Table 3.
Key monitoring and risk mitigation strategies for preferred glucose-lowering agents
| Medication | Consideration | Monitoring and/or risk mitigation strategies |
|---|---|---|
| Metformin | Metformin-associated lactic acidosis | • Monitor eGFR with increasing frequency as eGFR falls to <60 mL/min/1.73 m2 |
| • Adjust metformin dose as appropriate per eGFR (see Table 4) | ||
| • Consider dose reduction in the presence of conditions that predispose patients to hypoperfusion and hypoxemia for eGFR 45–59 mL/min/1.73 m2 | ||
| • Discontinue for eGFR <30 mL/min/1.73 m2 | ||
| • Institute a sick day protocol | ||
| B12 malabsorption | • Monitor patients for vitamin B12 deficiency when treated with metformin for >4 years | |
| SGLT2i | Genital mycotic infections | • Counsel on genital hygiene |
| Volume depletion | • Monitor for hypovolemia and consider proactive dose reduction of diuretics in patients at high risk | |
| • Hold SGLT2i during illness | ||
| Diabetic ketoacidosis | • Educate about signs/symptoms to facilitate early recognition | |
| • Monitor blood or urine ketones in the case of very high risk | ||
| • Institute a sick day protocol | ||
| • Maintain at least low-dose insulin in insulin-requiring individuals | ||
| Hypoglycemia | • Adjust background glucose-lowering agents (e.g., insulin or sulfonylureas) as appropriate | |
| GLP-1 receptor agonists | Nausea/vomiting/diarrhea | • Educate on tolerability and symptom recognition |
| • Start at lowest recommended dose and titrate slowly | ||
| Hypoglycemia | • Adjust background glucose-lowering agents (e.g., insulin or sulfonylureas) as appropriate |
eGFR, estimated glomerular filtration rate; GLP-1, glucagon-like peptide 1; SGLT2i, sodium–glucose cotransporter 2 inhibitor.