Figure 3: Pharmacologic Approaches to Managing Adults with Type 2 Diabetes: Cardiorenal Risk Reduction Diabetes Self-Management Education and Support (DSMES): Goal: Cardiorenal Risk Reduction in High-Risk Patients with Type 2 Diabetes Established/high risk of atherosclerotic cardiovascular disease (ASCVD) • May include transient ischemic attack, Heart failure (HF) • Current or prior symptoms of HF. Chronic kidney disease (CKD) • eGFR <60 mL/min per 1.73 m2 or albuminuria (ACR >30 mg/mmol).
unstable angina, amputation, symptomatic or asymptomatic coronary artery disease
Either/or:
Preferably • SGLT2i with evidence of reducing CKD progression; use SGLT2i in people with an eGFR >20 mL/min per 1.73 m 2 . Or • GLP-1 RA with proven CVD benefit if SGLT2i not tolerated or contraindicated. If A1C continues to be above target: • For patients on a SGLT2i, consider adding GLP-1 RA or vice versa.
• SGLT2i with proven HF benefit.
• GLP-1 RA with proven CVD benefit. • SGLT2i with proven CVD benefit. If A1C continues to be above target: • For patients on a GLP-1 RA, consider adding SGLT2i with proven CVD or vice versa.
Adapted from ElSayed et al., 2023a
Table 7: Dipeptidyl Peptidase-4 (DPP-4) Inhibitors DPP-4 Inhibitor Generic Name (Trade Name) Available Strengths
Starting Dose How to Titrate Dose
Dosage Range
Alogliptin (Nesina)
• 6.25 mg
• 6.25 mg/daily.
• Start at 6.25 mg/ daily.
• Dose adjustment needed for patients with moderate to several renal impairment. • 12.5 mg/daily if eGFR >30 to <60 mL/ min/1.73 2 . • 6.25 mg/daily if eGFR <30 mL/min/1.73 2 or ESRD. • No dose adjustment for moderate to several renal impairment; hepatobiliary elimination. • Dose adjustment needed for patients with moderate to severe renal impairment. • 2.5 mg/daily if eGFR <45 mL/min/1.73 2 or ESRD. • Dose adjustment needed for patients with moderate to severe renal impairment. • 50 mg/daily if eGFR >30 to <45 mL/ min/1.73 2 . • 25 mg/daily if eGFR <30 mL/min/1.73 2 or ESRD.
Linagliption (Tradjenta) Saxagliptin (Onglyza)
• 5 mg
• 5 mg/daily.
• 5 mg/daily.
• 2.5 mg • 5.0 mg
• 2.5 to 5 mg/ daily.
• 2.5 to 5 mg/ daily.
Sitagliptin (Januvia)
• 25 mg • 50 mg
• 25 mg.
• 25 to 50 mg/ daily.
GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS (GLP-1 RAS)
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a class of injectable glucose-lowering agents that lower A1C with added benefits of weight loss and improved effects on cardiovascular risk factors (Trujillo, 2022). Several GLP-1 RAs are currently available in the U.S., including exenatide (Byetta), exenatide extended release (Bydureon), liraglutide (Victoza), lixisenatide (Adlyxin), dulaglutide (Trulicity), and semaglutide (Ozempic). The first noninsulin agent of a GLP-1 RA, oral semaglutide (Rybelsus), was approved in 2019. Mechanism of action Glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) are incretin hormones secreted by the GI tract in response to the ingestion of food. Because incretin hormones
Differences exist in the characteristics of individual GLP-1 RAs based on half-life and duration of action. The half-life of a drug is the time it takes for the drug’s active substance in the body to reduce by half. Short-acting GLP-1 RAs include exenatide (Byetta), lixisenatide (Adlyxin), and liraglutide (Victoza), all of which are taken one to two times daily. Long-acting GLP-1 RAs include exenatide extended release (Bydureon), dulaglutide (Trulicity), and semaglutide (Ozempic), all of which are taken once weekly (Trujillo, 2022).
are peptides that rapidly inactivate if administered orally, GLP-1 RAs are primarily administered as injectables (subcutaneously). During a meal, GLP-1 and GIP rise rapidly and return to baseline
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Book Code: RPTTX2024
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