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choosing among insulin delivery systems,\nindividual preferences, cost, insulin type,dosing plan, and self-management capabil-ities should be considered. See Section 7,\n“Diabetes Technology, ”for a full discussion\nof insulin delivery devices.\nIn general, individuals with type 1 dia-\nbetes require approximately 30 –... | [
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betes require approximately 30 –50% of\ntheir daily insulin as basal and the re-mainder as prandial (43). This proportion\nis dependent on a number of factors,diabetesjournals.org/care Pharmacologic Approaches to Glycemic Treatment S159\n©AmericanDiabetesAssociation | [
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including but not limited to carbohydrate\nconsumption, age, pregnancy status, andpuberty stage (4,44– 48). Total daily insulin\nrequirements can be estimated based onweight, with typical doses ranging from\n0.4 to 1.0 units/kg/day. Higher amounts\nmay be required during puberty, menses,and medical illness. The America... | [
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tes Association/JDRF Type 1 Diabetes\nSourcebook notes 0.5 units/kg/day as a\ntypical starting dose in adults with type 1\ndiabetes who are metabolically stable,with approximately one-half administered\nas prandial insulin given to manage blood | [
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as prandial insulin given to manage blood\nglucose after meals and the remainingportion as basal insulin to manage glyce-mia in the periods between meal absorp-tion (49). Starting doses and those soon\nafter diagnosis may be higher, if an individ-\nual presents with ketoacidosis, or lower(0.2–0.6 units/kg), particularl... | [
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children and those with continued endoge-\nnous insulin production (during the partial\nremission phase or “honeymoon period,”\nor in people who present with type 1 dia-betes in adulthood) (49 –52). This guideline\nprovides detailed information on intensi fi- | [
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provides detailed information on intensi fi-\ncation of therapy to meet individualizedneeds. In addition, the American DiabetesAssociation (ADA) position statement “Type 1\nDiabetes Management Through the Life\nSpan” provides a thorough overview of\ntype 1 diabetes treatment (53).\nTypical multidose treatment plans for | [
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type 1 diabetes treatment (53).\nTypical multidose treatment plans for\nindividuals with type 1 diabetes combine\npremeal use of prandial insulins with a\nlonger-acting formulation. The long-acting\nbasal dose is titrated to regulate overnightand fasting glucose. Postprandial glucoseexcursions are best managed by a wel... | [
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timed injection or inhalation of prandial\ninsulin. Prandial insulin should ideally beadministered prior to meal consumption;however, the optimal time to administer\nvaries based on the pharmacokinetics of | [
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varies based on the pharmacokinetics of\nthe formulation (regular, RAA, or inhaled),the premeal blood glucose level, and carbo-hydrate consumption. Recommendationsfor prandial insulin dose administration\nshould therefore be individualized. Physio- | [
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should therefore be individualized. Physio-\nlogic insulin secretion varies with glycemia,meal size, meal composition, and tissue de-mands for glucose. To approach this vari-\nability in people using insulin treatment,\nstrategies have evolved to adjust prandialdoses based on predicted needs. Thus, edu-cation on how to... | [
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account for nutritional intake and the cor-\nrection dose based on premeal glucoselevels, anticipated activity, and sick-daymanagement can be effective and should\nbe offered to most individuals (54 –59). Ed- | [
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be offered to most individuals (54 –59). Ed-\nucation regarding adjustment of prandialinsulin dose for glycemic trends should beprovided to individuals who are using CGMalone or an AID system (60 –63). Further ad-\njustment of prandial insulin doses for nutri-tional intake of protein and fat, in additionto carbohydrate... | [
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be more feasible for individuals using CSII\nthan for those using multiple daily injections(56). With some AID systems, use of a sim-plified meal announcement method may\nbe an alternative for prandial insulin dosing(31,64) (see Section 5, “Facilitating Positive\nHealth Behaviors and Well-being to Im-prove Health Outcom... | [
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“Diabetes Technology ”).\nD u et ot h er i s ko fh y p o g l y c e m i aw i t h\ninsulin treatment, all individuals withtype 1 diabetes should be prescribed glu-cagon. Individuals with type 1 diabetesand/or those in close contact with indi-viduals with type 1 diabetes should beeducated on the use and administration | [
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of the individual ’s prescribed glucagon\nproduct. The glucagon product availableto individuals may differ based on cover-\nage and cost, however those that do notrequire reconstitution are preferred forease of administration (65,66). Clinicians\nshould routinely review the individual ’sa c -\ncess to glucagon, as appr... | [
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cess to glucagon, as appropriate glucagon\nprescribing is low (67,68). See Section 6,“Glycemic Goals and Hypoglycemia, ”\nfor additional information on hypoglycemiaa n dg l u c a g o ni ni n d i v i d u a l sw i t hd i a b e t e s .The 2021 ADA/European Association forthe Study of Diabetes (EASD) consensus re-\nport on... | [
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port on the management of type 1 diabe-\ntes in adults summarizes different insulinplans and glucose monitoring strategies in\nindividuals with type 1 diabetes (Fig. 9.1\nandTable 9.1 )( 4 ) .\nInsulin Administration Technique\nEnsuring that individuals and/or caregiversunderstand correct insulin administrationtechniqu... | [
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mic management and insulin use safety.\nThus, it is important that insulin be deliv-ered into the proper tissue in the correctway. Recommendations have been pub-\nlished elsewhere outlining best practices\nGreater flexibilityRepresentative relative attributes of insulin deliveryRepresentative relative attributes of ins... | [
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approaches in people with type 1 diabetesapproaches in people with type 1 diabetes1\nInjected insulin plans Greater flexibility Higher costsLower risk of\nhypoglycemia\nHigher costsLower risk of\nhypoglycemiaContinuous insulin infusion plansMDI with LAA + RAA or URAA\nMDI with NPH + RAA or URAA\nMDI with NPH + short-ac... | [
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MDI with NPH + short-acting (regular) insulin\nAutomated Insulin delivery systems\nInsulin pump therapy without automationInsulin pump with threshold/\npredictive low-glucose suspendTwo daily injections with NPH + short-acting (regular)\ninsulin or premixedLess-preferred, alternative injected insulin plans | [
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insulin or premixedLess-preferred, alternative injected insulin plans\nFigure 9.1 —Choices of insulin plans in people with type 1 diabetes. Continuous glucose moni-\ntoring improves outcomes with injected or infused insulin and is superior to blood glucose | [
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monitoring. Inhaled insulin may be used in place of injectable prandial insulin in the U.S.1The\nnumber of plus signs ( 1) is an estimate of relative association of the plan with increased flexi- | [
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bility, lower risk of hypoglycemia, and higher costs between the considered plans. LAA, long-acting insulin analog; MDI, multiple daily injections; RAA, rapid-acting insulin analog; URAA,ultra-rapid-acting insulin analog. Adapted from Holt et al. (4).S160 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Vol... | [
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to Glycemic Treatment Diabetes Care Volume 47, Supplement 1, January 2024 | [
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©AmericanDiabetesAssociation | [
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for insulin administration (69). Proper insu-\nlin administration technique includes injec-tion or infusion (for CSII or AID systems)into appropriate body areas, injection orinfusion site rotation, appropriate careof injection or infusion sites to avoidinfection or other complications, and\navoidance of intramuscular (... | [
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avoidance of intramuscular (IM) insulin\ndelivery. Selection of method of admin-istration (vial and syringe, insulin pen,connected insulin pens/devices, or in-sulin pumps) will depend on a varietyof individual-speci fic factors and needs,\ncost and coverage, and individual prefer-\nences. Reassessment of the appropriate | [
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ences. Reassessment of the appropriate\nadministration technique via whichevermethod is used should be completed dur-ing routine follow-up.\nExogenously delivered insulin should\nbe injected into subcutaneous tissue, notintramuscularly. Recommended sites for\ninsulin administration include the abdo- | [
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insulin administration include the abdo-\nmen, thigh, buttock, and upper arm. Insu-lin absorption from IM sites differs fromthat in subcutaneous sites and is alsoinfluenced by the activity of the muscle.\nInadvertent IM injection can lead to un-predictable insulin absorption and vari- | [
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able effects on glucose and is associatedwith frequent and unexplained hypoglyce-\nmia. Risk for IM insulin delivery isincreased in younger, leaner individualswhen injecting into the limbs rather thantruncal sites (abdomen and buttocks) andwhen using longer needles. Recent evi-dence supports the use of short needles | [
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(e.g., 4-mm pen needles) as effective and\nw e l lt o l e r a t e dw h e nc o m p a r e dw i t hl o n -ger needles, including a study performedin adults with obesity (70).\nInjection or infusion site rotation is\nadditionally necessary to avoid lipohy-pertrophy, an accumulation of subcuta-\nneous fat in response to the... | [
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neous fat in response to the adipogenic\nactions of insulin at a site of multipleinjections. Lipohypertrophy appears assoft, smooth raised areas several centi-meters in breadth and can contribute toerratic insulin absorption, increased gly-cemic variability, and unexplained hypo-\nglycemic episodes. People treated with | [
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-0.0016... |
glycemic episodes. People treated with\ninsulin and/or caregivers should receiveeducation about proper injection or infu-sion site rotation and how to recognizeand avoid areas of lipohypertrophy. Asnoted in Table 4.1 , examination of insulin\ninjection sites for the presence of lipohy- | [
0.046356480568647385,
-0.03958550840616226,
-0.03777342662215233,
0.045340053737163544,
-0.10599695146083832,
0.012961165979504585,
0.028963832184672356,
0.057764675468206406,
-0.11206576228141785,
-0.06832834333181381,
0.029934844002127647,
0.02634088322520256,
-0.07644149661064148,
-0.02... |
pertrophy, as well as assessment ofadministration device use and injectiontechnique, are key components of a com-prehensive diabetes medical evaluationand treatment plan. Proper insulin injec-tion or infusion technique may lead tomore effective use of this therapy and, assuch, holds the potential for improvedclinical o... | [
-0.0381426177918911,
0.04694339260458946,
-0.06368028372526169,
-0.0060350485146045685,
-0.0899331197142601,
0.058260057121515274,
0.10762438178062439,
0.10709552466869354,
0.0008264602511189878,
0.005942431278526783,
-0.014901742339134216,
0.040848176926374435,
-0.028109105303883553,
0.01... |
Noninsulin Treatments for Type 1\nDiabetes\nInjectable and oral glucose-lowering med-\nications have been studied for their ef fi-\ncacy as adjunct to insulin treatment of\ntype 1 diabetes. Pramlintide is based onthe naturally occurring b-cell peptide | [
-0.04455353319644928,
-0.03988192602992058,
-0.13632822036743164,
0.020977912470698357,
-0.03421810641884804,
0.03997756168246269,
0.12350523471832275,
0.1173175722360611,
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0.00416833208873868,
-0.016089938580989838,
0.09731678664684296,
-0.08312324434518814,
-0.00758... |
amylin and is approved for use in adultswith type 1 diabetes. Clinical trials havedemonstrated a modest reduction in A1C(0.3–0.4%) and modest weight loss\n(/C241 kg) with pramlintide (71). Similar results | [
-0.037705738097429276,
-0.00821489468216896,
-0.04008592292666435,
0.052241455763578415,
0.008664693683385849,
-0.009670739993453026,
0.09800039976835251,
0.10983560979366302,
0.04730688035488129,
-0.033046964555978775,
-0.05413886159658432,
0.10245770215988159,
-0.08848918229341507,
-0.00... |
(/C241 kg) with pramlintide (71). Similar results\nhave been reported for several agentscurrently approved only for the treatmentof type 2 diabetes. The addition of met-formin in adults with type 1 diabetes wasassociated with small reductions in bodyweight, insulin dose, and lipid levels butdid not sustainably improve ... | [
-0.08747923374176025,
-0.005053882487118244,
-0.10755126923322678,
0.06791696697473526,
-0.06150611862540245,
0.011519196443259716,
0.06457039713859558,
0.17137591540813446,
-0.0016053352737799287,
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-0.020514750853180885,
0.03549765422940254,
-0.07370520383119583,
-0.... |
The largest clinical trials of glucagon-like\nSimplified overview of indications for Simplified overview of indications for ββ-cell replacement therapy in people with type 1 diabetes-cell replacement therapy in people with type 1 diabetes\nSevere diabetic chronic kidney disease\n(GFR <30 mL mln−1 [1.73 m]−2)Hypoglycemi... | [
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-0.0199297983199358,
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0.025725150480866432,
0.10675498843193054,
0.011751974932849407,
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0.09139975160360336,
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-0... |
(GFR <30 mL mln−1 [1.73 m]−2)HypoglycemiaHypoglycemia\nKetoacidosisKetoacidosis\nImpaired kidney functionImpaired kidney function\nSimultaneous transplantationSimultaneous transplantation Living donor kidneyLiving donor kidney\nPancreas afterPancreas after\nkidneykidneyIslet afterIslet after\nkidneykidneySimultaneousSi... | [
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-0.03711923956871033,
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-0.02833334170281887,
-0.03000326082110405,
-0.06812231242656708,
0.051885440945625305,
0.08971519768238068,
-0.03584596887230873,
-0.017746245488524437,
0.04003958776593208,
-0.030602479353547096,
-0.03269036486744881,
-0.... |
kidneykidneySimultaneousSimultaneous\npancreas andpancreas and\nkidneykidneySimultaneousSimultaneous\nislet and kidneyislet and kidneyPancreasPancreas\ntransplantationtransplantation\nalonealoneIsletIslet\ntransplantationtransplantation | [
-0.02658647485077381,
-0.004665846936404705,
0.02478429302573204,
-0.050882913172245026,
-0.11811849474906921,
-0.047887831926345825,
0.06706448644399643,
0.04253806918859482,
-0.016581103205680847,
-0.028297539800405502,
0.0796218290925026,
0.0019154385663568974,
0.02940896525979042,
0.02... |
alonealoneIsletIslet\ntransplantationtransplantation\nalonealoneIntact/stable kidney functionIntact/stable kidney functionIncapacitating problems with exogenous insulin therapyIncapacitating problems with exogenous insulin therapy\nFailure of insulin-based management to prevent acuteFailure of insulin-based management ... | [
-0.07428388297557831,
0.029832199215888977,
-0.026690689846873283,
0.017815038561820984,
-0.0802672952413559,
-0.011288139037787914,
0.06439781934022903,
0.06920136511325836,
-0.029209930449724197,
-0.06220916658639908,
0.03492341190576553,
0.047734614461660385,
-0.00838872417807579,
-0.00... |
complicationscomplicationsHypoglycemia unawarenessHypoglycemia unawarenessSevere metabolic complications\nBalancing surgical risk, metabolic need, and the choice of the individual with diabetes\nFigure 9.2 —Simpli fied overview of indications for b-cell replacement therapy in people with type 1 diabetes. The two main fo... | [
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0.03522564843297005,
0.003647223813459277,
0.035142019391059875,
-0.07924281060695648,
0.06583210080862045,
0.08656275272369385,
0.11034999042749405,
-0.05274997279047966,
-0.01524407509714365,
-0.07322079688310623,
0.023462289944291115,
-0.06060735508799553,
-0.07240... |
ment therapy are whole-pancreas transplantation or islet cell transplantation. b-Cell replacement therapy can be combined with kidney transplan-\ntation if the individual has end-stage renal disease, which may be performed simultaneously or after kidney transplantation. All decisions about | [
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-0.027987319976091385,
-0.09579721093177795,
0.011208840645849705,
0.062139276415109634,
0.036765988916158676,
-0.016314346343278885,
-0.02098262868821621,
-0.04369782283902168,
0.0633719339966774,
-0.02400847151875496,
0.03... |
transplantation must balance the surgical risk, metabolic need, and the choice of the individual with diabetes. GFR, glomerular filtration rate.\nReprinted from Holt et al. (4).diabetesjournals.org/care Pharmacologic Approaches to Glycemic Treatment S161\n©AmericanDiabetesAssociation | [
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0.008588231168687344,
-0.04787198081612587,
-0.05137158930301666,
-0.05748838558793068,
-0.04119613766670227,
0.0012961792526766658,
0.042104676365852356,
-0.04718960076570511,
-0.018459444865584373,
-0.004582983907312155,
0.0337279736995697,
-0.009493544697761536,
0... |
Table 9.1 —Examples of subcutaneous insulin treatment plans\nPlans Timing and distribution Advantages Disadvantages Adjusting doses\nPlans that more closely mimic normal insulin secretion\nInsulin pump therapy (also\nincluding AID systems: hybrid\nclosed-loop, low-glucosesuspend, CGM-augmented\nopen-loop, BGM-augmented | [
-0.09265420585870743,
-0.0007462450885213912,
-0.09580069780349731,
0.0037099546752870083,
-0.028545133769512177,
-0.0043012057431042194,
0.037633366882801056,
0.12304213643074036,
-0.10218649357557297,
-0.010251377709209919,
0.0149419279769063,
0.10288061946630478,
-0.018306178972125053,
... |
open-loop, BGM-augmented\nopen-loop)Basal delivery of URAA or RAA;\ngenerally 30 –50% of TDD.\nMealtime and correction: URAA or\nRAA by bolus based on ICR and/or\nISF and target glucose, with\npremeal insulin /C2415 min\nbefore eating.Can adjust basal rates for varying\ninsulin sensitivity by time of day,for exercise, ... | [
-0.018166037276387215,
-0.048879995942115784,
-0.09369353204965591,
0.011873101815581322,
-0.08444900810718536,
-0.018688440322875977,
0.04576174169778824,
0.09555056691169739,
-0.04817880317568779,
0.021002208814024925,
0.051708340644836426,
0.016170835122466087,
-0.0670422688126564,
-0.0... |
insulin sensitivity by time of day,for exercise, and for sick days.\nFlexibility in meal timing and\ncontent.\nPump can deliver insulin in\nincrements of fractions of units.\nPotential for integration with CGM\nfor AID systems.\nTIR % highest and TBR % lowest\nwith: hybrid closed-loop >low-\nglucose suspend >CGM-\naugm... | [
-0.022434614598751068,
0.018132653087377548,
-0.10972808301448822,
0.012371672317385674,
-0.02140328474342823,
0.03150666505098343,
0.07314002513885498,
0.10279438644647598,
-0.09574995189905167,
-0.03294254094362259,
-0.026150410994887352,
0.008028090931475163,
-0.010125567205250263,
0.03... |
glucose suspend >CGM-\naugmented open-loop >BGM-\naugmented open-loop.Most expensive plan.Must continuously wear one or more\ndevices.\nRisk of rapid development of ketosis\nor DKA with interruption of insulindelivery.\nPotential reactions to adhesives and\nsite infections.\nMost technically complex approach | [
-0.0690263956785202,
0.05448061600327492,
-0.06403351575136185,
-0.0048955935053527355,
-0.058096881955862045,
-0.019108114764094353,
0.007619801908731461,
0.08824548125267029,
-0.03299777954816818,
0.03951508551836014,
-0.002521288814023137,
0.015880439430475235,
-0.1035752221941948,
0.04... |
site infections.\nMost technically complex approach\n(harder for people with lowernumeracy or literacy skills).Mealtime insulin: if carbohydrate\ncounting is accurate, change ICR ifglucose after meal consistently outof target.\nCorrection insulin: adjust ISF and/or\ntarget glucose if correction doesnot consistently bri... | [
0.01511088665574789,
0.01899968832731247,
-0.0394337996840477,
-0.016153763979673386,
-0.012055482715368271,
-0.04798717051744461,
0.03606594353914261,
0.07848116010427475,
-0.012623948976397514,
0.018206946551799774,
-0.011492865160107613,
0.0053855907171964645,
-0.03809595853090286,
0.11... |
range.\nBasal rates: adjust based on\novernight, fasting or daytime\nglucose outside of activity of\nURAA/RAA bolus.\nMDI: LAA 1flexible doses of URAA\nor RAA at mealsLAA once daily (insulin detemir or\ninsulin glargine may require twice-daily dosing); generally 30 –50% of\nTDD.\nMealtime and correction: URAA or | [
0.027549361810088158,
-0.008197127841413021,
-0.11641616374254227,
0.0273401141166687,
-0.12514443695545197,
-0.02387845143675804,
-0.00136020896025002,
0.10038741677999496,
-0.01638110727071762,
-0.01078390795737505,
0.05510830134153366,
-0.0272758100181818,
-0.05295972526073456,
-0.00362... |
TDD.\nMealtime and correction: URAA or\nRAA based on ICR and/or ISF andtarget glucose.Can use pens for all components.\nFlexibility in meal timing and\ncontent.\nInsulin analogs cause less\nhypoglycemia than human insulins.At least four daily injections.Most costly insulins.\nSmallest increment of insulin is | [
-0.06572321802377701,
0.0034979640040546656,
-0.0753985345363617,
-0.005757486447691917,
-0.03572027012705803,
0.015674319118261337,
0.07970152795314789,
0.10030154883861542,
0.016227785497903824,
0.06590837985277176,
0.021310392767190933,
0.06156657636165619,
-0.06773477792739868,
0.04909... |
Smallest increment of insulin is\n1 unit (0.5 unit with some pens).LAAs may not cover strong dawn\nphenomenon (rise in glucose in\nearly morning hours) as well as\npump therapy.Mealtime insulin: if carbohydrate\ncounting is accurate, change ICR if\nglucose after meal consistently out\nof target.\nCorrection insulin: ad... | [
0.0013368567451834679,
-0.0014566521858796477,
-0.0841132402420044,
-0.01920258440077305,
0.013388460502028465,
0.004795518238097429,
0.056498389691114426,
0.07684703171253204,
0.0038124690763652325,
0.007564125582575798,
0.036816712468862534,
-0.03308314457535744,
-0.06608846783638,
0.007... |
of target.\nCorrection insulin: adjust ISF and/or\ntarget glucose if correction does\nnot consistently bring glucose into\nrange.\nLAA: based on overnight or fasting\nglucose or daytime glucoseoutside of activity time course, orURAA or RAA injections.\nMDI plans with less flexibility\nFour injections daily with fixed | [
-0.0009591360576450825,
0.06013527512550354,
-0.09282056242227554,
0.04058631509542465,
0.007884669117629528,
-0.008522734977304935,
0.052802082151174545,
0.0582689605653286,
-0.02190563641488552,
0.009243720211088657,
0.009345006197690964,
0.029280083253979683,
-0.0429544672369957,
-0.003... |
MDI plans with less flexibility\nFour injections daily with fixed\ndoses of N and RAAPre-breakfast: RAA /C2420%\n of TDD.\nPre-lunch: RAA /C2410% of TDD.\nPre-dinner: RAA /C2410% of TDD.\nBedtime: N /C2450% of TDD.May be feasible if unable to\ncarbohydrate count.\nAll meals have RAA coverage.\nN is less expensive than LA... | [
-0.009433011524379253,
0.033454183489084244,
-0.05514919385313988,
-0.027724191546440125,
-0.0412081740796566,
-0.010752126574516296,
-0.05661388114094734,
0.08389776200056076,
-0.0755201205611229,
-0.011044017039239407,
-0.041555050760507584,
0.04646458476781845,
0.022898683324456215,
-0.... |
N is less expensive than LAAs.Shorter duration RAA may lead to\nbasal de ficit during day; may need\ntwice-daily N.\nGreater risk of nocturnal\nhypoglycemia with N.\nRequires relatively consistent\nmealtimes and carbohydrateintake.Pre-breakfast RAA: based on BGM\nafter breakfast or before lunch.\nPre-lunch RAA: based on... | [
-0.0068392218090593815,
-0.0008287570672109723,
-0.06044727563858032,
0.060283370316028595,
-0.024978041648864746,
0.017831506207585335,
-0.01711239106953144,
0.09259773045778275,
0.00044912032899446785,
-0.004406042862683535,
0.024870850145816803,
-0.0017983330180868506,
-0.0748355388641357... |
Pre-lunch RAA: based on BGM after\nlunch or before dinner.\nPre-dinner RAA: based on BGM after\ndinner or at bedtime.\nEvening N: based on fasting or\novernight BGM.\nContinued on p. S163S162 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
-0.05407140403985977,
-0.006709915120154619,
-0.07472427934408188,
0.0530046708881855,
-0.0764721930027008,
0.04252360016107559,
0.013910557143390179,
0.09185758978128433,
-0.046509068459272385,
-0.01988045684993267,
-0.0019517646869644523,
0.051900334656238556,
-0.041663508862257004,
-0.0... |
Table 9.1 —Continued\nPlans Timing and distribution Advantages Disadvantages Adjusting doses\nFour injections daily with fixed\ndoses of N and RPre-breakfast: R /C2420% of TDD.\nPre-lunch: R /C2410% of TDD.\nPre-dinner: R /C2410% of TDD.\nBedtime: N /C2450% of TDD.May be feasible if unable to\ncarbohydrate count.\nR can... | [
0.001275814138352871,
-0.021667588502168655,
-0.010152879171073437,
-0.02906050719320774,
-0.031887754797935486,
0.02222258597612381,
0.020846083760261536,
0.16112323105335236,
-0.09465529024600983,
-0.010915294289588928,
0.001691243378445506,
0.018715985119342804,
0.011213104240596294,
0.... |
carbohydrate count.\nR can be dosed based on ICR and\ncorrection.\nAll meals have R coverage.\nLeast expensive insulins.Greater risk of nocturnal\nhypoglycemia with N.\nGreater risk of delayed post-meal\nhypoglycemia with R.\nRequires relatively consistent\nmealtimes and carbohydrateintake.\nR must be injected at least... | [
0.015775814652442932,
0.03641446307301521,
-0.08762042224407196,
0.044581349939107895,
-0.01596984826028347,
0.018753284588456154,
0.04723721370100975,
0.09054585546255112,
-0.047484833747148514,
-0.03851193189620972,
-0.027500854805111885,
-0.016687149181962013,
-0.03195495903491974,
0.04... |
mealtimes and carbohydrateintake.\nR must be injected at least 30 min\nbefore meal for better effect.Pre-breakfast R: based on BGM after\nbreakfast or before lunch.\nPre-lunch R: based on BGM after\nlunch or before dinner.\nPre-dinner R: based on BGM after\ndinner or at bedtime.\nEvening N: based on fasting or\novernig... | [
-0.024451548233628273,
-0.01921660639345646,
0.007503791246563196,
0.020744990557432175,
-0.065374456346035,
0.03593432158231735,
-0.004132436588406563,
0.058641184121370316,
-0.05589951574802399,
-0.08020759373903275,
-0.004207253456115723,
0.0010463327635079622,
-0.033255256712436676,
0.... |
dinner or at bedtime.\nEvening N: based on fasting or\novernight BGM.\nPlans with fewer daily injections\nThree injections daily: N 1Ro r\nN1RAAPre-breakfast: N /C2440% TDD 1Ro r\nRAA/C2415% TDD.\nPre-dinner: R or RAA /C2415% TDD.\nBedtime: N /C2430% TDD.Morning insulins can be mixed in one\nsyringe.\nMay be appropriat... | [
-0.02422880008816719,
0.06388963013887405,
-0.04717117175459862,
0.048300955444574356,
-0.04921175539493561,
-0.014310061000287533,
0.03344229981303215,
0.022144867107272148,
-0.04660141468048096,
-0.05378012731671333,
-0.0451374351978302,
0.006450694520026445,
-0.06755781918764114,
0.0462... |
syringe.\nMay be appropriate for those who\ncannot take injection in middle of\nday.\nMorning N covers lunch to some\nextent.\nSame advantages of RAAs over R.Least (N 1R) or less expensive\ninsulins than MDI with analogs.Greater risk of nocturnal\nhypoglycemia with N than LAAs.\nGreater risk of delayed post-meal\nhypog... | [
-0.003915763460099697,
0.021770145744085312,
-0.02331562340259552,
0.02231125347316265,
-0.02953832410275936,
-0.018560098484158516,
0.06864212453365326,
0.11574367433786392,
-0.04741334915161133,
0.019867215305566788,
-0.012031234800815582,
0.04497300460934639,
-0.0038444260135293007,
0.0... |
Greater risk of delayed post-meal\nhypoglycemia with R than RAAs.\nRequires relatively consistent\nmealtimes and carbohydrate\nintake.\nCoverage of post-lunch glucose often\nsuboptimal.\nR must be injected at least 30 min\nbefore meal for better effect.Morning N: based on pre-dinner\nBGM.\nMorning R: based on pre-lunch... | [
-0.03676343709230423,
0.025445643812417984,
-0.08537814021110535,
0.08431022614240646,
0.01594509370625019,
0.010643932968378067,
0.008600162342190742,
0.13173730671405792,
-0.058783017098903656,
0.01565568335354328,
-0.03743379935622215,
0.056728191673755646,
-0.01001893263310194,
0.01117... |
BGM.\nMorning R: based on pre-lunch BGM.\nMorning RAA: based on post-\nbreakfast or pre-lunch BGM.\nPre-dinner R: based on bedtime\nBGM.\nPre-dinner RAA: based on post-\ndinner or bedtime BGM.\nEvening N: based on fasting BGM.\nTwice-daily “split-mixed ”:N1Ro r\nN1RAAPr\ne-breakfast: N /C2440% TDD 1Ro r\nRAA/C2415% TDD... | [
-0.05873280018568039,
-0.038033436983823776,
-0.0059915222227573395,
0.031620703637599945,
-0.06703288108110428,
0.014304207637906075,
0.0015640499768778682,
0.06977919489145279,
-0.06828206777572632,
-0.050404950976371765,
-0.002348513575270772,
-0.031182358041405678,
-0.04307094216346741,
... |
RAA/C2415% TDD.\nPre-dinner: N /C2430% TDD 1Ro r\nRAA/C2415% TDD.Least number of injections for people\nwith strong preference for this.\nInsulins can be mixed in one syringe.\nLeast (N 1R) or less (N 1RAA)\nexpensive insulins vs. analogs.\nEliminates need for doses during the\nday.Risk of hypoglycemia in afternoon or\... | [
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0.016976170241832733,
-0.0413026325404644,
0.041566... |
day.Risk of hypoglycemia in afternoon or\nmiddle of night from N.\nFixed mealtimes and meal content.Coverage of post-lunch glucose often\nsuboptimal.\nDifficult to reach targets for blood\nglucose without hypoglycemia.Morning N: based on pre-dinner\nBGM.\nMorning R: based on pre-lunch BGM.Morning RAA: based on post-\nbr... | [
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0.08256539702415466,
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breakfast or pre-lunch BGM.\nEvening R: based on bedtime BGM.\nEvening RAA: based on post-dinner\nor bedtime BGM.\nEvening N: based on fasting BGM.\nAID, automated insulin delivery; BGM, blood glucose monitoring; CGM, continuous glucose monitoring; ICR, insulin-to-carbohydrate ratio; ISF, insulin sensitivity factor; LA... | [
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0.00035503122489899397,
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0.03... |
tiple daily injections; N, NPH insulin; R, short-acting (regular) insulin; RAA, rapid-acting analog; TBR, time below range; TDD, total daily insulin dose; TIR, time in range; URAA, ultra-rapid-acting analog.\nAdapted from Holt et al. (4).diabetesjournals.org/care Pharmacologic Approaches to Glycemic Treatment S163\n©Am... | [
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peptide 1 receptor agonists (GLP-1 RAs)\nin type 1 diabetes have been conductedwith liraglutide 1.8 mg daily, and resultsshowed modest A1C reductions ( /C240.4%),\ndecreases in weight ( /C245 kg), and reduc-\ntions in insulin doses (74,75). Similarly,sodium –glucose cotransporter 2 (SGLT2)\ninhibitors have been studied... | [
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inhibitors have been studied in clinical tri-\nals in people with type 1 diabetes, andresults showed improvements in A1C, re-duced body weight, and improved bloodpressure (76); however, SGLT2 inhibitoru s ei nt y p e1d i a b e t e sw a sa s s o c i a t e dw i t h\nan increased rate of DKA. The SGLT1/2 in-\nhibitor sota... | [
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-0.0734536424279213,
0.02... |
hibitor sotagli flozin has been studied in\nclinical trials in people with type 1 diabe-\ntes, and results showed improvements inA1C and body weight (77); however, sota-gliflozin use was associated with an eight-\nfold increase in DKA compared with | [
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0.05... |
fold increase in DKA compared with\nplacebo (78). The studies that led to theapproved indication for heart failure (HF)excluded individuals with type 1 diabetesor a history of DKA (79,80). See section\nPRE-\nVENTION AND TREATMENT OF HEART FAILURE within\nSection 10, “Cardiovascular Disease and\nRisk Management, ”for in... | [
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0.01... |
Risk Management, ”for information on risk\nmitigation with the use of SGLT inhibitors\nin those with type 1 diabetes. The risksand benefi ts of adjunctive agents continue\nto be evaluated, with consensus statementsproviding guidance on patient selection\nand precautions (81).\nThere are currently no approved thera- | [
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0.015218275599181652,
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0.018179498612880707,
0.04409221187233925,
0.06670890003442764,
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0.0006... |
and precautions (81).\nThere are currently no approved thera-\npies for preservation of C-peptide or de-\nlaying the progression of clinical type 1diabetes. Higher C-peptide levels havebeen associated with better A1C, lower\nrisk of retinopathy, lower risk of nephropa- | [
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0.04... |
risk of retinopathy, lower risk of nephropa-\nthy, and lower risk of severe hypoglycemia(82). Several therapies, including verapamiland monoclonal antibodies, are currentlyunder active investigation.\nSURGICAL TREATMENT FOR TYPE 1\nDIABETES\nPancreas and Islet Transplantation\nSuccessful pancreas and islet transplanta- | [
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Successful pancreas and islet transplanta-\ntion can normalize glucose levels and miti-gate microvascular complications of type 1\ndiabetes. However, people receiving these | [
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... |
diabetes. However, people receiving these\ntreatments require lifelong immunosup-pression to prevent graft rejection and/orrecurrence of autoimmune islet destruc-tion. Given the potential adverse effectsof immunosuppressive therapy, pancreas\ntransplantation should be reserved for | [
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0.0023580139968544245,
0.05370553210377693,
-0.03940625861287117,
0.04981... |
transplantation should be reserved for\npeople with type 1 diabetes undergoingsimultaneous kidney transplantation,following kidney transplantation, or for\nthose with recurrent ketoacidosis or se-\nvere hypoglycemia despite intensive gly- | [
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0.01701662316918373,
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0.03243772312998772,
0.0037371814250946045,
-0.055353179574012756,
-0.01... |
vere hypoglycemia despite intensive gly-\ncemic management (83). In much of theworld, allogenic islet transplantation isregulated as an organ transplant. How-ever, in the U.S., allogenic islet transplan-tation is regulated as a cell therapy, andthefirst such allogeneic islet cell therapy, | [
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0.03963030129671097,
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donislecel-jujn, was approved in 2023.Donislecel is indicated for the treatmentof adults with type 1 diabetes who areunable to approach their A1C goal be-cause of current repeated episodes ofsevere hypoglycemia despite intensivediabetes management and education.\nThe 2021 ADA/EASD consensus report | [
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0.013536905869841576,
0.005320222582668066,
0.0692545473575592,
0.036348335444927216,
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0.06880197674036026,
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The 2021 ADA/EASD consensus report\non the management of type 1 diabetesin adults offers a simplifi ed overview of\nindications for b-cell replacement ther-\napy in people with type 1 diabetes ( Fig.\n9.2)( 4 ) .\nPHARMACOLOGIC THERAPY FOR\nADULTS WITH TYPE 2 DIABETES\nRecommendations\n9.8Healthy lifestyle behaviors, di... | [
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0.05777721852064133,
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9.8Healthy lifestyle behaviors, dia-\nbetes self-management education\nand support, avoidance of therapeuticinertia, and social determinants of healthshould be considered in the glucose-lowering management of type 2 dia-\nbetes. A\n9.9A person-centered shared decision-\nmaking approach should guide the | [
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0.0972052812576294,
0.08717222511768341,
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0.046116914600133896,
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making approach should guide the\nchoice of pharmacologic agents foradults with type 2 diabetes. Considerthe effects on cardiovascular and re-nal comorbidities; effectiveness; hypo-glycemia risk; impact on weight, cost\nand access; risk for adverse reactions\nand tolerability; and individual prefer-ences ( Fig. 9.3 and... | [
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0.15052255988121033,
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0.06206301227211952,
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-... |
9.10 The glucose-lowering treatment\nplan should consider approaches thatsupport weight management goals(Fig. 9.3 andTable 9.2 ) for adults with\ntype 2 diabetes. A\n9.11 For adults with type 2 diabetes,\nuse pharmacological strategies that pro-\nvide suf ficient effectiveness to achieve\nand maintain the intended treat... | [
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0.07934893667697906,
0.006048681680113077,
0.02011280134320259,
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0.04535616189241409,
0.12624883651733398,
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0.04291822761297226,
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-0.018898... |
and maintain the intended treatment\ngoals. A\n9.12 Treatment modi fication (inten-\nsification or deintensi fication) for\nadults not meeting individualizedtreatment goals should not be de-layed. A9.13 Medication plan and medication-\ntaking behavior should be reevaluated at\nregular intervals (e.g., every 3 –6m o n t h ... | [
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0.08446379005908966,
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0.06306733191013336,
0.07107697427272797,
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0.06795562... |
regular intervals (e.g., every 3 –6m o n t h s )\nand adjusted as needed to incorporatespecifi c factors that impact choice of\ntreatment ( Fig. 4.1 andTable 9.2 ).E\n9.14 Early combination therapy can\nbe considered in adults with type 2diabetes at treatment initiation to\nshorten time to attainment of indi-\nvidualize... | [
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0.042714986... |
shorten time to attainment of indi-\nvidualized treatment goals. A\n9.15 In adults with type 2 diabetes\nwithout cardiovascular and/or kidneydisease, pharmacologic agents shouldaddress both the individualized glyce-mic and weight goals ( Fig. 9.3 ).A\n9.16 In adults with type 2 diabetes | [
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9.16 In adults with type 2 diabetes\nwho have not achieved their individual-ized glycemic goals, selection of subse-quent glucose-lowering agents shouldtake into consideration the individual-ized glycemic and weight goals as wellas the presence of other metabolic co-morbidities and the risk of hypoglyce-mia. A\n9.17 In... | [
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9.17 In adults with type 2 diabetes\nwho have not achieved their individu-alized weight goals, additional weightmanagement interventions (e.g.,intensi fication of lifestyle modi fica-\ntions, structured weight managementprograms, pharmacologic agents, ormetabolic surgery, as appropriate) arerecommended. A\n9.18 In adults... | [
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9.18 In adults with type 2 diabetes\nand established or high risk of ath-erosclerotic cardiovascular disease,heart failure (HF), and/or chronic\nkidney disease (CKD), the treatment\nplan should include agent(s) that re-duce cardiovascular and kidney diseaserisk (e.g., sodium –glucose cotransporter | [
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2 inhibitor [SGLT2] and/or glucagon-likepeptide 1 receptor agonist [GLP-1 RA])(Fig. 9.3, Table 9.2 ,Table 10.3B ,a n d\nTable 10.3C ) for glycemic management\nand comprehensive cardiovascular riskr\neduction, independent of A1C and in\nconsideration of person-speci ficf a c t o r s\n(Fig. 9.3) (see Section 10, “Cardiova... | [
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(Fig. 9.3) (see Section 10, “Cardiovascular\nDisease and Risk Management,” for de-\ntails on cardiovascular risk reduction rec-ommendations). A\n9.19 In adults with type 2 diabetes\nwho have HF (with either reducedor preserved ejection fraction), anSGLT2 inhibitor is recommended, forglycemic management and prevention | [
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of HF hospitalizations (see Section 10,S164 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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“Cardiovascular Disease and Risk\nManagement,” for details on cardio-\nvascular risk reduction recommenda-\ntions). A\n9.20 In adults with type 2 diabetes\nw h oh a v eC K D( w i t hc o n firmed esti-\nmated glomerular filtration rate [eGFR]\nof 20 –60 mL/min per 1.73 m2and/or | [
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0.11346990615129471,
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0.04156386852264404,
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of 20 –60 mL/min per 1.73 m2and/or\nalbuminuria), an SGLT2 inhibitor shouldbe used for minimizing progression ofCKD, reduction in cardiovascular events,and reduction in hospitalizations for HF\n(Fig. 9.3); however, the glycemic bene-\nfits of SGLT2 inhibitors are reduced at\neGFR<45 mL/min per 1.73 m\n2(see\nSection 11,... | [
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2(see\nSection 11, “Chronic Kidney Disease and\nRisk Management ”for details on renal\nrisk reduction recommendations). A\n9.21 In adults with type 2 diabetes\nand advanced CKD (eGFR <30 mL/min\nper 1.73 m2), a GLP-1 RA is preferred\nfor glycemic management due to lower\nrisk of hypoglycemia and for cardiovas-cular eve... | [
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risk of hypoglycemia and for cardiovas-cular event reduction. B\n9.22 In adults with type 2 diabetes, | [
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9.22 In adults with type 2 diabetes,\ninitiation of insulin should be consid-ered regardless of background glucose-lowering therapy or disease stage ifthere is evidence of ongoing catabolism(e.g., unexpected weight loss), if symp-toms of hyperglycemia are present, orwhen A1C or blood glucose levels are veryhigh (i.e., ... | [
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or blood glucose $300 mg/dL\n[$16.7 mmol/L]). E\n9.23 In adults with type 2 diabetes, a\nGLP-1 RA, including a dual glucose-dependent insulinotropic polypeptide(GIP) and GLP-1 RA, is preferred to in-sulin ( Fig. 9.4 ).A\n9.24 If insulin is used, combination | [
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9.24 If insulin is used, combination\ntherapy with a GLP-1 RA, including adual GIP and GLP-1 RA, is recom-mended for greater glycemic effective-ness as well as bene ficial effects on\nweight and hypoglycemia risk for adultswith type 2 diabetes. Insulin dosingshould be reassessed upon addition ordose escalation of a GLP-... | [
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