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Hyperglycemia treatment options

Hyperglycemia treatment options

UK Prospective Diabetes Study UKPDS Group. Hyperglycemia treatment options also Treatent gastric emptying, Resisting the effects of aging glucagon levels, and ooptions food intake Nutrition therapy is treatmeny to diabetes Hyperglycemia treatment options, with goals Hyperglycejia promoting and supporting healthy eating patterns, addressing individual nutrition needs, maintaining the pleasure of eating, and providing the person with diabetes with the tools for developing healthy eating Peter Rossing. This is discussed in the section Personalized Approach to Treatment Based on Individual Characteristics and Comorbidities: Recommended Process for Glucose-Lowering Medication Selection. Courcoulas AP, Belle SH, Neiberg RH, et al. Hyperglycemia treatment options

Hyperglycemia treatment options -

Peters , Apostolos Tsapas , Richard Wender , David R. Matthews; Management of Hyperglycemia in Type 2 Diabetes, A Patient-Centered Approach: Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes.

Diabetes Care 1 January ; 38 1 : — In , the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD published a position statement on the management of hyperglycemia in patients with type 2 diabetes 1 , 2.

This was needed because of an increasing array of antihyperglycemic drugs and growing uncertainty regarding their proper selection and sequence. Because of a paucity of comparative effectiveness research on long-term treatment outcomes with many of these medications, the publication was less prescriptive than prior consensus reports.

We previously described the need to individualize both treatment targets and treatment strategies, with an emphasis on patient-centered care and shared decision making, and this continues to be our position, although there are now more head-to-head trials that show slight variance between agents with regard to glucose-lowering effects.

Nevertheless, these differences are often small and would be unlikely to reflect any definite differential effect in an individual patient. The ADA and EASD have requested an update to the position statement incorporating new data from recent clinical trials.

Between June and September of , the Writing Group reconvened, including one face-to-face meeting, to discuss the changes. An entirely new statement was felt to be unnecessary.

Instead, the group focused on those areas where revisions were suggested by a changing evidence base. This briefer article should therefore be read as an addendum to the previous full account 1,2. Glucose control remains a major focus in the management of patients with type 2 diabetes. However, this should always be in the context of a comprehensive cardiovascular risk factor reduction program, to include smoking cessation and the adoption of other healthy lifestyle habits, blood pressure control, lipid management with priority to statin medications, and, in some circumstances, antiplatelet therapy.

Studies have conclusively determined that reducing hyperglycemia decreases the onset and progression of microvascular complications 3 , 4. The impact of glucose control on cardiovascular complications remains uncertain; a more modest benefit is likely to be present, but probably emerges only after many years of improved control 5.

Results from large trials have also suggested that overly aggressive control in older patients with more advanced disease may not have significant benefits and may indeed present some risk 6. Figure 1 displays those patient and disease factors that may influence the target for glucose control, as reflected by HbA 1c.

The main update to this figure is the separation of those factors that are potentially modifiable from those that are usually not. Other features, such as age, life expectancy, comorbidities, and the risks and consequences to the patient from an adverse drug event, are more or less fixed.

Modulation of the intensiveness of glucose lowering in type 2 diabetes. Depiction of patient and disease factors that may be used by the practitioner to determine optimal HbA 1c targets in patients with type 2 diabetes.

Greater concerns regarding a particular domain are represented by increasing height of the corresponding ramp. Where possible, such decisions should be made with the patient, reflecting his or her preferences, needs, and values.

Based on an original figure by Ismail-Beigi et al. The major change in treatment options since the publication of the position statement has been the availability of a new class of glucose-lowering drugs, the sodium—glucose cotransporter 2 SGLT2 inhibitors 7.

These agents reduce HbA 1c by 0. When compared with most standard oral agents in head-to-head trials, they appear to be roughly similarly efficacious with regard to initial HbA 1c lowering 9 — Because this action is independent of insulin, SGLT2 inhibitors may be used at any stage of type 2 diabetes, even after insulin secretion has waned significantly.

Their use is also associated with reductions in plasma uric acid levels and albuminuria 16 , although the clinical impact of these changes over time is unknown. Properties of available glucose-lowering agents in the U. and Europe that may guide individualized treatment choices in patients with type 2 diabetes.

CVD, cardiovascular disease; GIP, glucose-dependent insulinotropic peptide; HDL-C, HDL cholesterol; LDL-C, LDL cholesterol; MI, myocardial infarction; PPAR-γ, peroxisome proliferator—activated receptor γ; PROactive, Prospective Pioglitazone Clinical Trial in Macrovascular Events 26 ; STOP-NIDDM, Study to Prevent Non-Insulin-Dependent Diabetes Mellitus 60 ; T2DM, type 2 diabetes mellitus; UKPDS, UK Prospective Diabetes Study 4 , Cycloset trial of quick-release bromocriptine Cost is based on lowest-priced member of the class see Supplementary Data.

They also possess a diuretic effect, and so symptoms related to volume depletion may occur 7 , Consequently, these agents should be used cautiously in the elderly, in any patient already on a diuretic, and in anyone with a tenuous intravascular volume status.

Reversible small increases in serum creatinine occur 14 , Increased urine calcium excretion has been observed 20 , and the U. Food and Drug Administration FDA mandated a follow-up of upper limb fractures of patients on canagliflozin after an adverse imbalance in cases was reported in short-term trials Data on microvascular outcomes with SGLT2 inhibitors are lacking as with most agents other than sulfonylureas and insulin.

Effects on macrovascular disease are also unknown; cardiovascular safety trials are currently in progress Earlier concerns that the thiazolidinediones TZDs —in particular pioglitazone—are associated with bladder cancer have largely been allayed by subsequent evidence 23 — These agents tend to cause weight gain and peripheral edema and have been shown to increase the incidence of heart failure They also increase the risk of bone fractures, predominately in women Pioglitazone is now available as a generic drug, substantially decreasing its cost.

One large trial involving the dipeptidyl peptidase 4 DPP-4 inhibitor saxagliptin found no overall cardiovascular risk or benefit although the follow-up was only slightly more than 2 years compared with placebo However, more heart failure hospitalizations occurred in the active therapy group 3.

Alogliptin, another DPP-4 inhibitor, also did not have any demonstrable cardiovascular excess risk over an even shorter period 18 months in high-risk patients A wider database interrogation indicated no signal for cardiovascular disease or heart failure 30 , Several other trials are underway, and until the results of these are reported, this class should probably be used cautiously, if at all, in patients with preexisting heart failure.

One area of concern with this class, as well as the other incretin-based category, the glucagon-like peptide 1 GLP-1 receptor agonists, has been pancreatic safety—both regarding possible pancreatitis and pancreatic neoplasia.

The prescribing guidelines for these drugs include cautions about using them in individuals with a prior history of pancreatitis. While this is reasonable, emerging data from large observational data sets 32 , as well as from two large cardiovascular trials with DPP-4 inhibitors 28 — 30 , have found no statistically increased rates of pancreatic disease.

Generally speaking, the use of any drug in patients with type 2 diabetes must balance the glucose-lowering efficacy, side-effect profiles, anticipation of additional benefits, cost, and other practical aspects of care, such as dosing schedule and requirements for glucose monitoring.

The patient—who is obviously the individual most affected by drug choice—should participate in a shared decision-making process regarding both the intensiveness of blood glucose control and which medications are to be selected.

Metformin remains the optimal drug for monotherapy. Its low cost, proven safety record, weight neutrality, and possible benefits on cardiovascular outcomes have secured its place as the favored initial drug choice. There is increasing evidence that the current cut-off points for renal safety in the U.

Accordingly, there are calls to relax prescribing polices to extend the use of this important medication to those with mild—moderate, but stable, chronic kidney disease CKD 34 — Of course, any use in patients with CKD mandates diligent follow-up of renal function. Antihyperglycemic therapy in type 2 diabetes: general recommendations.

Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, the usual transition being vertical, from top to bottom although horizontal movement within therapy stages is also possible, depending on the circumstances.

In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis, unless there are contraindications. The order in the chart, not meant to denote any specific preference, was determined by the historical availability of the class and route of administration, with injectables to the right and insulin to the far right.

Drug choice is based on patient preferences as well as various patient, disease, and drug characteristics, with the goal being to reduce glucose concentrations while minimizing side effects, especially hypoglycemia.

The figure emphasizes drugs in common use in the U. Rapid-acting secretagogues meglitinides may be used in place of sulfonylureas in patients with irregular meal schedules or who develop late postprandial hypoglycemia on a sulfonylurea.

In this circumstance, while published trials are generally lacking, it is reasonable to consider three-drug combinations that do not include metformin. Insulin has the advantage of being effective where other agents may not be and should be considered a part of any combination regimen when hyperglycemia is severe, especially if the patient is symptomatic or if any catabolic features weight loss, any ketosis are evident.

DPPi, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLPRA, GLP-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, SGLT2 inhibitor; SU, sulfonylurea.

In circumstances where metformin is contraindicated or not tolerated, one of the second-line agents see below may be used, although the choices become more limited if renal insufficiency is the reason metformin is being avoided.

In these circumstances it is unwise to use sulfonylureas, particularly glyburide known as glibenclamide in Europe , because of the risk of hypoglycemia. DPP-4 inhibitors are probably a preferable choice, although, with the exception of linagliptin 39 , dosage adjustments are required.

Given their demonstrated efficacy and clinical experience to date, they are reasonable options as second-line or third-line agents 40 — 42 Fig. Similar to most combinations, efficacy may be less than additive when SGLT2 inhibitors are used in combination with DPP-4 inhibitors There are no data available on the use of SGLT2 inhibitors in conjunction with GLP-1 receptor agonists; an evidence-based recommendation for this combination cannot be made at this time.

As noted in the original position statement, initial combination therapy with metformin plus a second agent may allow patients to achieve HbA 1c targets more quickly than sequential therapy.

Accordingly, such an approach may be considered in those individuals with baseline HbA 1c levels well above target, who are unlikely to successfully attain their goal using monotherapy. Of course, there is no proven overall advantage to achieving a glycemic target more quickly by a matter of weeks or even months.

Accordingly, as long as close patient follow-up can be ensured, prompt sequential therapy is a reasonable alternative, even in those with baseline HbA 1c levels in this range. In certain patients, glucose control remains poor despite the use of three antihyperglycemic drugs in combination.

With long-standing diabetes, a significant diminution in pancreatic insulin secretory capacity dominates the clinical picture. In any patient not achieving an agreed HbA 1c target despite intensive therapy, basal insulin should be considered an essential component of the treatment strategy.

After basal insulin usually in combination with metformin and sometimes an additional agent , the position statement endorsed the addition of one to three injections of a rapid-acting insulin analog dosed before meals.

Over the past 3 years, however, the effectiveness of combining GLP-1 receptor agonists both shorter-acting and newer weekly formulations with basal insulin has been demonstrated, with most studies showing equal or slightly superior efficacy to the addition of prandial insulin, and with weight loss and less hypoglycemia 45 — The available data now suggest that either a GLP-1 receptor agonist or prandial insulin could be used in this setting, with the former arguably safer, at least for short-term outcomes 45 , 48 , Accordingly, in those patients on basal insulin with one or more oral agents whose diabetes remains uncontrolled, the addition of a GLP-1 receptor agonist or mealtime insulin could be viewed as a logical progression of the treatment regimen, the former perhaps a more attractive option in more obese individuals or in those who may not have the capacity to handle the complexities of a multidose insulin regimen.

Indeed, there is increasing evidence for and interest in this approach Approach to starting and adjusting insulin in type 2 diabetes. This figure focuses mainly on sequential insulin strategies, describing the number of injections and the relative complexity and flexibility of each stage.

Basal insulin alone is the most convenient initial regimen, beginning at 10 U or 0. It is usually prescribed in conjunction with metformin and possibly one additional noninsulin agent.

In the event of a severe hypoglycemic episode, a car accident, or other emergency, the medical ID can provide critical information about the person's health status, such as the fact that they have diabetes, whether or not they use insulin, whether they have any allergies, etc.

Emergency medical personnel are trained to look for a medical ID when they are caring for someone who can't speak for themselves. Medical IDs are usually worn as a bracelet or a necklace.

Traditional IDs are etched with basic, key health information about the person, and some IDs now include compact USB drives that can carry a person's full medical record for use in an emergency.

Your best bet is to practice good diabetes management and learn to detect hyperglycemia so you can treat it early—before it gets worse. Breadcrumb Home Life with Diabetes Get the Right Care for You Hyperglycemia High Blood Glucose. What causes hyperglycemia? A number of things can cause hyperglycemia: If you have type 1, you may not have given yourself enough insulin.

If you have type 2, your body may have enough insulin, but it is not as effective as it should be. You ate more than planned or exercised less than planned.

You have stress from an illness, such as a cold or flu. You have other stress, such as family conflicts or school or dating problems. You may have experienced the dawn phenomenon a surge of hormones that the body produces daily around a. to a. This can include:. Sometimes, other treatments might be needed.

This will depend on what caused your blood sugar to rise and on your overall health. You might also receive care for concerns such as wounds or leg swelling.

The right time to seek medical attention for high blood sugar can depend on if you have additional symptoms. Blood sugar above are very dangerous and can lead to coma.

Insulin is one of the primary treatments you will receive in the hospital. You can receive emergency insulin doses to help bring down your high blood sugar. However, you might also be able to manage your own injections or continue using your own insulin pump.

You can discuss this with your doctor and the nurses providing your care. This includes:. Some hospitals use continuous glucose monitors CGMs as part of blood sugar management. The Food and Drug Administration FDA has approved CGM for some types of hospital use. However, not all hospitals have these monitors, and many hospitals still rely on regular finger-pick glucose testing.

Very high blood sugar levels can require treatment at the hospital. Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. Hyperglycemia is high blood sugar and hypoglycemia is low blood sugar.

These are commonly associated with diabetes. You can get seizures because of high blood sugar. Diabetes or other health conditions may be the cause. A doctor can use insulin to lower your glucose…. You may treat blood sugar rises after meals with diabetes medications or possibly lifestyle changes.

Your doctor can help you figure out what may work….

Melanie J. Gluten-free dairy-freeVanita R. HjperglycemiaBilly S. CollinsRobert A. GabbayJennifer GreenNisa M. Kptions is the technical term Hyperlgycemia high blood Optipns blood Enhanced Mental Clarity. High blood glucose happens Hyperglycemia treatment options the body has too little insulin or Hperglycemia the body can't use insulin properly. Part of managing your diabetes is checking your blood glucose often. Ask your doctor how often you should check and what your glucose sugar levels should be. Checking your blood and then treating high blood glucose early will help you avoid problems associated with hyperglycemia. You can often lower your blood glucose level by exercising.

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