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Chapter 61. Diabetes Mellitus

AM is 45-year-old male patient who is newly diagnosed with diabetes with an A1c value of 8.1% which is down from 6 weeks ago. Despite improvements in lifestyle choices, he has met the diagnosis for diabetes. As the clinical pharmacist in charge of the diabetes management clinic, you provide him options of lifestyle, medications, or both. At this time, he would like to start a drug therapy in addition to more stringent lifestyle modifications. Which drug therapy would be the best for AM to trial?

a. Pramlintide subcutaneously 15 µg twice daily

b. Liraglutide subcutaneously 0.6 mg daily for 1 week with an upward titration until glycemic goals have been met (do not exceed more than 1.8 mg daily)

c. Metformin 500 mg daily by mouth with an upward titration to 2000 mg/d (QD or BID) over several days to weeks

d. Acarbose 100 mg three times daily by mouth with each meals

Answer c is correct. Metformin is the drug of choice recommended for most patients with diabetes in addition to lifestyle modifications assuming no contraindications or intolerabilities are present upon evaluation. Metformin has also shown to provide positive weight neutral/loss effects in obese patients. It is crucial to know renal status of patients commencing metformin therapy to limit the risk of lactic acidosis (AM is without contraindication).

Answer a is incorrect. Pramlintide could be used for this patient as its weight loss abilities might help and his A1c is less than 9%, however, the American Diabetes Association (ADA) medical management of hyperglycemia guidelines does not mention this agent as a first-line agent. The dose indicated above is the starting dose for patients diagnosed with type 1 diabetes mellitus (T1DM).

Answer b is incorrect. Liraglutide is a glucagon-like peptide 1 (GLP-1) analog and has data to support an A1c reduction necessary to gain glycemic control and may assist with weight loss goals for this patient; however, AM has a past history of pancreatitis and GLP-1 analogs are not recommended due to this contraindication.

Answer d is incorrect. Although acarbose does have data to indicate its use in prediabetes, this agent is not recommended as first-line therapy by the ADA medical management of hyperglycemia. The starting dose provided above is not recommended due to the intolerability of gastrointestinal side effects. It is important to titrate this product up and educate the patient about appropriate administration with meals.

Which of the following has a labeled indication for use in patients with type 1 diabetes?

a. Insulin glargine

b. Canagliflozin

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