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Newest FDA recommendations formetformin
FDA Revised Metformin TreatmentGuidelines Recommendations based on eGFR rather thanserum creatinine eGFR of 60 is no longer the cutoff Can start on metformin if eGFR 45 Starting is not recommended if eGFR 30-45– However, those already on metformin can continue Contraindicated if eGFR 30
Revised Metformin and ContrastStudies Recommendations If eGFR 60 no need to stop for most contraststudies DC at or before contrast study if:––––eGFR 30-60History of liver disease, alcoholism, heart failureIntra-arterial iodinated contrastRe-evaluate eGFR 48 hours after imaging
Newer InsulinsKeith Cryar, MD, FACE, ECNUBaylor Scott & White HealthAnthony.cryar@BSWHealth.org
Newer insulins Lispro U200 (Humalog U200) Glargine U300 (Tujeo) U500 insulin pen Degludec U100 and U200 (Tresiba)
Humalog U200 No significant pharmacokinetic advantages Advantages:– Lower volume provides a more comfortable injection– Each pen lasts longer U100 pen 300 units or 14 units tid for 1 week U200 pen 600 units or 28 units tid for 1 week 1:1 conversion in either direction
Glargine U300 (Tujeo) Lantus at a concentration of 300 units/mL ratherthan the standard concentration of 100 units/mL Increased comfort due to lower volume– Each pen has still has 300 units Glargine U300 has less peak and is closer to atrue basal
Tujeo vs LantusU100 vs. U300
Converting between Lantus and Tujeo Converting from U100 to U300 is 1:1 When converting from U300 to U100, decreaseby 20% to avoid hypoglycemia from U100 peak
U500 Pen U500 is 5x the concentration of U100 With no delivery system designed for U500:– By volume in a tuberculin syringe (0.2 mL x500U/mL 100 units)– Using a U100 insulin syringe where the actual doseis 5x the dose seen on the syringe (20 unit mark 100 units) Resulted in significant confusion about dosing With a U500 pen, the dose clear– 100 units is truly 100 units
Degludec insulin (Tresiba) A new insulin providing true basal insulinpharmacokinetics with a duration of actionaround 42 hours Given as a single injection with no need to splitthe dose as may be needed with Lantus orLevemir– U100 pen doses up to 80 units, holds 300 units– U200 pen doses up to 160 units, holds 600 units
Converting Lantus/Levemir to Tresiba Conversion from Lantus/Levemir to Tresibais1:1 May have 1-2 days of hyperglycemia No standard for Tresiba to Lantus/Levemir
Lantus Mechanism of Action
Variability of Tresiba vs LantusHeise, T., Diabetes Obes Metab, 14: 859–864
Lispro U200 (Humalog U200) Glargine U300 (Tujeo) U500 insulin pen Degludec U100 and U200 (Tresiba) Humalog U200 No significant pharmacokinetic advantages . Tujeo vs Lantus U100 vs. U300. Converting between Lantus and Tujeo Converting from U100 to U300 is 1:1 When converting from U300 to U100, decrease
