agents should be avoided in patients who have liver cirrhosis. In addition, patients taking alpha-glucosidase inhibitors do Dosing of alpha-glucosidase inhibitors The recommended dose for alpha-glucosidase inhibitors is shown in Table 5. Both acarbose (Precose) and miglitol (Glyset) should be given with meals. To avoid GI side effects, start with low doses and titrate up as necessary. After starting patients on an alpha-glucosidase inhibitor, check postprandial blood glucose levels to determine if there has been a response to administering the medication. Dosing and administration of alpha-glucosidase inhibitors are individualized for each patient
not experience hypoglycemia unless they are administered in conjunction with sulfonylureas or insulin.
based on their effectiveness and tolerance to ensure maximal efficacy (McKeirnan & Rodin, 2022). According to 2023 guidelines for managing hyperglycemia in type 2 diabetes, alpha-glucosidase inhibitors effectively reduce postprandial glycemia and may be appropriate for use in certain cultures where high-carbohydrate meals are consumed. However, there is limited evidence on the impact of this class of drugs on glycemic targets (Davies et al., 2022; ElSayed et al., 2023a).
Table 5: Noninsulin Antihyperglycemic Agents: Alpha-Glucosidase Inhibitors Alpha-Glucosidase Inhibitor
Available Strengths
Starting Dose
How to Titrate Dose
Dosage Range
Generic Name (Trade Name)
Acarbose (Precose)
• 25 mg • 50 mg • 100 mg
• 25 mg/3 times daily.
• Begin with 25 mg/3 times daily and gradually increase to 100 mg/3 times daily. • Individualize dosage based on effectiveness and tolerance.
• 50–100 mg/3 times daily: ○ (if patient’s body weight <60 kg, should not exceed 50 mg/3 times daily). ○ (if patient’s body weight >60 kg, should not exceed 100 mg/3 times daily). • 50–100 mg/3 times daily (maximum dose: 100 mg/daily).
Miglitol (Glyset)
• 25 mg • 50 mg • 100 mg
• 25 mg/3 times daily.
• Begin with 25 mg/3 times daily and gradually increase to 100 mg/3 times daily. • Individualize dosage based on effectiveness and tolerance.
● If hypoglycemia occurs while taking an alpha-glucosidase inhibitor, you must use dextrose (4 tabs), honey (1 Tbsp), or milk (1 cup) to correct the low blood sugar. Other sugars typically used to treat hypoglycemia—such as table sugar, juice, regular soda, or sugar candy—will not work.
Key points for patients taking an alpha-glucosidase inhibitors: ● Alpha-glucosidase inhibitors often cause gas (flatulence), diarrhea, and abdominal pain; start with a low dose to minimize these side effects. ● Alpha-glucosidase inhibitors should be taken three times per day with the first bite of each meal.
SODIUM–GLUCOSE COTRANSPORTER INHIBITORS (SGLT2I)
The FDA approved several sodium–glucose cotransporter 2 inhibitors (SGLT2i) in 2013 and 2014. SGLT2i work in the proximal renal tubules of the kidney and function by suppressing glucose reabsorption and increasing urinary glucose excretion. The current ADA/EASD consensus report recommends SGLT2 inhibitors for patients with T2DM where metformin is not
appropriate or tolerated or as an option for add-on therapy in patients who do not achieve their glycemic targets after three months of monotherapy. In addition, use of SGLT2i is indicated if patients have ASCVD, heart failure, and CKD (Davies et al., 2022; White, 2022).
Evidence-Based Practice Being diagnosed with type 2 diabetes is linked with an increased risk of cardiovascular and renal disease, with favorable effects on glycemia, blood pressure, weight, intrarenal hemodynamics, and albuminuria achieved when using sodium- glucose transporter 2 inhibitor noninsulin agents. The CANVAS program was a randomized control trial (RCT) where patients with type 2 diabetes over the age of 30 with a history of symptomatic ASCVD and at least two risk factors for cardiovascular disease were randomly assigned to receive canagliflozin (Invokana) or a placebo and followed for approximately three years. Study findings indicated that those patients treated with canagliflozin (Invokana) had significantly lower rates of primary cardiac outcomes (e.g., death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke) compared to patients assigned to the placebo group. Effects of SGLT2i on two integrated trials were similar (Neal et al., 2017).
Mechanism of action The kidneys regulate glucose homeostasis by glomerular filtration, reabsorption, and urine glucose excretion (UGE). The reabsorption of glucose from urine begins with the transport of glucose from the tubule into the tubular epithelial cells through SGLTi. SGLT2i is a high-capacity transporter found primarily in the kidney and accounts for approximately 90% of glucose reabsorption (White, 2022). The kidneys filter about 160 to 180 g of glucose daily with fasting blood glucose concentrations
in the general range of 90 to 100 mg/dL. When blood glucose concentrations exceed the maximum capacity of the kidneys to reabsorb glucose (transport maximum), as seen in patients with T2DM, glucose appears in the urine (glucosuria). The target maximum is reached when blood glucose concentrations reach approximately 200 mg/dL. In patients with T2DM, the transport maximum for glucose reabsorption is increased; therefore, glucosuria does not occur until plasma glucose concentrations
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