| Agent | Class | Primary Action | Typical Dosage | Side Effects | Precautions | Critical Tests | Comments |
|---|---|---|---|---|---|---|---|
| Tolbutamide (Ornase TM) Tolazamide (Tolinase TM) Chlorpropamide (Diabenese TM) |
Sulfonylureas (1st generation) | Increases insulin production in pancreas | Tolbutamide: 0.25–2.0 g/day in divided doses; maximum, 3 g/day Tolazamide: 100–1,000 mg/day in divided doses; maximum, 1 g/day Chlorpropamide: 100–500 mg/day twice a day; maximum, 750 mg/day | Hypoglycemia, weight gain, hyperinsulinemia Disulfiram reaction with alcohol | Chlorpropamide remains active for up to 60 hours. Use extreme caution with elderly patients or patients with hepatic or renal impairment. | Metabolized in liver. Periodic evaluation of liver function tests. | Use of these agents is not recommended unless the patient has a well-established history of taking them. Second-generation sulfonylureas provide more predictable results with fewer side effects and more convenient dosing. |
| Glyburide (Micronase TM, Diabeta TM, Glynase TM) glipizide (Glucotrol, Glucotrol XL TM), glimepiride (Amaryl TM) | Sulfonylureas (2nd generation) | Increases insulin production in pancreas | Glyburide: 1.25–2.50 mg/day twice a day; maximum 29 mg/day Glynase: 0.75–12.0 mg/day; maximum 20 mg/day Glipizide: 2.5–20.0 mg/day twice a day; Maximum, 40 mg/day; or XL* 2.5–10.0 mg/day twice a day; maximum, 20 mg/day Glimepiride: 1–8 mg/day; maximum, 8 mg/day | Hypoglycemia, weight gain, hyperinsulinemia | Clearance may be diminished in patients with hepatic or renal impairment. | Metabolized in liver.Periodic evaluation of liver function tests. | Glipizide is preferred with renal impairment. Doses >15 mg should be split. |
| Repaglinide (Prandin TM) | Meglitinide | Increases insulin release from pancreas | New diagnosis or HbAlc <8% 0.5 mg before meals 2–4 times a day HbA1c >8: 1–2 mg, 15–30 min after each meal; increase weekly until results are obtained; maximum, 16 mg/day | Hypoglycemia, weight gain, hyperinsulinemia | Should not be used in patients with diabetic ketoacidosis and known hypersensitivity to drug or its inactive ingredients. | Metabolized in liver.Periodic evaluation of liver function tests. | Patients should be instructed to take medication ≤30 min before a meal. If meals are skipped or added, medication should be skipped or added as well. |
| Nateglinide (Starlix TM) | Phenylalanine derivative | Increases insulin release from pancreas | 120, or 60 mg 3 times a day before meals | Hypoglycemia, weight gain, hyperinsulinemia | Should not be used in patients with diabetic ketoacidosis and known hypersensitivity to drug or its inactive ingredients. | Metabolized in liver.Periodic evaluation of liver function tests. | Patients should be instructed to take medication ≤30 min before a meal. If meals are skipped or added, medication should be skipped or added as well. Nateglinide is approved only as monotherapy or in combination with Metformin. |
| Metformin (Glucophage TM) | Biguanide | Increases insulin sensitivity | 500 mg/day twice a day with meals increase by 500 mg every 1–3 wk, twice or three times a day; usually most effective at 2,000 mg/day; maximum, 2,550 mg/day | Nausea, diarrhea, metallic taste, very rare lactic acidosis | Should not be used in patients who use alcohol frequently, liver, kidney disease or CHF because of risk of lactic acidosis. | Contraindicated if serum creatinine is: >1.5 mg/dL in men or >1.4 mg/dL women, or use if creatinine clearance is abnormal. Monitor hematological and renal function annually. | Metformin is especially beneficial in obese patients due to potential for weight loss, improved lipid profile, and lack of potential for hypoglycemia requiring supplemental carbohydrate intake. Discontinue for 48 hr after procedure using contrast dye. |
| Rosiglitazone (Avandia TM) | Thiazolidinedione | Increases insulin sensitivity | 4 mg/day in single or divided doses Increase to 8 mg/day in 12 wk, if needed; maximum, 8 mg/day with or without food | Weight gain, fluid retention, edema | Should not be used in patients with CHF or hepatic disease. Can cause mild-to-moderate edema. | Avoid initiation with patients with increased baseline liver enzyme levels (ALT >2.5 times upper limit of normal). Liver enzymes monitored every 2 months for 12 months, then periodically. If ALT levels increase to >3 times the upper limit of normal, discontinue use and recheck liver enzyme levels. | Rosiglitazone is approved for use as monotherapy and in combination with metformin or sulfonylureas. |
| Pioglitazone (Actos TM) | Thiazolidinedione | Increases insulin sensitivity | 15 or 30 mg/day; Maximum with or without food 45 mg for monotherapy 30 mg for combination therapy | Weight gain, fluid retention, edema | Clearance may be diminished in patients with hepatic or renal impairment. | Avoid initiation with patients who have liver disease or ALT levels >2.5 times the upper limit of normal. Patients with mildly elevated liver enzymes (ALT levels 1–2.5 times the upper limit of normal) should be evaluated. Discontinue if >3 times the upper limit of normal. | Pioglitazone is approved for use as monotherapy or with metformin, sulfonylureas, or insulin. |
| Acarbose (Precose TM) Miglitol (Glyset TM) | Alpha-glucosidase inhibitor | Blocks gut absorption of complex sugars | 25 mg/day; increase by 25 mg/day every 4–6 wk; maximum, split dose before meals with first bite of food 300 mg/day (150 mg/day for weight <60 kg) | Gas and bloating, sometimes diarrhea for both drugs | Should not be used if GI disorders are concurrent. | Avoid if serum creatinine is >2.0 mg/dL. Monitor serum transaminase every 3 months for 1st year of therapy. | |
| Combinations | |||||||
| Glucovance TM | glyburide and metformin | Decreases hepatic glucose production and increases insulin secretion. | Initial, 1.25 mg/250 mg once or twice a day with meals; increase every 2 wk by 1.25 mg/250 mg per day; 2nd line, 2.5mg/500 mg or 5 mg glyburide/ 500 mg twice a day with meals; maximum, 20 mg/2000 mg per day | Possible hypoglycemia, nausea, diarrhea, abdominal pain for this combination drug | Should not be used if frequent alcohol use, liver or kidney disease, or CHF is suspected. | Contraindicated if serum creatinine is >1.5 mg/dL in men or 1.4 mg/dL in women, or if creatinine clearance is abnormal. Monitor hematological and renal function annually. | May use 1.25mg/250mg and 2.5mg/500mg doses at different times of day for best glucose control. Incidence of hypoglycemia is higher for combination than for single agent use. |
| Metaglip TM | glipizide and metformin | Decreases hepatic glucose production and increases insulin secretion | Initial, 2.5 mg/250 mg once or twice a day with meals. Increase every 2 wk to maximum of 10 mg/1000 mg or 10 mg/2000 mg per day. 2nd line, 2.5 mg/500 mg or 5 mg/500 mg twice a day with meals. Maximum, 20 mg/2000 mg per day | Diarrhea, nausea/ vomiting, headache for this combination drug | Should not be used if frequent alcohol use, liver or kidney disease, or CHF is suspected. | Contraindicated if serum creatinine is >1.5 mg/dL in men, or >1.4 mg/dL in women, or if creatinine clearance <60–75 mL/min. Monitor hematologic and renal function annuallys. | May use 1.25mg/250mg and 2.5mg/500mg doses at different times of day for best glucose control. Incidence of hypoglycemia is higher for combination than for single agent use. |
| Avandamet TM | rosiglitazone and metformin | Decreases hepatic glucose production, increases glucose uptake, and decreases insulin resistance | 1 mg/500 mg, 2 mg/500 mg or 4 mg/500 mg twice a day; dosage individualized based on current therapy. Maximum, 8 mg/2000mg per day | Diarrhea, edema, anemia for this combination drug | Should be avoided in patients with hepatic disease, CHF, renal disease. | Contraindicated if serum creatinine is >1.5 mg/dL in men or >1.4 mg/dL in women, or if creatinin clearance is abnormal. | Agent is less expensive than its components separately. Decrease in GI upset is reported with metformin compared with rosiglitazone alone. |
| Insulin | Onset | Peak | Effective Duration | Maximal Duration | Comments |
|---|---|---|---|---|---|
| Human | |||||
| Lispro (humalog) | <15 min | 1–2 hr | 2–4 hr | 3–5 hr | Must be taken just before or immediately after eating. |
| Aspart (novalog) | <15 min | 1–3 hr | 3–5 hr | 4–6 hr | |
| Regular | 0.5–1 hr | 2–4 hr | 3–5 hr | 4–8 hr | Best if administered 30 min before meal. |
| NPH | 2–4 hr | 4–10 hr | 10–16 hr | 14–18 hr | |
| Lente | 3–4 hr | 4–12 hr | 12–18 hr | 16–20 hr | Frequently used instead of NPH in children. |
| Ultralente | 6–10 hr | Minimal | 18–20 hr | 20–30 hr | |
| 70/30 | 0.5–1 hr | 2–10 hr | 10–16 hr | 14–18 hr | |
| Humalog mix 75/25 | <15 min | 1–2 hr | 10–16 hr | 14–18 hr | Must be taken before or immediately after eating. |
| Insulin glargine (Lantus TM) | 4–6 hr | None | 24 hr | 24 hr | Administered at bedtime once a day. Cannot be mixed in same syringe and should not be given with use of same needle in same place as previous injection. |
| Animal Source | |||||
| Regular | 0.5–2 hr | 3–4 hr | 4–6 hr | 6–8 hr | Change over to human insulin recommended. Dose changes required; consult physician. |
| NPH | 4–6 hr | 8–14 hr | 16–20 hr | 20–24 hr | |
| Lente | 4–6 hr | 8–14 hr | 16–20 hr | 20–24 hr | |
| Recommended Insulin Storage | Refrigerated (36°F–46°F) | Room Temperature (59°F–86°F) | ||
| VIAL | Opened | Unopened | Opened | Unopened |
| Humalog, novolog, humulin, novolin | 28 days | until expiration date | 28 days | 28 days |
| Novalog (release pending) | until expiration date | |||
| Lantus TM (10 mL) | 28 days | until expiration date | 28 days | 28 days |
| Lantus TM (5 mL) | 28 days | until expiration date | 14 days | 14 days |
| PENS/CARTRIDGES | Not in use | In use | ||
| Humalog | Until expiration date | 28 days | ||
| Humulin R (cartridge) | Until expiration date | 28 days | ||
| Humulin N | Until expiration date | 14 days | ||
| Humulin 70/30 | Until expiration date | 10 days | ||
| Humalog Mix 75/25 | Until expiration date | 10 days | ||
| Novolog | Until expiration date | 28 days | ||
| Novolin R (prefilled and 1.5-mL cartridge) | Until expiration date | 30 days | ||
| Novolin R (3-mL cartridge) | Until expiration date | 28 days | ||
| Novolin N (prefilled and 1.5-mL cartridge) | Until expiration date | 7 days | ||
| Novolin N (3-mL cartridge) | Until expiration date | 14 days | ||
| Novolin 70/30 (prefilled and 1.5-mL cartridge) | Until expiration date | 7 days | ||
| Novolin 70/30 (3-mL cartridge) | Until expiration date | 10 days | ||
| Lantus TM | Until expiration date | 28 days | ||
| Self-filled syringes | 14 days* | 7 days* | ||
| Medication | Blood Glucose Most Affected | SMBG* Testing to Recommend | Greatest Risk for Hypoglycemia |
| Sulfonylureas | Fasting and postprandial | 2–3 times per day,especially fasting | 4–6 hr after meal and fasting |
| Meglitinide phenylalanine derivative | Postprandial | 2 hr after meal | 2–3 hr after meal |
| Biguanide | Fasting | Fasting | None if used as single agent |
| Alpha-glucosidase inhibitor | Postprandial | 2 hr after meal | 2 hr after meal |
| Thiazolidinedione | Fasting and postprandial | 2–3 times per day, especially fasting | After exercise when used with sulfonylureas or insulin |
| Glucovance | Fasting and postprandial | 2–3 times per day, especially fasting | 4–6 hr after meal and fasting |
| Biochemical Index | Normal | Goal | Action Suggested |
| Before meals (mg/dL) plasma whole blood |
<110 <100 |
90–130 80–120 |
<90, >150 <80, >140 |
| Bedtime (mg/dL) plasma whole blood |
<120 <110 |
110–150 100–140 |
<110, >180 <100, >160 |
| HbA1c* | <6 | <7 | >8 |
| Category | Brand Name | Generic Name | Manufacturer | Minimum Daily Dose | Maximum Daily Dose | Special Considerations* |
| HMG-CoA reductase inhibitors (statins) | ||||||
| Lipitor | atorvastatin | Pfizer | 10 mg | 80 mg | Main action: Lowers LDL ("bad")
cholesterol. Have blood tests for liver enzyme concentrations. Notify physician immediately of muscle pain. Use caution if combining with fibric acid derivatives or bile acid sequestrants (described below). (increased risk of rhabdomyolysis) |
|
| Lescol | fluvastatin | Novartis | 20 mg | 80 mg | ||
| Lescol XL | fluvastatin | Novartis | 80 mg | 80 mg | ||
| Mevacor | lovastatin | Merck | 10 mg | 80 mg | ||
| lovastatin | generic† | 10 mg | 80 mg | |||
| Altocor | lovastatin (extended-release) | Aura Labs | 20 mg | 60 mg | ||
| Pravachol | pravastatin | Bristol-Myers Squibb | 10 mg | 80 mg | ||
| Zocor | simvastatin | Merck | 5 mg | 80 mg | ||
| Cholesterol absorption inhibitors | Zetia | ezetimibe | Merck Schering-Plough | 10 mg | 10 mg | Main action: Lowers LDL cholesterol; inhibits absorption of cholesterol. If used with a statin, take together. If used with bile acid sequestrant,ezetimibe should be taken 2 hr before or 4 hr after bile acid sequestrant. |
| Nicotinic acid (niacin) | ||||||
| Niaspan | nicotinic acid (extended release) | Kos | 300 mg (starting dose) | 2,000 mg | Main action: Lowers LDL cholesterol increases HDL ("good") cholesterol, lowers triglycerides. Take with food. May cause flushing. May increase blood glucose levels. Have blood tests for liver enzyme concentrations. Long-acting forms may be more likely to cause liver malfunction. |
|
| nicotinic acid | generic† | 300 mg | 2,000 mg | |||
| Lipid combinations | Advicor | lovastatin niacin | Kos | 20 mg 500 mg |
40 mg 2,000 mg |
Main Action: Reduces LDL, TC, and TG and increases HDL due to the individual actions of niacin and lovastatin. |
| Fibric acid derivatives | ||||||
| Lopid | gemfibrozil | Pfizer | 1,200 mg | 1,200 mg | Main action: Lowers triglycerides, increases HDL cholesterol. Perform blood tests for liver enzyme concentrations. Notify physician of muscle pain immediately. |
|
| gemfibrozil | generic† | 1,200 mg | 1,200 mg | |||
| Tricor | fenofibrate | Abbott | 54 mg | 160 mg | ||
| Bile acid sequestrants | ||||||
| LoCHOLEST | cholestyramine | Warner Chilcott | 4 g | 24 g | Main action: Lowers LDL cholesterol. May cause constipation and stomach upset. May need to be taken at a different time than other medications to avoid drug interactions. May increase triglycerides blood concentrations. |
|
| LoCHOLEST light | cholestyramine light | Warner Chilcott | 4 g | 24 g | ||
| Questran | cholestyramine | Par Pharmaceuticals | 4 g | 24 g | ||
| Questran light | cholestyramine light | Par Pharmaceuticals | 4 g | 24 g | ||
| Prevalite | cholestyramine | Upsher Smith | 4 g | 24 g | ||
| cholestyramine | generic† | 4 g | 24 g | |||
| cholestyramine light | generic† | 4 g | 24 g | |||
| Welchol | colesevelam | Sankyo | 1,875 (3 tablets) | 4,375 (7 tablets) |
| Category | Brand Name | Generic Name | Manufacturer | Minimum Daily Dose | Maximum Daily Dose | Special Considerations |
|---|---|---|---|---|---|---|
| Angiotensin-8 converting enzyme (ACE) inhibitors | ||||||
| Mavik | trandolapril | Abbot | 1 | 8 | May cause cough. May increase potassium concentrations. Do not use potassium or salt substitutes without consulting physician. Do not use if pregnant or if trying to conceive. Caution if creatinine >1.5. |
|
| Altace | ramipril | Monarch | 1.25 | 20 | ||
| Capoten | captopril | Apothecon | 25 | 450 | ||
| captopril | generic† | 25 | 450 | |||
| Univasc | moexipril | Schwarz | 7.5 | 60 | ||
| Monopril | fosinopril | Bristol-Myers Squibb | 10 | 80 | ||
| Lotensin | benazepril | Novartis | 5 | 20 | ||
| Prinivil | lisinopril | Merck | 2.5 | 80 | ||
| Zestril | lisinopril | AstraZeneca | 2.5 | 80 | ||
| lisinopril | generic† | 2.5 | 80 | |||
| Vasotec | enalapril | Merck | 2.5 | 40 | ||
| Vasotec | enalapril | Merck | 2.5 | 40 | ||
| enalapril | generic† | 2.5 | 40 | |||
| Accupril | quinapril | Pfizer | 5 | 80 | ||
| Aceon | perindopril | Solvay | 4 | 16 | ||
| Angiotensin II receptor blockers | ||||||
| Cozaar | losartan | Merck | 25 | 100 | May cause dizziness and upset stomach. Do not use potassium or salt substitutes without consulting physician. Do not use if pregnant or if trying to conceive. Caution if creatinine >1.5. |
|
| Benicar | olmesartan | Sankyo | 20 | 40 | ||
| Diovan | valsartan | Novartis | 80 | 320 | ||
| Avapro | irbesartan | Bristol-Myers Squibb | 150 | 300 | ||
| Atacand | candesartan | AstraZeneca | 15 | 32 | ||
| Micardis | telmisartan | Boehringer-Ingelheim | 20 | 80 | ||
| Teveten | eprosartan | Biovail | 400 | 800 | ||
| Calcium channel blockers | ||||||
| Sular | nisoldipine | AstraZeneca | 20 | 60 | May cause constipation, dizziness, upset stomach, and flushing. Call physician for shortness of breath, unusual heartbeat, or swelling of feet or hands. |
|
| Adalat CC* | nifedipine | Bayer | 30 | 120 | ||
| Procardia | nifedipine | Pfizer | 30 | 120 | ||
| Procardia XL* | nifedipine | Pfizer | 30 | 120 | ||
| nifedipine | generic† | 30 | 120 | |||
| Cardene | nicardipine | Roche | 60 | 120 | ||
| Cardene SR* | nicardipine | Roche | 60 | 120 | ||
| DynaCirc | isradipine | Reliant | 2.5 | 20 | ||
| DynaCirc CR* | isradipine | Reliant | 2.5 | 20 | ||
| Plendil | felodipine | AstraZeneca | 5 | 20 | ||
| Cardizem | diltiazem | Biovail | 120 | 360 | ||
| Cardizem CD* | diltiazem | Biovail | 120 | 360 | ||
| diltiazem | generic† | 120 | 360 | |||
| Dilacor XR* | diltiazem | Watson | 180 | 540 | ||
| Tiazac | diltiazem | Forest | 120 | 540 | ||
| Calan | verapamil | Searle | 120 | 480 | ||
| Calan SR* | verapamil | Searle | 120 | 480 | ||
| verapamil | generic† | 120 | 480 | |||
| Isoptin | verapamil | Abbott | 120 | 480 | ||
| Isoptin SR* | verapamil | Abbott | 120 | 480 | ||
| Verelan | verapamil | Schwarz | 120 | 480 | ||
| Verelan PM* | verapamil | Schwarz | 100 | 400 | ||
| Covera HS* | verapamil | Searle | 180 | 480 | ||
| Norvasc | amlodipine | Pfizer | 5 | 10 | ||
| Thiazides and related diuretics | ||||||
| Diuril | chlorothiazide | Merck | 500 | 2,000 | May increase blood glucose concentrations. Take in morning to minimize diuretic effect at night. May cause low potassium. Need blood test to monitor level. |
|
| chlorothiazide | generic† | 500 | 2,000 | |||
| HydroDIURIL | hydrochlorothiazide | Merck | 15 | 50 | ||
| Microzide | hydrochlorothiazide | Watson | 12.5 | 200 | ||
| hydrochlorothiazide | generic† | 12.5 | 200 | |||
| Enduron | methyclothiazide | Abbott | 2.5 | 10 | ||
| Zaroxolyn | metolazone | Fisons | 2.5 | 10 | ||
| Hygroton | chlorthalidone | Aventis | 2.5 | 100 | ||
| Lozol | indapamide | Aventis | 1.25 | 5 | ||
| Loop diuretics | ||||||
| Lasix | furosemide | Aventis | 80 | 80 | May cause low potassium. Need blood test to monitor level. May cause photosensitivity:sunscreen recommended. |
|
| furosemide | generic† | 80 | 80 | |||
| Bumex | bumetanide | Roche | 0.5 | 10 | ||
| bumetanide | generic† | 0.5 | 10 | |||
| Demadex | torsemide | Roche | 5 | 20 | ||
| Potassium sparing diuretics | ||||||
| Aldactone | spironolactone | Searle | 50 | 400 | Do not use potassium or salt substitutes without consulting physician. | |
| spironolactone | generic† | 50 | 400 | |||
| Dyrenium | triamterene | GlaxoSmithKline | 50 | 300 | ||
| Midamor | amiloride | amiloride | 5 | 20 | ||
| amiloride | generic† | 5 | 20 | |||
| Carbonic anhydrase inhibitors | ||||||
| Diamox | acetazolamide | Wyeth-Ayerst | 250 | 1,000 | May take with food if medicine upsets stomach. May cause hand/foot tingling that can be confused with neuropathy. |
|
| acetazolamide | generic† | 250 | 1,000 | |||
| β-blockers | ||||||
| Tenormin | atenolol | AstraZeneca | 25 | 100 | May mask signs of low blood glucose levels. May alter blood glucose. Call physician for slow heart rate (<60),confusion, or swelling of feet or legs. Can cause claudication. |
|
| atenolol | generic† | 25 | 100 | |||
| Kerlone | betaxolol | Searle | 5 | 40 | ||
| betaxolol | generic† | 5 | 40 | |||
| Levatol | penbutolol | Schwarz | 10 | 40 | ||
| Zebeta | bisoprolol | Lederle | 2.5 | 20 | ||
| Lopressor | metoprolol | Novartis | 25 | 450 | ||
| metoprolol | generic† | 25 | 450 | |||
| Toprol XL* | metoprolol | AstraZeneca | 50 | 400 | ||
| Corgard | nadolol | Bristol-Myers Squibb | 40 | 320 | ||
| nadolol | generic† | 40 | 320 | |||
| Inderal | propranolol | Wyeth-Ayerst | 40 | 640 | ||
| Inderal LA* | propranolol | Wyeth-Ayerst | 40 | 640 | ||
| generic† | 40 | 640 | ||||
| α-blockers | ||||||
| Minipress | prazosin propranolol | Pfizer | 1 | 20 | To prevent dizziness, avoid standing up suddenly, especially with the first few doses. | |
| prazosin | generic† | 2 | 40 | |||
| Hytrin | terazosin | Abbott | 1 | 40 | ||
| terazosin | generic† | 1 | 40 | |||
| Cardura | doxazosin | Roerig | 1 | 16 | ||
| doxazosin | generic† | 1 | 16 | |||
| Combined α- and β-blockers | ||||||
| Trandate | labetalol | Faro | 100 | 2,400 | May mask signs of low blood glucose levels. Take with food to avoid stomach upset. |
|
| Normodyne | labetalol | Key | 100 | 2,400 | ||
| labetalol | generic† | 100 | 2,400 | |||
| Coreg | carvedilol | GlaxoSmithKline | 6.25 | 50 | ||
| Direct vasodilators | ||||||
| Apresoline | hydralazine | Novartis | 40 | 300 | May cause headaches, fluid retention, or fast heart rate. | |
| Central α-agonists | ||||||
| Catapres | clonidine | Boehringer-Ingelheim | 0.1 | 2.4 | Do not discontinue drug suddenly without consulting physician. | |
| clonidine | generic† | 0.1 | 2.4 | |||
| Catapres TTS* (patch) | clonidine | Boehringer-Ingelheim | 0.1 | 0.6 | ||
| Aldomet | methyldopa | Merck | 250 | 3,000 | ||
| methyldopa | generic† | 250 | 3,000 |