Table 2: Pharmacologic Therapy for Pediatric Patients with Type 2 Diabetes Medication Adverse Effects Impact Metformin
Self-Assessment Quiz Question #5 Billy is initiated on immediate-release metformin to treat his type 2 diabetes. Which of the following is true regarding met- formin therapy? a. Metformin should be continued in patients with diabetic ketoacidosis to control glucose levels. b. Metformin should be started at the highest dose to achieve maximal glycemic control. c. Patients should be evaluated for vitamin B12 deficiency one month into metformin therapy. d. Metformin should be started at a lower dose and incrementally titrated to effect. While metformin monotherapy can be effective in asymptomat- ic patients, patients who are symptomatic or who have marked hyperglycemia may require more intensive therapy (ADA et al., 2022g). Symptoms include polyuria, polydipsia, and weight loss. These symptoms may also be indicative of T1DM, and patients may need to be managed under this diagnosis until more patient data is available. Marked hyperglycemia is defined as a blood glucose level ≥250 mg/dL or an HbA1C ≥8.5%. These patients should receive insulin therapy in addition to metformin. Insulin therapy is usually given via a long-acting formulation once daily to mimic pancreatic basal release. If patients present with ketosis or ketoacidosis as part of their symptoms, both basal insulin and rapid-acting insulin may be required. In the most severe cases, pa- tients may need to be admitted for treatment of DKA and receipt of intravenous insulin therapy. In these patients, metformin should be added once the acidosis resolves. Case study: Julia Julia is a 16-year-old female who was diagnosed with type 2 dia- betes when she was 14 years old. She presents for a routine en- docrinology visit to evaluate her therapy. At the office visit, she shared that she joined a running club at school, which keeps her active most days of the week. She and her family have also been cooking more meals at home and working to make healthy life- style choices. For her diabetes, she is on metformin immediate-re - lease tablets 1,000 mg twice daily and a once-daily long-acting insulin. Despite adherence to lifestyle changes and this regimen, her most recent hemoglobin A1C is 8.2%, and her body mass in - dex is in the overweight range for her age. She does not have any other symptoms or complaints currently, and all other laboratory values are within normal range. Long-acting insulin is available in the form of insulin degludec, in- sulin detemir, and insulin glargine. These insulin formulations are administered subcutaneously and typically last for approximately 24 hours, but the effect can be dose dependent. Long-acting in- sulin formulations do not result in a significant peak and thereby mimic steady insulin release throughout the day. They are dosed in a weight-based fashion starting at 0.5 unit/kg/day and titrated every 2 to 3 days as needed (ADA et al., 2022g). Patients who are unable to achieve glycemic control with long-acting insulin may need additional rapid-acting insulin. In these cases, treat- ment shifts to T1DM-related management, which assumes near or absolute insulin deficiency. Patients may need coverage for hy - perglycemia and meals, utilizing an insulin sensitivity factor and insulin-to-carbohydrate ratio, respectively, to calculate doses. Rapid-acting insulin is available as insulin aspart, insulin glulisine, and insulin lispro. These formulations start taking effect about 15–30 minutes after injection with a peak effect of about 2 hours and a duration of about 5 hours, depending on the formulation.
Gastrointestinal symptoms, lactic acidosis, vitamin B12 deficiency.
Decreases hemoglobin A1C by ~1.1%.
Insulin
Hypoglycemia.
Dose- and formulation- dependent. Decreases hemoglobin A1C by ~1%.
Liraglutide
Gastrointestinal symptoms, hypersensitivity reactions, local injection site reactions. Gastrointestinal symptoms, local injection site reactions.
Exenatide
Extended-release demonstrated to decrease hemoglobin A1C by 0.85%– 1.9%.
Note : Adapted from by Jones, K. L., Arslanian, S., Peterokova, V. A., Park, J. S., & Tomlinson, M. J. (2002). Effect of metformin in pediatric patients with type 2 diabetes: A randomized controlled trial. Diabetes Care, 25( 1), 89-94. https://doi.org/10.2337/diacare.25.1.89; Lexicomp. (2022). Insulin products. https://online.lexi.com
Healthcare Consideration: Initial pharmacologic therapy for treatment of type 2 diabetes in youth is dependent on the pa- tient’s hemoglobin A1C and degree of acidosis at presentation (ADA et al., 2022g). Patients with a hemoglobin A1C <8.5% with no acidosis or ketosis can be managed on metformin alone. Those with more elevated A1C values will need insulin in addi- tion to metformin. If acidosis is present, patients must be evalu- ated for diabetic ketoacidosis and hyperglycemic hyperosmolar state. Management of these conditions should be prioritized, and then metformin and insulin can be initiated once resolved. Insulin can be administered via one of three different delivery met hods: ● Insulin vials for administration via insulin syringes. ● Insulin pens. ● Insulin vials for administration via insulin pump. Selection of an insulin delivery method is largely dependent on the patient’s insulin requirements, insurance coverage, and dex- terity (ADA et al., 2022f). Patients requiring basal insulin as an ad- junct to metformin will likely only need once-daily injections given via a syringe or pen. While insulin pumps can adjust basal rates of insulin throughout the day for variable insulin requirements, this feature is likely not to be of significant benefit in patients who do not also require rapid-acting insulin boluses. If patients elect to utilize insulin vials, insulin is withdrawn from a vial using a needle and syringe for subcutaneous injection (ADA et al., 2022f). Syringes with attached needles are preferred to en- hance dosing accuracy, and a new needle should be utilized with each injection (Frid et al., 2016). Insulin vials should always be inspected prior to use to ensure there are no precipitates. For most accurate results, patients should draw up air into the syringe at a volume equivalent to the intended dose. After insertion of the needle into the vial, the air should be pushed from the syringe into the vial, and then the vial should be inverted. Once inverted, the appropriate volume of insulin can be withdrawn into the syringe. Prior to removal from the vial, the syringe should be inspected
EliteLearning.com/Pharmacy
Book Code: RPTX3024
Page 126
Powered by FlippingBook