Drug classes differ by their mechanism of action, A1c lowering capacity, side effects, risk of hypoglycemia, effect on weight and vascular protection. Click the class headings below to review these and specific brand considerations. To view brand indications, doses and cost visit the Complete Diabetes Medication Table.
Prior to adjusting or adding more medications to address hyperglycemia, consider these questions.
- How much does A1c need to change to reach individualized target? Or does it, e.g. frail with A1c 8.0%?
- Will some drugs be more effective than others in getting A1c into target?
- Safety - Will new medication or dose impact:
- Risk of hypoglycemia (commercial driver, frail elderly etc),
- Ability to adhere to the complexity of the new regime
- Comborbidities (e.g. chronic kidney disease)
- Risk of DKA - ability and willingness to test for ketones if increasing SGLT-2
- Will increased adherence impact glycemic control?
- Can a simplified regimen with combination medications or once daily versions of medications improve adherence? If yes, are they affordable?
- Can lifestyle changes help to improve glycemia (e.g. what is duration of diabetes)? If adequate beta cell function remains in type 2 diabetes, lifestyle changes could potentially reduce A1c by 0.5-2.0% depending on the type and extent of the change. Consider offering the Worksheet: Managing Blood Sugars.
- Current medication dose change:
- Will adusting current medication likely bring them to target or is another agent also needed? E.g. if A1c 10%, client on max metformin with near maximum gliclazide, consider an increase to the latter with a simultaneous request for another agent to be added. Maximum daily doses are outlined in our Complete Diabetes Medications Table.
- Will adusting current medication address the blood glucose pattern
- Are there factors that would suggest a more aggressive dose adjustment (prednisone, minimal effects of last adjustment, obesity)?
- Are there factors that would suggest a more conservative dose adjustment? (frail, low eGFR, inability to self-treat hypoglycemia, lean patient, anticipated rapid weight loss with bariatric surgery, planned significant dietary changes, planned increased exercise, history of severe hypoglycemia, fear of hypoglycemia, etc)?
- What do you anticipate will happen to the glucose pattern after the medication adjustment? Are there safety concerns to address now or when readings drop to a certain level? Eg. Readings are in target except high at bed. An increase to supper repaglinide may require a reduction in overnight basal insulin.
The use of two medications from the same class is generally not indicated E.g. two secretagogues or 2 incretin-based medications (DPP-4 and GLP-1). To learn Health Canada indications and doses, visit the Drug Product Database or our Complete Diabetes Medications Table.
A. Consider the Diabetes Canada's tool "Pharmacotherapy for Type 2 Diabetes" to help decide next line agents. Sort by the most relevant features for your client:
- Relative A1c Lowering
- Renal benefits
- Heart failure benefits
- Cardiovascular benefits
- Other therapeutic considerations (safety of drug with comorbidities)
- Pregnant or planning pregnancy
- Additional considerations: Patient preference and adherence (consider once-daily/once weekly dosing if adherence is a concern)
B. Consider Renal Impairment:
Patients should review potential drug interactions or side effects with pharmacists when starting any medication. Educators can review interactions in product monographs via Canada's Drug Product Database. A few interactions that impact glycemia are listed below.
Hypoglycemia risk increases with:
- Beta blockers – may decrease symptoms of lows
- Salicylates/NSAIDs – if 4-6 g/day or greater
- Antibiotics: Fluoroquinolones (e.g. ciprofloxacin) can stimulate beta cells to secrete insulin. Hypoglycemia has been reported in patients without diabetes and in patients with diabetes on any antihyperglcyemic agent, especially those on insulin or secretagogues.
Hyperglycemia risk increases with:
- Glucocorticoids- including those injected for joints
- Thiazide diuretics – at doses > 25 mg/day