients who are intolerant of metformin are unlikely to be successful with a
third trial of that agent. Empagliflozin, an SGLT2 inhibitor, is considered a
second-line choice for patients who are intolerant of metformin. Both
sitagliptin, a DPP-4 inhibitor, and liraglutide, a GLP-1 receptor agonist, should
be avoided or used with caution in patients with a history of pancreatitis
 -Linagliptin is not cleared by the kidney second choice if GFR<35(Stop
Metformin)
 only liraglutide has been shown to lower the risk of recurrent cardiovascular
events and has received FDA approval for this indication
 Empagliflozin, an SGLT2 inhibitor, has also been associated with secondary
prevention of cardiovascular disease .
 Fasting C-peptide levels are markedly elevated in patients with T2DM, but in
people with T1DM, C-peptide levels should be low

3.  .TZDs tend to cause fluid retention and should not be used in patients with
congestive heart failure
References
ADA
Step up to medicine
Toronto notes
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