Treatment of the type II diabetes is complex and challenges exist in long-term management, including minimizING in the risks of hypoglycemia, glycemic fluctuations and weight gain.
Hypoglycemia, especially nocturnal hypoglycemia is observed in a substantial number of patients, especially the elderly, with some patients experiencing severe hypoglycemia episodes.
Among patients with T2D initially receiving metformin, which treatment intensified with sulfonylureas or insulin, the incidence of hypoglycemia, is approximately 25 events 1000 person-years with sulfonylureas, and almost 31 events for 1000 person-years with insulin.
With a continuous glucose monitoring patients treated with metformin plus a second class of the agents, particularly in elderly, have significant likelihood of hypoglycemic episodes.
Glycemic peaks and troughs are therapeutic targets T2D.
Basal glucose levels are elevated and loss of postprandial control results in further elevations after meals, this blood glucose levels can fluctuate to dramatically throughout the day despite achieving hemoglobin a 1C targets.
Treatment is a progressive stepwise approach to pharmacotherapy.
Management includes individualization glycated chemical levels and goals based on patient specific variables and adverse effects of therapy, especially hypoglycemia.
An initial hemoglobin A-1 C goal of 6 1/2% or less for most patients is recommended.
A hemoglobin A-1 C of 7-8% may be appropriate for some patients with limited life expectancy, a hostoory of severe hypoglycemia, or advanced morbid disease.
ADA recommends a hemoglobin A-1 C goal of less than 7% the most non-pregnant patients.
ADA suggests that more stringent goals of hemoglobin A-1 C of less than 6.5% be considered if this can be achieved without increasing the risk of hypoglycemia or other adverse therapy outcomes, and less stringent goals of less than 8% considered for patients with a history of severe hypoglycemia, limited life expectancy, advanced complications, extensive comorbidity, or long-standing type two diabetes.
Recommended initial treatment for type two diabetes includes lifestyle changes and monotherapy usually with metformin.
If hemoglobin A-1 C goals has not been met within approximately three months, treatment should be intensified by adding a second agent.
If hemoglobin A-1 C goals are not met, triple therapy should be considered.
Metformin treatment should be continued after the introduction of insulin in patients with type two diabetes, unless contraindicated.
Macrovascular disease, the leading cause of death in type two diabetes, is not benefited by the use of glycemic lowering interventions, even when a stringent glycemic control is achieved.
Challenges for patients with type two diabetes is that a number of treatments including: sulfonylureas, thiazolidinediones, and insulin are associated with weight gain.
Weight loss in patients with type two diabetes include: improved glycemic control, improve lipid profile, and reduction in blood pressure.
Weight loss reduction of 5% or more is necessary to achieve benefits in glycemic control, lipid profile, and blood pressure.
GLP-1 receptor agonists reduce hemoglobin A-1 C levels and bodyweight, as monotherapy and in combination with other glucose lowering agents.
Patients with a hemoglobin A-1 C of less than 7.5% typically begin on monotherapy, with metformin as the recommended first line treatment.
GLP-1 receptor agonists are among the initial recommended treatments because they’re associated with low risk of hypoglycemia and with the reductions in both fasting and postprandial glucose.
For patients with a hemoglobin A-1 C of 7.5% dual therapy is recommended followed by triple therapy if that goal is not met with dual therapy.
If a patient has a hemoglobin A-1 C of greater than 9% initial dual therapy is considered.
Patients receiving dual therapy and triple therapy who did not achieve hemoglobin A-1 C targets should proceed to triple therapy and combination injectable therapy, respectively.
Empagliflozin/linagliptin/metformin, sold under the brand name Trijardy XR
A drug combination used for the treatment of type 2 diabetes.
It is a combination of empagliflozin, linagliptin, and metformin.
Routes of administration by mouth.
Empagliflozin should each be stopped at least three days before scheduled surgery to prevent ketoacidosis.
In randomized studies in a total of 60 healthy adults found that the three drug combination tablet is bio equivalent to individual tablets of empagliflozin, linagliptin an extended release Metformin taken together.
The 3 drug combination is available in four different strengths making dosing instructions complex.
By controlling hemoglobin A1c, low density lipoprotein cholesterol, albuminuria, smoking, and blood pressure in type 2 diabetes, the risks of death and myocardial infarction and stroke is similar to patients without type two diabetes.