Diabetes

Disease State Overview

Diabetes is a chronic endocrine disorder characterized by lack of insulin production, varying degrees of insulin resistance, or both. Diabetes is categorized broadly into 2 types. Type 1 diabetes is characterized by a complete lack of insulin production by the pancreas while type 2 diabetes is characterized by both insulin resistance and inadequate insulin production.  

 

Risk of Condition 

Diabetes can lead to several microvascular and macrovascular complications.  

1. Macrovascular complications of diabetes include coronary artery disease, peripheral arterial disease  
   and stroke.  

1. Microvascular complications of diabetes include diabetic nephropathy, neuropathy, and retinopathy.  

 

Medication 

Role of Medication 

Type 1 Diabetes: Insulin therapy is required due to the body’s loss or near loss of beta cell function resulting in no or minimal endogenous insulin production. 

 

Types 2 Diabetes: Guidelines recommended metformin and lifestyle modifications as initial therapy in patients with type 2 diabetes. Non-insulin medications can be used to increase the body’s sensitivity to insulin or stimulate production of endogenous insulin. As type 2 diabetes progresses, insulin supplementation may be required to achieve adequate blood glucose control. Choice of therapy should be based on multiple factors including A1c, medication side effect profile, insurance coverage, patient preference, patient’s age, comorbid conditions, and concurrent medications.  

 

Medications for the Management of Diabetes from the American Diabetes Association (ADA):  

Drug Class	Drug Names		Common Class Side Effects
Biguanide	metformin		GI: diarrhea, nausea, vomiting, abdominal pain, bloating  Weight change: neutral   Hypoglycemia risk: No     Taking with food may minimize GI upset
Sulfonylurea	glipizide   glimepiride  glyburide		Weight change: gain   Hypoglycemia risk: yes (glyburide > glimepiride > glipizide)
Meglitinide	repaglinide  nateglinide		Weight change: gain   Hypoglycemia: yes
Thiazolidinedione	pioglitazone		Weight change: gain  Hypoglycemia risk: no  Other: edema, bone fractures, congestive heart failure (BBW), bladder cancer (pioglitazone only)
DPP-4 Inhibitor	sitagliptin (Januvia)  saxaglipitin (Onglyza)  linagliptin (Tradjenta)		Weight change: neutral   Hypoglycemia risk: no   Other: nasopharyngitis, upper respiratory tract infections, headache, pancreatitis, joint pain
GLP-1 Analog	exenatide (Byetta, Bydureon)  liraglutide (Victoza)*  dulaglutide (Trulicity)*  semaglutide (Ozempic*, Rybelsus)		GI*: nausea, vomiting, diarrhea  Weight change: loss   Hypoglycemia risk: no  Other: thyroid C-cell tumors (BBW), injection site reactions     *GI side effects are minimized by starting the patient on the right starting dose and following the appropriate titration schedule
SGLT2 Inhibitor	canagliflozin (Invokana)*  dapagliflozin (Farxiga)  empagliflozin (Jardiance)*   ertugliflozin (Steglatro)		Weight change: loss   Hypoglycemia risk: no  Other: Urinary tract infections, dizziness, hypotension, hyperkalemia
Alpha Glucosidase Inhibitor	acarbose  miglitol		GI: diarrhea, flatulence  Weight change: loss  Hypoglycemia risk: no
Amylin Analog	pramlintide		GI: nausea, vomiting  Weight change: loss  Hypoglycemia risk: no
Insulin	Rapid Acting:   aspart  glulisine   lispro     Short Acting:   regular	Intermediate Acting:  NPH       Long Acting:   degludec   detemir   glargine	Weight change: gain   Hypoglycemia risk: yes (highest risk)

* Demonstrated cardiovascular benefit in clinical trials and have a labeled indication of reducing CVD events. Consider in patients at high cardiovascular risk or in patients with established ASCVD. 

Abbreviations used: DPP-4 = dipeptidyl peptidase-4, GLP-1 = glucagon-like peptide-1, SGLT2 = sodium-glucose cotransporter-2 

 

Cardiovascular Disease Management in Diabetes 

Cardiovascular disease (CVD) is the leading cause of death amongst people with diabetes making cardiovascular risk management an essential component diabetes management. 

 

 

Therapy	Recommended Medication Options	Rationale
Hypertension Therapy	ACEi (first-line therapy)  ARB (first-line therapy)   Calcium channel blocker  Thiazide diuretic	Hypertension is common in people with diabetes and increases risk of microvascular complications
Lipid Therapy	Primary Prevention   Moderate-intensity statin (all patients age 40 – 75 years)   High-intensity statin (multiple ASCVD risk factors or age 40-75 years)  Ezetimibe (consider adding to max tolerated statin in patients with ASCVD risk > 20%)    Secondary Prevention   High-intensity statin	Statin therapy has been shown to decrease cardiovascular risk in people with diabetes with and without coronary heart disease.
Antiplatelet Therapy	Primary Prevention   Aspirin (high risk patients only)    Secondary Prevention   Aspirin  Clopidogrel (patient with allergy to aspirin)   DAPT (only used in certain patients)	Aspirin has been shown to reduce cardiovascular morbidity and mortality in high-risk patients using for secondary prevention. For use in primary prevention, risk of bleed may outweigh potential benefit so risks should be discussed with the patient.

Abbreviations used: ACEi = angiotensin converting enzyme inhibitor, ARB = angiotensin receptor blocker  

 

Adherence 

Medication adherence is an essential component of treating diabetes and preventing further complications. Discuss barriers to adherence and provide appropriate solutions. You may use the DRAW tool located within the Worksheets & Forms category in this Knowledge Base.

 

Administration 

Pharmacists play a key role in the training and education of appropriate administration and storage of insulin and other injectables. Refer to the package insert or manufacturer website of the specific product for further guidance.  

 

Monitoring 

The goal of therapy is to reduce microvascular and macrovascular complications by achieving and maintaining glycemic control while minimizing the risk of side effects. Treatment should be reassessed and modified on a regular basis (every 3-6 months) to ensure treatment appropriateness and efficacy.  

Hemoglobin A1c 

A1c should be monitored every 3 months if uncontrolled and every 6 months if controlled. Although target A1c should be individualized per patient, the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologist provide the following recommendations:  

	ADA	ACCE
General Recommendation	< 7	< 6.5
Older Adults	< 7 – 7.5

 

Blood glucose 

Blood glucose should be monitored regularly in patients with diabetes and can be self-monitored in many cases. Glucose targets may be altered based on many factors including duration of diabetes, age/life expectancy, and comorbid conditions. However, general recommendations are outlined below:  

	ADA	ACCE
Fasting/Pre-prandial	80-130 mg/dL	< 110 mg/dL
Peak post prandial	< 180 mg/dL	< 140 mg/dL

 

Health Screenings 

In addition to regular monitoring of A1c and blood glucose, patients with diabetes should receive the following screenings/exams: 

1. Eye exams (at least annually)  

1. Renal function (at least annually)  

1. Blood pressure screenings (at every routine visit)  

1. Foot exams (at least annually)  

1. Dental exams 

 

Lifestyle Education 

Lifestyle modifications can provide great benefit in patients with diabetes. Discussion points may include: 

1. Encourage weight loss in patients who are overweight or obese  

1. Encourage a healthy diet which may include meal planning, counting carbohydrates, and/or the “MyPlate” method  

1. Recommend 150 minutes or more of moderate-to vigorous intensity aerobic activity each week spread over at least 3 days of the week 

1. In patients who smoke, recommend smoking cessation and provide counseling on appropriate options and resources  
2. Strongly encourage participation in a diabetes self-management education and support (DSMES) program if available 
   
   

Additional Points 

Immunization Assessment: 

It is important to review a patient’s immunization history and recommend vaccines that are important in patients with diabetes by the Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (e.g. influenza, pneumonia, Hepatitis B). 

 

Hypoglycemia Education: 

Patients should be instructed how to treat and monitor for signs and symptoms of hypoglycemia, including: dizziness, hunger, sweating, shakiness, confusion, and lightheadedness. Hypoglycemia in patients with diabetes is generally defined as a blood glucose of < 70mg/dL.  

 

Rule of 15 for Treating Hypoglycemia 

 

 

 

Resources: 

1. American Diabetes Association. Standards of Care in Diabetes – 2024. Diabetes Care 2024.  
   https://diabetesjournals.org/care/issue/47/Supplement_1 
2. Blonde L, Umpierrez GE, Reddy SS, et al. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update [published correction appears in Endocr Pract. 2023 Jan;29(1):80-81. doi: 10.1016/j.eprac.2022.12.005]. Endocr Pract. 2022;28(10):923-1049. doi:10.1016/j.eprac.2022.08.002 
   https://pubmed.ncbi.nlm.nih.gov/35963508/ 
3. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive Type 2 Diabetes Management Algorithm – 2020 Executive Summary. Endocr Pract. 2020;26(1): 107 – 139.  
   https://www.endocrinepractice.org/action/showPdf?pii=S1530-891X%2820%2935066-7