University of Illinois Chicago College of Pharmacy, Department of Pharmacy Practice (Drs. Elmes and Jarrett); University of Illinois College of Medicine at Chicago (Drs. Loza and Wells) jarrett8@uic.edu
The authors reported no potential conflict of interest relevant to this article.
Even if cost weren’t an issue, many medications such as insulin and GLP-1 receptor agonists should be kept refrigerated and are only stable at room temperature for a limited time. Medications that are stable at room temperature should be prioritized in patients with limited or inconsistent access to refrigeration or unstable housing who may find it difficult to store their medications appropriately.
Do not delay insulin initiation in patients with high baseline A1C
Whenever possible, a GLP-1 receptor agonist is the preferred injectable medication to insulin. Starting insulin introduces numerous risks, including hypoglycemia, weight gain, and stigma. However, in the patient with newly diagnosed T2D, choose basal insulin when the baseline hyperglycemia is severe,34 as indicated by:
blood glucose > 300 mg/dL (16.7 mmol/L),
A1C > 10% (86 mmol/mol),
symptoms of hyperglycemia (polyuria or polydipsia), or
evidence of catabolism (weight loss, hypertriglyceridemia, ketosis).
Basal insulin analogs are preferred over NPH given their reduced variability, dosing, and hypoglycemic risk.35 Mixed insulins may be used if a patient is unable to afford an insulin analog, which can be quite costly. However, extensive counseling on dosing and management of hypoglycemia is crucial to patient safety with these agents. The ADA recommends initiating 0.1 to 0.2 units/kg of basal insulin daily or 10 units daily.34 The AACE follows this recommendation for patients with baseline A1C < 8%, but it proposes a more aggressive initiation of 0.2 to 0.3 units/kg/d for patients with baseline A1C > 8%.35 Titrate the dose by 2 units every 3 days to reach the target fasting blood glucose level. As hyperglycemia resolves, simplify the regimen and transition to noninsulin options per the previously discussed considerations.
It’s not just about glycemic control
In addition to the direct effects of hyperglycemia, a T2D diagnosis introduces an increased risk for ASCVD, a reduced ability to fight infection, and heightened risk for depression. Order a lipid panel at the time of T2D diagnosis and initiate lipid management as needed (TABLE 335,63,64). Both the ADA and the American Heart Association recommend starting a moderate-intensity statin as primary prevention for all patients with T2D between 40 and 75 years of age regardless of the 10-year ASCVD risk.63 The AACE uses specific lipid targets and recommends moderate- to high-intensity statin therapy for patients with T2D.35 All recommendations by professional organizations list high-intensity statins for patients with established ASCVD.
Both the ADA and the AHA recommend starting a moderate-intensity statin as primary prevention for all patients with T2D between 40 and 75 years of age regardless of the 10-year ASCVD risk.
It is also vital to recommend that patients with newly diagnosed T2D remain up to date on all indicated vaccinations. They should promptly receive the hepatitis B and pneumococcal vaccines if they have not already done so for a previous indication. COVID-19 and annual influenza vaccines also should be prioritized for these patients.65
Finally, patients with diabetes are twice as likely to develop depression than patients without diabetes.66 Individuals with T2D and depression exhibit poorer medication adherence, lifestyle choices, and glycemic control.66 Screen for and treat these issues in all patients with T2D across the course of the disease.
Overall, work closely with patients to support them in managing their new diagnosis with evidence-based pharmacologic and nonpharmacologic approaches. The importance of lifestyle changes including high-fiber diets, regular exercise, and weight loss should not be overlooked. Do not delay starting pharmacotherapy after diagnosing T2D and consider medication-specific and patient-specific factors to individualize therapy, improve adherence, and prevent complications.
CORRESPONDENCE Jennie B. Jarrett, PharmD, MMedEd, 833 South Wood Street (MC 886), Chicago, IL 60612; jarrett8@uic.edu
