• Rapid onset-short duration
• Onset: 15-30 min
• Peak: 0.5-2.5 hours
• Duration: 3-6.5 hours
• Clear
• Administered with meals, or shortly after
• subQ, IV in emergencies
• similar to regular insulin, 2 AA switched= less aggregation

• rapid onset-short duration
• onset: 10-20 min
• peak: 1-3 hours
• duration: 3-5 hours
• clear
• give 5-10 minutes before meals
• available in vials and PenFill cartridges
• subQ, IV in emergencies
• one amino acid different from regular insulin

• rapid onset-short duration
• onset: 10-15 minutes
• peak: 1-1.5 hours
• duration: 3-5 hours
• clear
• 15 min before or 20 min after eating
• subQ, IV in emergencies
• different from regular insulin by 2 AA

• Slower onset-short duration
• onset:30-60 min
• peak:1-5 hours
• duration:6-10 hours
• clear
• OTC
• only insulin available U-500 []
• subQ injection(before meals), subQ infusion(basal glycemic control), IM (rare), inhalation, IV (emergencies)

• intermediate duration
• onset:60-120 min
• Peak:6-14 hours
• duration:16-24 hours
• OTC
• cloudy
• only longer acting that can be mixed with short acting
• injected twice daily to promote glycemic control between meals and during the night
• subQ only
• insulin conjugated with protamine, can cause allergic reactions. decreases solubility and slows absorption

• intermediate duration
• onset: 1-2 hours
• peak:12-24 hour
• duration: dose dependent
• clear
• 1-2 doses, with evening meal or bedtime, basal control
• do not mix with other insulin
• subQ only
• one less AA than regular and has an added fatty acid chain, so molecules bind to each other and albumin

• Long duration
• onset: 70 min
• peak: none
• duration:24 hours
• clear
• only subQ
• once daily at bedtime
• less risk of hypo/hyperglycemia
• 3 AA different from regular, low solubility, forms ppt that slowly dissolves

Bigaunides

Metformin (Glucophage)

• MOA:Inhibits glucose production in the liver, increases insulin sensitivity in fat/skeletal mm, slightly reduces glucose absorption in gut
• Does NOT actively drive down blood sugar
• results equal to insulin for gestational DM
• TU: first drug of choice for type II DM, prevent T2DM, PCOS
• SE:decreased appetite, nausea and vomiting.
• AE: lactic acidosis, AEB hyperventilation, myalgia, malaise, and unusual somnolence. Do not use in pts w/ excess LA (liver disease, severe infection, HX of LA; alcoholics; shock; HF?) or those with renal failure
• Do not take with: alcohol, Cimetidine, or iodinated rasiocontrast media
• can reduce vitamin B12 and folic acid

Sulfonylureas

Glipizide (Glucotrol)

• 2nd generation, more potent, less drug-drug effects
• MOA:primarily increase insulin production, may eventually increase sensitivity too
• TU:T2DM
• AE:Hypoglycemia, esp with kidney/liver disease, cardiovascular toxicity?
• Do not take with:pregnancy, alcohol, B-blockers, cimetidine, NSAIDs, sulfonamides

Glinides

Repaglinide (Prandin)

• MOA: stimulate pancreatic insulin release
• TU:T2DM, can reduce HbA1c by 1.7% over time
• AE: hypoglycemia, esp with liver failure. Must eat within 30 of admin.
• Do not take with:Gemfibrozil, pregnancy
  

Thiazolidinediones

Rosiglitazone (Avandia)

• MOA:decreases insulin resistance, PPAR gamma activation
• TU: T2DM, reduce FBG, HbA1c
• May be combined with insulin(w/ caution-fluid retention) or glucotrol
• AE:Raises LDL, fluid retention-bad in CHF pts, Hepatoxic (ALT-not intensively)
• SE: mild headache, URI, myalgia
• Do not take with: Gemfibrozil

Alpha-glucosidase inhibitors

acarbose (Precose)

• MOA: delay absorption of CHO in intestines, completely independent of insulin. postprandial rise in BG
• Does NOT drive down BG
• TU:T2DM, lowers ppBG and HbA1c
• SE:flatulence, cramps, abdominal distention, borborygmus (rumbling bowel sounds), and diarrhea.
• AE: anemia (less absorption of iron), liver failure
• Do not take with: Glucotrol (GI)