Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-

cardiorenal benefit.

o If a GLP-1 RA is already on-board, consider:

→ uptitrate the GLP-1 RA to maximally-tolerated dose or maximum recommended dose of GLP-1 RA for glycemic lowering; and/or → add an SGLT2i with proven cardiorenal benefit

o If a SGLT2i is already on-board, consider:

→ adding a GLP-1 RA with proven cardiorenal benefit [Rationale: The dose response curve for SGLT2i is rather flat — such that going to the higher dose generally has only a small effect to further reduce blood glucose levels. Also note that the glycemic-lowering efficacy of the SGLT2i class is reduced with lower GFR, particularly when eGFR is <45 mL/min/1.73m 2 ] o If both a GLP-1 RA at maximally-tolerated/recommended dose AND a SGLT2i at cardiorenal protective dose is already on-board, continue to B (v.) below.

B. Individuals who are not amongst the identified “high-risk populations” requiring additional glucose lowering i. reinforce healthy behaviour interventions and lifestyle choices expected to lower blood glucose levels ii. Selection of agent should be based on the following clinical considerations: o Avoidance of hypoglycemia, weight gain and demonstrated glucose lowering efficacy. o Individual characteristics: comorbidities and frailty, renal function, cost and coverage, contraindications, relativecontributionsof insulindeficiencyversus resistance, individual preference (eating patterns, side effect profile and goals of care, planning pregnancy, and access and engagement in glucose monitoring. iii. The Diabetes Canada Guidelines recommend GLP-1 receptor agonists, SGLT2 inhibitors, or DPP-4 inhibitors are preferred over other agents as they improve glycemic control with low rates of hypoglycemia and weight gain, unless contraindicated or cost is an issue (24).

o Consider use of the above agents prior to insulin or sulfonylurea in people at increased risk of hypoglycemia (elderly/impaired renal function) and/or people with adiposity. o eGFR should also be considered in the treatment decision, see “Antihyperglycemic Agents and Kidney Function” Renal Dosing Chart available at: http://guidelines.diabetes.ca/reduce-complications/renal-dosing-chart,