Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-28

Table 4. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) (13,24,38,49,51,50, 58- 68,71) Glucagon-like peptide-1 receptor agonists (GLP-1 RA) Therapeutic Considerations Mechanism of action

Considerations • If A1C at individualized target, consider decreasing the dose of the sulfonylurea by 50% when starting GLP-1 RA to reduce the risk of hypoglycemia. Monitor • Assess renal function prior to initiation and periodically, as needed. • Monitor signs and symptoms of pancreatitis. • Monitor retinopathy (especially if pre-existing retinopathy) because of risk of progression with rapid drops in A1C Adverse effects (dose dependent and improve over time) • Mild-moderate nausea (11%-40%) in first 4-6 weeks. • Diarrhea 9-17%, vomiting 4-13% • 5% will stop therapy • Increase in heart rate (2-4 BPM)/ PR interval prolongation. Tips to minimize nausea • Slow dose titration; delay dose uptitration by 1-2 weeks if GI symptoms. • Eat slower (with delayed gastric emptying) • Stay hydrated • Eat only until you are no longer hungry, (may eat only when you are hungry. may eat smaller portions) Contraindication • Type 1 diabetes, pregnancy or breastfeeding women. • Personal or family history of medullary thyroid carcinoma or in individuals with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). • May slow absorption of medications; caution with medications that require rapid absorption (e.g. acetaminophen, pain medications). Caution • Use with prandial insulin has not been studied and cannot be recommended. • Rare cases of acute pancreatitis have been reported.

• Binds to and activates the pancreatic GLP-1 receptor, resulting in an increase in glucose-dependent insulin secretion. • Suppresses inappropriate glucagon secretion, slows gastric emptying and decreases food intake (69,70). Subcutaneous injection Benefits • ↓ A1C 1.0% (less with short-acting GLP-1) • Weight loss of 1.6 - 3 kg • Does not cause hypoglycemia. • Long-acting GLP-1: Target FBG & lower postprandial glucose excursions for all meals of the day • Short-acting GLP-1: more pronounced postprandial BG for meals directly following their daily or twice-daily administration. • Durable glucose lowering. • Improves lipid profile and lowers systolic BP 2 mmHg.