Selecting a Treatment Regimen
Table 10. Diabetes Drug Properties Agent
Durability
Biguanides Metformin appears intermediate in durability between SUs and TZDs.
DPP-4 Inhibitors
Mechanism
Improve insulin sensitivity; suppress nocturnal hepatic glucose production.
Endogenous incretins (GIP, GLP) rise following meals blunting PPG excursions via multiple mechanisms. DPP-4 inhibitors greatly retard the enzymatic degradation of incretins.
Incretin Mimetics (GLP-1 receptor agonists)
Insulin Secretagogues (SU or shorter-acting glinides)
With SUs, glucose lowering is maximal at 6 months; glucose levels return towards baseline at about 3 years.
Mimic effects of GLP and GIP following meals, blunting PPG excursions via multiple mechanisms.
Stimulate secretion of insulin.
Advantages
Generally weight neutral or modest weight loss.
Improve the inappropriate hyperglucagonemia of DM.
DPP-4 inhibitors do not cause weight gain; they can be administered in patients with renal insufficiency with appropriate dosing adjustment.
Patients have weight loss, usually modest, sometimes significant. More potent than DPP-4 inhibitors. Improve the inappropriate hyperglucagonemia of DM. Approved for initial monotherapy as well as combination with all oral agents.
Glimepiride 1 mg dose approved for use in renal failure. Glinides can be useful for postprandial hyperglycemia or hypoglycemia. Repaglinide is safe with liver/ renal disease.
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