Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-41

Table 7. Insulin secretagogues: Meglitinides (9,13,24,38,45,97,101,102) Antihyperglycemic agent Therapeutic Considerations Mechanism of action •

Less likely to cause hypoglycemia than sulfonylureas, especially in renal impairment

• Bind to the sulfonylurea receptor of the islet-cell membranes, stimulating insulin secretion in the presence of glucose. Benefit • ↓ A1C 0.7-1.1 % • Rapid onset of action and clearance. • Targets postprandial BG. • Ideal for individuals with irregular meal times; dose should be omitted if the meal Repaglinide (GlucoNorm®) • TDD: 0.5 mg - 16 mg • Frequency: QD–QID • Taken before the first bite, up to 15 – 30 min prior to meal. Dosing Schedule • Initiate at 0.5 mg TID if A1C <8%. • Initiate at 1- 2 mg TID if A1C ≥ 8%. • Titrate every 1-2 weeks based on fasting BG: Double pre-meal dose (max 4 mg). Benefits • ↓ A1C 0.7% (13,35) • Can be used in renal insufficiency (90% eliminated in feces). • Available: 0.5 mg, 1 mg, 2 mg

Weight gain 1.4 – 3.3 kg.

•

• Hepatically metabolized and renally cleared. • Preferred for use in elderly individuals with irregular eating patterns. • Requires dosing with each meal (e.g. 3 times daily) Requires slower dose titration in people with renal/hepatic impairment. • Consider lower doses if eGFR <45 mL/min/1.73m 2 due to increased risk of hypoglycemia. • Consider lower doses and beware of extended duration of action/increase risk of hypoglycemia if eGFR <30 mL/min/1.73m 2 . Contraindicated • Severe liver disease • When co-administered with clopidogrel or gemfibrozil (in vivo studies show 8-fold increase in exposure; associated with severe prolonged hypoglycemia). Considerations in the elderly • Initiate at half usual starting dose. • Slower dose titration. Caution •

QD = once daily; TID = three times per day; QID = four times per day