Type II diabetes mellitus

Updated: November 24, 2022

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Background

Epidemiology

Anatomy

Pathophysiology

Etiology

Genetics

Prognostic Factors

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

 

insulin human 

Subcutaneous injection:

Ten units/day subcutaneous in the evening or divided every 12 hours
Morning-administer 2/3 of the required daily dose
Evening-administer 1/3 of the required daily dose



insulin glargine 

0.2

unit/kg

Solution

Subcutaneous (SC)

once a day

increase the dose as required



insulin isophane human/​insulin regular human 

0.5 - 1

unit/kg

Suspension

Subcutaneous (SC)

every day



insulin regular human 

0.1 - 0.2

unit/kg

Solution

Subcutaneous (SC)

every 12 hrs



semaglutide 

3

mg

Orally 

every day

1

month

; then 7 mg orally daily; may increase to 7-14 mg orally daily

Do not exceed 14 mg/day

or

0.25 mg subcutaneously (SC) once a week for 4 weeks, then 0.5-1 mg subcutaneously (SC) once a week

Do not exceed 1 mg/week

Switching between administration of Subcutaneous (SC) and Oral Tablets:

14 mg orally once a day can be switched to 0.5 mg subcutaneously (SC) once a week after the last oral dose

0.5 mg subcutaneously once a week, switched to 7 or 14 mg orally once a day for 7 days after the last subcutaneous injection



miglitol 

In the case of hepatic or renal impairment, no dose adjustment is required:

In this type of condition, drug is given as monotherapy or combined with sulfonylureas
Initial dose- 25 mg orally every 8 hours with meals
Maintenance dose- 50 mg orally every 8 hours; increase the dose after 4-8 weeks
Do not increase the dose more than 100 mg orally every 8 hours



acarbose 

In the case of severe renal impairment, when serum creatinine is more than 2 mg/dl the medication is not recommended
In the case of hepatic consideration, if transaminase levels increase, reduce the dose or withdraw the therapy :

Initial dose- 25 mg orally every 8 hours with meals
Maintenance dose- 50 mg orally every 8 hours; increase the dose after 4-8 weeks
Maximum dose- For <60 kg, 50 mg orally every 8 hours
For >60 kg, 100 mg orally every 8 hours
If there is no reduction in Hb1Ac or postprandial glucose seen with titration. Consider dose reduction
The drug can be used in monotherapy of type 2 diabetes or can be combined with sulfonylurea



liraglutide 

0.6 mg (Victoza) subcutaneously each day for 1 week
Increase to 1.2 mg each day after that
If an optimum glycemic level is not achieved increase the dose to 1.8 mg each day
0.6 mg initial dose subcutaneously is only



chromium 

200-1000 mcg daily orally in divided doses



propolis 

400-1500mg of propolis every day to diminish blood sugar levels and also boost antioxidant defense



glyburide/metformin 

1.25mg/250mg orally each day or every 12 hours
Titrate the dose every fortnight
Keep maximum dose to 20/2000 mg/day



glyburide/metformin 

1.25mg/250mg orally each day or every 12 hours
Titrate the dose every 2 weeks
Keep maximum dose to 20/2000 mg/day



glyburide/metformin 

1.25mg/250mg orally each day or every 12 hours
Titrate the dose every 2 weeks
Keep maximum dose to 20/2000 mg/day
Dose Modification
In the case of hepatic impairment, avoid the use as it may cause lactic acidosis
In the case of renal impairment when eGFR <30 mL/min/1.73 m², the drug is contraindicated



dapagliflozin/ metformin/saxagliptin   

patients who are not taking dapagliflozin, the recommended starting dose is dapagliflozin 5 mg/saxagliptin 5 mg/metformin HCl extended-release 1000 mg or 2000 mg orally daily
maximum daily dose that is recommended for this medication is dapagliflozin 10 mg/saxagliptin 5 mg/metformin HCl extended-release 2000 mg, which should not be exceeded



metformin/sitagliptin  

(Not currently treated with metformin) The immediate-release form of the medication should be taken orally twice daily, containing 50 mg sitagliptin and 500 mg metformin
For the extended-release form, take 100 mg sitagliptin and 1000 mg metformin orally daily
To minimize the gastrointestinal side effects related to metformin, the dose should be gradually increased
However, the daily dose of metformin should not exceed 2,000 mg or 100 mg of sitagliptin
(Currently treated with metformin) Immediate release sitagliptin 50 mg orally twice a day Together with the current daily amount of metformin
For patients taking 850 mg of metformin HCl twice a day, the recommended starting dose of sitagliptin is 50 mg orally twice a day along with 1000 mg of metformin HCl orally twice a day
Extended-release Sitagliptin 100 mg Together with the current daily amount of metformin For patients who take 850 mg or 1000 mg of metformin HCl immediate-release orally twice a day, the recommended starting dose is 100 mg of sitagliptin along with 1000 mg of metformin
It's important not to exceed a daily dose of 2000 mg of metformin or 100 mg of sitagliptin



ertugliflozin/sitagliptin 

Orally once daily in the morning as an initial dose, 5 mg/100 mg; if further regulation of blood sugar levels is required and the initial dose is well-tolerated, the maximum dose of 15 mg/100 mg may be increased.
Dosage Modifications
Renal impairment
eGFR ≥45 ml/min/1.73 m²: dose modification not required
eGFR <45 ml/min/1.73 m²: not suggested
Severe, end-stage renal disease: not recommended
Hepatic impairment
Mild-to-moderate: dose modification not required
Severe: not suggested
Dosing Considerations
Limitation of use
Discouraged for individuals suffering from type 1 diabetes mellitus and also potentially elevate the possibility of diabetic ketoacidosis in such patients



exenatide subdermal implant 


Indicated for Type 2 Diabetes Mellitus
Pending FDA approval for type-2 DM, a Subdermal implant that provides continuous Subcutaneous delivery of the exenatide for over months



empagliflozin and linagliptin 

10mg/5mg orally every day in the morning, taken along with or without food
Do not exceed the dose by 25mg/5mg



ertugliflozin/metformin 

Individualize the initial dose based on the patient's current regimen, but do not exceed 15 mg ertugliflozin and 2000 mg metformin daily.
Take twice a day along with the meals

Switching from ertugliflozin and/or metformin individually
Patients using metformin should switch to 2.5 mg ertugliflozin tablets, maintaining the exact metformin dosage throughout the day.
Patients on ertugliflozin: Switch to 500 mg metformin tablets with a comparable total daily dosage of ertugliflozin.
If you already use ertugliflozin and metformin, consider switching to tablets with the total daily dosage of ertugliflozin and a comparable daily metformin dose.



Dose Adjustments

Iodine-contrast imaging techniques
Patients with an 60 mL/min/1.73 m2 of eGFR , a history of liver disease, intoxication, or heart failure, or those who will receive intra-arterial iodinated contrast should discontinue iodinated contrast imaging at the time of or before the procedure.

48 hours after the imaging procedure, reevaluate eGFR; if renal function is stable, resume drug administration.

Renal impairment
eGFR 45 mL/min/1.73 m2: No dose change is required.
eGFR of 45 mL/min/1.73 m2: Not recommended.
End-stage renal disease, dialysis, or severe (eGFR 30 mL/min/1.73 m2): Contraindicated

Hepatic impairment
Not advised.
Some lactic acidosis instances in people with hepatic impairment have been linked to metformin.

insulin NPH 

Beginning dose- 0.2 unit/kg/day subcutaneously
In the morning, give 2/3rd of daily insulin subcutaneously
Keep the ratio of 1:2 regular and NPH insulin
In the evening, give 1/3rd of daily insulin subcutaneously
Keep the ratio of 1:1 regular and NPH insulin



canagliflozin/metformin 

Patients currently not on canagliflozin or metformin: Oral: -
Initial dose of canagliflozin 100 mg/metformin 1 g per day in 2 divided doses in form of immediate release
Patients on metformin: Oral: -
Initial dose of canagliflozin 100 mg/day with similar total daily dose of metformin in 2 divided doses in form of immediate release
Patients on canagliflozin: Oral:
Initial dose of metformin 1 g/day with same total daily dose of canagliflozin in 2 divided doses in form of immediate release
Patients switching from combination therapy of canagliflozin and metformin: Oral: -
Administer same total daily dose of canagliflozin with similar total daily dose of metformin in 2 divided doses in form of immediate release
Patients switching from immediate release to extended release: Oral: - Use the current total daily dose (TDD)
Maximum: Oral: -
Take canagliflozin 300 mg/metformin 2 g daily
Dosage Modifications
UDP-glucuronosyl transferase (UGT) enzyme inducers:
For GFR ≥60 mL/min/1.73 m2:
canagliflozin dose raised to 200 mg daily, if current tolerating dose is 100 mg daily
canagliflozin dose raised to 300 mg daily, if current tolerating dose is 200 mg daily
For eGFR <60 mL/min/1.73 m2:
canagliflozin dose raised to 200 mg daily, if current tolerating dose is 100 mg daily
Renal impairment
For eGFR ≥60 mL/min/1.73 m2: dose modification not required
For eGFR 45 to <60 mL/min/1.73 m2: Limit canagliflozin total daily dose up to 100 mg
Dosing Considerations
Not to be used in the management of type 1 diabetes or diabetic ketoacidosis



glimepiride/rosiglitazone 

Take one tablet as starting dose containing 4 mg rosiglitazone with 1 mg glimepiride daily with first food of the day
For titrate raised the dose of glimepiride components but not more than 2 mg in every 1 to 2 weeks
Dose not more than 8 mg rosiglitazone/4 mg glimepiride
Dosage Modifications
Renal impairment
Take one tablet as starting dose containing 4 mg rosiglitazone with 1 mg glimepiride daily with first food of the day and titrate cautiously
Hepatic impairment
Take one tablet as starting dose containing 4 mg rosiglitazone with 1 mg glimepiride daily with first food of the day and titrate cautiously
ALT <2.5 xULN: caution should be taken
ALT >2.5 xULN: avoid administration
ALT >3 xULN: Discontinue



linagliptin/metformin 

Administer the drug as an adjunct to exercise and diet that helps in improving glycemic control in people with type 2 diabetes mellitus
Adjust the dose based on tolerance and efficacy
Prompt release tablets-
Initially, 2.5 mg/500 mg orally twice daily (people who are not taking metformin)
Initially, 2.5 mg/1000 mg orally twice daily (people who are taking metformin)
Do not exceed more than 2.5 mg/1000 mg twice daily
Extended-release tablets-
Initially, 5 mg/1000 mg orally each day (people who are not taking metformin)
Initially, 5 mg linagliptin with a similar metformin dose orally twice daily (people who are taking metformin)
In case of a switch from prompt release dosage, 5 mg of total linagliptin and similar metformin each day



albiglutide 

30 mg subcutaneously once a week
If the glycemic response is inadequate, increase to 50 mg once a week 30 mg subcutaneously once a week
Not indicated to treat severe gastric disease, type 1 diabetes mellitus, or diabetic ketoacidosis



dulaglutide 

Administer 0.75 mg subcutaneously one time in a week and increase the dose up to 1.5 mg one time in a week, if required
3 mg one time in a week after 4 weeks on 1.5 mg dose if required for glycemic control
4.5 mg one time in a week after 4 weeks on 3 mg dose if required for glycemic control
Dosage Modifications
Renal impairment
Dosage adjustment not required
Hepatic impairment
Dosage adjustment not required



lixisenatide 


Indicated for Diabetes Mellitus Type 2
Initial dose: 10 mcg subcutaneously every day for 14 days
Maintenance dose: Enhance the dose to 20 mcg every day from Day-15 It is used to improve glycemic control as with addition to diet and regular exercise



metformin/rosiglitazone 


Indicated for Diabetes mellitus Type 2
Initial dose:
500mg of metformin /2mg of rosiglitazone orally every day or two times a day
HbA1c >11% or the fasting plasma glucose levels >270 mg/dl, an initial dose of 500mg of metformin /2mg of rosiglitazone orally two times a day can be considerable
Titration by enhancement of 500mg of metformin /2mg of rosiglitazone at two weeks intervals. It should not exceed 2000mg of metformin /8mg of rosiglitazone in a day
The initial dose for earlier therapy:
1000 mg of metformin in a day: 500mg of metformin /2mg of rosiglitazone orally two times a day
2000 mg of metformin in a day: 1000mg of metformin /2mg of rosiglitazone orally two times a day
4mg of rosiglitazone in a day: 500mg of metformin /2mg of rosiglitazone orally two times a day
8mg of rosiglitazone in a day: 500mg of metformin /4mg of rosiglitazone orally two times a day
Combination therapy: the dose of metformin and rosiglitazone already taken; might titrate at the two-week intervals. It should not exceed 2000mg of metformin /8mg of rosiglitazone



bitter melon 

50-100 ml of bitter melon juice daily
900 mg of fruit thrice daily



saxagliptin/metformin 

Administer the drug as an adjunct to exercise and diet that helps in improving glycemic control
Adjust the dose based on tolerance and efficacy
Do not exceed the dose of more than 5mg/2000mg
Administer the dose every evening with a meal
Inadequate metformin- 2.5-5 mg saxagliptin orally each day with the current dose of metformin
Inadequate saxagliptin- 500 mg metformin orally each day with 5 mg saxagliptin daily
The dose is not recommended in the case of severe renal impairment



glymidine 


Indicated for Type-II DM
250 mg one-two times a day (i.e., prior to breakfast and if required another dose prior to meal)



benfluorex 

150 mg thrice a day



acetohexamide 

Take 250 mg to 1500 mg twice daily
The maximum recommended dose is 1500 mg a day



glyclopyramide 

In vivo data suggests taking 125-250 mg orally every day as needed; the possibility of raising the dosage to establish an appropriate maintenance dose may be considered, not exceeding a maximum of 500 mg a day



taspoglutide 

taspoglutide is taken once a week as a single therapy



arhalofenic acid 

The suggested oral dose is 200 mg, 400 mg, or 600 mg, to be taken one time a day for sixteen weeks



luseogliflozin 

2.5

mg

Orally 

every 24 hours

Note: the dose can be increased to 5mg depending on the response of the patient



jiaogulan 

(Off label)
:

There are restricted scientific facts to be had. Jiaogulan tea, administered as an aqueous extract at a dosage of 6 g/day in divided doses before food, has been investigated in two clinical trials for type 2 diabetes

Additionally, an ordeal focusing on anti-obesity used a dosage of 225 mg twice day by day for 12 weeks



pramlintide 

Subcutaneous injection of 60 mcg immediately before each meal



 

insulin human 

> 10 years: Metformin, once daily intermediate-acting insulin or basal insulin, along with dietary modifications
<10 years: Safety and efficacy not established



metformin 

Indicated to improve glycemic control in pediatric patients ≥10 years with type 2 DM :


Age: 10 to <17 years

Immediate release
Initial dose- 500 mg orally twice daily
Increase the dose weekly as per tolerability
Divide the daily dose 2-3 times per day, with meals
Do not exceed the dose more than 2000 mg/day

Extended-release oral suspension
Initially 500 mg orally once daily with evening meal
Increase the dose weekly as per tolerability
Do not exceed the dose more than 2000 mg/day
To minimize gastrointestinal side effects, dose titration should be performed slowly



chromium 

200-1000 mcg daily orally in divided doses



dulaglutide 

for ≥10 years:
Administer 0.75 mg subcutaneously one time in a week
May increase up to 1.5 mg one time in a week after 4 weeks on 0.75 mg if required for glycemic control
Do not exceed 1.5 mg/week



 

tolbutamide 

250mg orally every day or twice or thrice a day
Do not exceed 3g per day
Maintenance doses of more than two g/day are rarely necessary



saxagliptin/metformin 

Do not exceed the dose of more than 5mg/2000 mg
Administer the dose every evening with a meal
Inadequate metformin- 2.5-5 mg saxagliptin orally each day with the current dose of metformin
Inadequate saxagliptin- 500 mg metformin orally each day with 5 mg saxagliptin daily
Potent CYP3A4/5 inhibitors- Do not exceed more than 2.5 mg each day
Do not administer in patients more than 80 years of age
The dose is not recommended in the case of severe renal impairment



luseogliflozin 

2.5

mg

Orally 

every 24 hours

Note: this should be used with caution in elderly population as the physiological function in these population may be altered



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Type II diabetes mellitus

Updated : November 24, 2022

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