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insulin, NPH, and 70/30 NPH/regular\nproducts can be purchased for consider-ably less than the AWP and NADAC priceslisted in Table 9.4 at select pharmacies. It\nis important to note that although thesecaps, price reductions, use of unbrandedor biosimilar versions of analogs, or useof human insulins may impact the cost | [
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of insulin products, there are no caps on\nthe costs of the other tools individualswith diabetes need for monitoring ortreatment (including glucose monitoringsupplies [strips or sensors], administrationtools [pen needles, syringes, and insulinpumps], ketone testing supplies, and glu-cagon). Therefore, routine assessmen... | [
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financial obstacles that may impact diabe-\ntes management is an important compo-\nnent of effective care of people withdiabetes. Collaboration between mem-\nbers of the health care team and with so-\ncial service professionals to identify andimplement cost reduction strategies tosupport and improve access to evidence- | [
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based care is important (120,130).\nPrandial Insulin\nMany individuals with type 2 diabetes\nrequire doses of insulin before meals, inaddition to basal insulin, to reach glyce-\nmic goals. If an individual is not already\nbeing treated with a GLP-1 RA or dualGIP and GLP-1 RA, a GLP-1 RA (either asan individual product ... | [
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combination with a basal insulin prod-uct) or dual GIP and GLP-1 RA should beconsidered prior to prandial insulin tofurther address prandial control and to\nminimize the risks of hypoglycemia and\nweight gain associated with insulin ther-apy (84,114). For individuals who ad-vance to prandial insulin, a prandial\ninsuli... | [
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insulin dose of 4 units or 10% of the\namount of basal insulin at the largestmeal or the meal with the greatestpostprandial excursion is a safe estimatefor initiating therapy. The prandial insu-\nlin plan can then be intensi fied based\non individual needs ( Fig. 9.4 ). Individu-\nals with type 2 diabetes are generally | [
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als with type 2 diabetes are generally\nmore insulin resistant than those with\ntype 1 diabetes, require higher daily\ndoses ( /C241 unit/kg), and have lower\nrates of hypoglycemia (133). Titrationcan be based on home self-monitored\nblood glucose or CGM. When signi ficant\nadditions to the prandial insulin dose | [
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additions to the prandial insulin dose\nare made, particularly with the eveningmeal, consideration should be given to\ndecreasing basal insulin. Meta-analyses\nof trials comparing rapid-acting insulinanalogs with human regular insulin intype 2 diabetes have not reported im-\nportant differences in A1C or hypoglyce-\nmi... | [
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mia (134,135).\nConcentrated Insulins\nSeveral concentrated insulin prepara-tions are currently available. U-500 reg-\nular insulin is, by de finition, five times\nmore concentrated than U-100 regularS170 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetes... | [
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1. Consider insulin as the first injectable if evidence of ongoing catabolism is present, symptoms of hyperglycemia are present, when A1C or blood glucose levels are very high (i.e., A1C >10% | [
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[>86 mmol/mol] or blood glucose ≥300 mg/dL [≥16.7 mmol/L]), or when a diagnosis of type 1 diabetes is a possibility.2. When selecting GLP-1 RAs, consider individual preference, A1C lowering, weight-lowering effect, or frequency of injection. If CVO is present. consider GLP-1 RA with proven CVO benefit. Oral o\nr | [
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r\n injectable GLP-1 RAs are appropriate.\n3. For people on GLP-1 RA and basal Insulin combination, consider use of a flxed-ratio combination product (IDegLira or iGlarLixi). | [
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4. Consider switching from evening NPH to a basal analog if the individual develops hypoglycemia and/or frequently forgets to administer NPH in the evening and would be better managed wtth an A.M. dose of a long-acting basal Insulin.5. If adding prandial insulin to NPH, consider initiation of a self-mixed or premixe... | [
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initiation of a self-mixed or premixed insulin plan to decrease the number of in jections required. | [
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Figure 9.4 —Intensifying to injectable therapies in type 2 diabetes. DSMES, diabetes self-management education and support; FPG, fasting plasma\nglucose; GLP-1 RA, glucagon-like peptide 1 receptor agonist; dual GIP and GLP-1 RA, dual glucose-dependent insulinotropic polypeptide and glucagon- | [
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like peptide 1 receptor agonist; max, maximum; PPG, postprandial glucose. Adapted from Davies et al. (151).diabetesjournals.org/care Pharmacologic Approaches to Glycemic Treatment S171\n©AmericanDiabetesAssociation | [
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insulin. U-500 regular insulin has distinct\npharmacokinetics with similar onset but a\ndelayed, blunted, and prolonged peak ef-\nfect and longer duration of action com-\npared with U-100 regular insulin; thus, it\nhas characteristics more like a premixed\nintermediate-acting (NPH) and regular in-\nsulin product and ca... | [
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sulin product and can be used as two or\nthree daily injections (136,137). U-300\nglargine and U-200 degludec are three\nand two times as concentrated as theirU-100 formulations, respectively, and al-\nlow higher doses of basal insulin adminis-\ntration per volume used. U-300 glargine\nhas a longer duration of action t... | [
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has a longer duration of action than\nU-100 glargine but modestly lower effi -\ncacy per unit administered (138 –140).\nThe U-200 formulations of insulin deglu-\ndec, insulin lispro, and insulin lispro-aabc\nhave similar pharmacokinetics to their\nU-100 counterparts (141 –143). These | [
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U-100 counterparts (141 –143). These\nconcentrated preparations may be moreconvenient (fewer injections to achievetarget dose) and comfortable (less volume\nto inject target dose and/or less injection\neffort) for individuals and may improve\ntreatment plan engagement in those with\ninsulin resistance who require large... | [
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insulin resistance who require large doses\nof insulin. While U-500 regular insulin is\na v a i l a b l ei nb o t hp r e filled pens and vials,\nother concentrated insulins are avail-able only in pre filled pens to minimize | [
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the risk of dosing errors. If U-500Table 9.3 —Median monthly (30-day) AWP and NADAC of maximum approved daily dose of noninsulin glucose-lowering\nagents in the U.S.\nClass Compound(s)Dosage strength/\nproduct (if applicable)Median AWP\n(min, max)*Median NADAC\n(min, max)*Maximum approved\ndaily dose †\nBiguanides /C15... | [
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0.04329422116279602,
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0.027893856167793274,
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0.03812432661652565,
0.16314294934272766,
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0.020572267472743988,
-0.04209643229842186,
0.03885475546121597,
-0.013638188131153584,
0.009... |
daily dose †\nBiguanides /C15Metformin 500 mg (ER)\n850 mg (IR)\n1,000 mg (IR)\n1,000 mg (ER)\n500 mg (Sol)$89 ($45, $6,719)\n$108 ($5, $189)\n$87 ($3, $144)\n$1,884 ($242, $7,214)\n$405 ($405, $739)$5\n$2$2\n$31 ($31, $226)\n$5352,000 mg2,550 mg2,000 mg\n2,000 mg\n2,000 mg\nSulfonylureas (2nd\ngeneration)/C15Glimepiri... | [
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0.04590124264359474,
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0.0265254694968462,
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0.015205532312393188,
-0.003311... |
generation)/C15Glimepiride\n/C15Glipizide\n/C15Glyburide4m g\n10 mg (IR)\n10 mg (XL/ER)\n6 mg (micronized)\n5m g$73 ($72, $198)\n$72 ($67, $91)\n$48 ($46, $48)\n$54 ($48, $71)\n$82 ($63, $432)$3$6\n$10$12\n$88m g\n40 mg\n20 mg\n12 mg20 mg\nThiazolidinedione /C15Pioglitazone 45 mg $348 ($7, $349) $4 45 mg\na-Glucosidase... | [
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0.0522930771112442,
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0.009428939782083035,
0.1387483924627304,
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0.04652359336614609,
-0.002089701360091567,
0.010755239985883236,
0.015361391007900238,
0.00527... |
a-Glucosidase inhibitors /C15Acarbose\n/C15Miglitol100 mg100 mg$106 ($104, $378)$294 ($241, $346)$27\nNA300 mg300 mg\nMeglitinides /C15Nateglinide\n/C15Repaglinide120 mg\n2m g$155\n$878 ($58, $897)$27$31360 mg\n16 mg\nDPP-4 inhibitors /C15Alogliptin\n/C15Linagliptin\n/C15Saxagliptin\n/C15Sitagliptin25 mg\n5m g\n5m\ng\n... | [
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0.06077074632048607,
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0.006877273321151733,
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-0.0... |
/C15Sitagliptin25 mg\n5m g\n5m\ng\n100 mg$234\n$630\n$524\n$657$161$504\n$466\n$52525 mg\n5m g\n5m g\n100 mg\nSGLT2 inhibitors /C15Canagli flozin\n/C15Dapagli flozin\n/C15Empagli flozin\n/C15Ertugli flozin300 mg\n10 mg\n25 mg15 mg$718\n$678\n$712$408$574\n$543\n$569$328300 mg\n10 mg25 mg15 mg\nGLP-1 RAs /C15Dulaglutide 4.5... | [
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0.026699071750044823,
-0.02300543710589409,
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... |
GLP-1 RAs /C15Dulaglutide 4.5 mg pen $1,117 $895 4.5 mg ‡\n/C15Exenatide 10mg pen $964 $771 20mg\n/C15Exenatide\n(extended release)2 mg pen $990 $793 2 mg ‡\n/C15Liraglutide 1.8 mg pen $1,340 $1,072 1.8 mg\n/C15Semaglutide 1 mg pen $1,123 $903 2 mg ‡\n14 mg (tablet) $1,097 ($1,070, $1,123) $899 14 mg\nDual GIP and GLP-... | [
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0.0009288081782869995,
0.04399879276752472,
-0.026166195049881935,
-0.04767952859401703,
0.0... |
14 mg (tablet) $1,097 ($1,070, $1,123) $899 14 mg\nDual GIP and GLP-1\nreceptor agonist/C15Tirzepatide 15 mg pen $1,228 $982 15 mg ‡\nBile acid sequestrant /C15Colesevelam 625 mg tabs\n3.75 g suspension$711 ($674, $712)\n$674 ($673, $675)$64\n$1303.75 g3.75 g\nDopamine-2 agonist /C15Bromocriptine 0.8 mg $1,200 $965 4.8... | [
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0.010624775663018227,
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0.0483442023396492,
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0.03611933812499046,
0.017006630077958107,
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0.0510... |
Dopamine-2 agonist /C15Bromocriptine 0.8 mg $1,200 $965 4.8 mg\nAmylin mimetic /C15Pramlintide 120mg pen $2,866 NA 120 mg/injection §\nAWP, average wholesale price; DPP-4, dipeptidyl peptidase 4; ER and XL, extended release; GIP, glucose-dependent insulinotropic polypeptide; | [
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0.0237908... |
GLP-1 RA, glucagon-like peptide 1 receptor agonist; IR, immediate release; max, maximum; min, minimum; NA, data not available; NADAC,National Average Drug Acquisition Cost; SGLT2, sodium –glucose cotransporter 2. AWP and NADAC prices as of July 2023. *Calculated for | [
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-0.05418354272842407,
0.047... |
30-day supply (AWP [116] or NADAC [117] unit price × number of doses required to provide maximum approved daily dose × 30 days); me-dian AWP or NADAC listed alone when only one product and/or price. †Used to calculate median AWP and NADAC (min, max); generic prices | [
-0.04271458461880684,
0.030581897124648094,
0.004884280730038881,
-0.055702582001686096,
-0.019105499610304832,
0.0003374344960320741,
0.06848391145467758,
0.15878790616989136,
0.027894053608179092,
0.0184719767421484,
0.019335566088557243,
-0.02686931937932968,
0.02527293749153614,
0.0676... |
used, if available commercially. Prices for bexagli flozin were not available at the time of this update. ‡Administ\n ered once weekly. §AWP and\nNADAC calculated based on 120 mg three times daily.S172 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAs... | [
-0.014831320382654667,
0.05075611546635628,
-0.06551779061555862,
0.05892287567257881,
-0.0582142099738121,
0.03826882317662239,
-0.0036163374315947294,
0.1483219861984253,
-0.011326038278639317,
0.02527426928281784,
-0.018419712781906128,
0.002526521449908614,
-0.0445563830435276,
-0.0063... |
regular insulin vials are prescribed, the\nprescription should be accompanied bya prescription for U-500 syringes tominimize the risk of dosing errors.\nAlternative Insulin Routes\nInsulin is primarily administered via sub-\ncutaneous injection or infusion. Adminis- | [
0.03496924415230751,
0.013505669310688972,
-0.09957469999790192,
-0.016029657796025276,
-0.08099344372749329,
-0.04728242754936218,
0.07457419484853745,
0.07960313558578491,
-0.0695517286658287,
-0.05809752643108368,
-0.0036866609007120132,
0.057853180915117264,
-0.046095311641693115,
0.07... |
cutaneous injection or infusion. Adminis-\ntration devices provide some additionalvariation in the subcutaneous deliverybeyond vial versus insulin pen. Those de-vices include continuous insulin pumps(programmable basal and bolus settingsandfixed basal and bolus settings) and\nbolus-only insulin patch pump. In addition, | [
-0.06479427963495255,
0.01133089791983366,
-0.031316302716732025,
-0.0003827942709904164,
-0.04978931322693825,
-0.05324161425232887,
0.0849270448088646,
0.06683743000030518,
-0.04551149904727936,
0.03167637437582016,
0.07606974244117737,
0.00497936038300395,
-0.02205127291381359,
0.021357... |
bolus-only insulin patch pump. In addition,\nprandial or correction insulin doses may be\nadministered using inhaled human insulin.\nInhaled insulin is available as monomers ofregular human insulin; studies in individualswith type 1 diabetes suggest that inhaledinsulin has pharmacokinetics similar to RAA(7). Studies co... | [
-0.05093124881386757,
0.015951862558722496,
-0.1349032074213028,
0.013852544128894806,
-0.017955373972654343,
-0.07103950530290604,
0.09591775387525558,
0.10174640268087387,
-0.03525184839963913,
-0.0646502822637558,
-0.010003680363297462,
0.10194732993841171,
-0.028683261945843697,
-0.006... |
injectable insulin have demonstrated its\nfaster onset and shorter duration comparedwith the RAA insulin lispro, as well as clini-cally meaningful A1C reductions and weightreductions compared with the RAA insulinaspart over 24 weeks (144 –146). Use of in-\nhaled insulin may result in a decline in lung\nfunction (reduce... | [
-0.03655870258808136,
-0.00015267267008312047,
-0.09969078004360199,
0.08833284676074982,
0.022569973021745682,
-0.032982148230075836,
0.06812462210655212,
0.08585179597139359,
-0.03797491267323494,
0.013347395695745945,
-0.02898264490067959,
0.091790109872818,
-0.011818774044513702,
0.018... |
function (reduced forced expiratory volume\nin 1 second [FEV\n1]). Inhaled insulin is contra-\nindicated in individuals with chronic lungdisease, such as asthma and chronic ob-structive pulmonary disease, and is not rec-ommended in individuals who smoke or\nwho recently stopped smoking. All individu-\nals require spiro... | [
-0.011775888502597809,
0.022429147735238075,
-0.12247756123542786,
0.04742917791008949,
0.060907404869794846,
-0.012845547869801521,
0.05201660469174385,
0.04221203550696373,
0.010601394809782505,
-0.05454077944159508,
0.03510656580328941,
0.06254176795482635,
-0.015805847942829132,
0.0594... |
als require spirometry (FEV\n1) testing to\nidentify potential lung disease prior to andafter starting inhaled insulin therapy.Table 9.4— Median cost of insulin products in the U.S. calculated as AWP and NADAC per 1,000 units of speci fied dosage\nform/product\nInsulins Compounds Dosage form/productMedian AWP\n(min, max... | [
0.007311220746487379,
-0.050076890736818314,
-0.08295232802629471,
0.010925509966909885,
0.012080170214176178,
0.004559034015983343,
0.02481052652001381,
0.07914572954177856,
-0.014511816203594208,
0.0003365728771314025,
0.013644392602145672,
0.027037203311920166,
-0.009677332825958729,
0.... |
(min, max)*Median\nNADAC*\nRapid-acting /C15Aspart U-100 vial $174 † $139 †\nU-100 cartridge $215 † $172 †\nU-100 pre filled pen $224 † $179 †\n/C15Aspart ( “faster acting product ”) U-100 vial $347 $277\nU-100 cartridge $430 $344\nU-100 pre filled pen $447 $357\n/C15Glulisine U-100 vial $341 $273\nU-100 pre filled pen $4... | [
0.011772733181715012,
0.011156849563121796,
-0.04418762028217316,
-0.058183107525110245,
-0.08564344793558121,
-0.004632832016795874,
0.01090709213167429,
0.18866397440433502,
-0.06682098656892776,
-0.012778150849044323,
-0.029795262962579727,
-0.046545203775167465,
-0.012115374207496643,
... |
/C15Glulisine U-100 vial $341 $273\nU-100 pre filled pen $439 $351\n/C15Inhaled insulin Inhalation cartridges $1,503 NA\n/C15Lispro U-100 vial $30 † $24†\nU-100 cartridge $408 $326\nU-100 pre filled pen $127 † $102 †\nU-200 pre filled pen $424 $339\n/C15Lispro-aabc U-100 vial $330 $261\nU-100 pre filled pen $424 $339\nU-20... | [
-0.013387533836066723,
0.08074469864368439,
-0.015724031254649162,
-0.0015944234328344464,
-0.01466965302824974,
-0.0005186854396015406,
0.08532006293535233,
0.0981854498386383,
-0.03214811161160469,
0.006312227807939053,
-0.02656996063888073,
-0.05803520604968071,
-0.031904689967632294,
0... |
U-100 pre filled pen $424 $339\nU-200 pre filled pen $424 $338\n/C15Lispro follow-on product U-100 vial $118 $94\nU-100 pre filled pen $151 $121\nShort-acting /C15Human regular U-100 vial $172 ($165, $178)‡ $137 ($132, $142) ‡\nU-100 pre filled pen $208 $166\nIntermediate-acting /C15Human NPH U-100 vial $172 ($165, $178) ‡... | [
0.011417059227824211,
0.029361765831708908,
-0.019642850384116173,
-0.023266855627298355,
-0.03288250416517258,
0.009612148627638817,
0.048388395458459854,
0.12885768711566925,
-0.0202036052942276,
-0.00375363533385098,
0.013660794124007225,
-0.030723026022315025,
-0.06102681905031204,
0.0... |
U-100 pre filled pen $208 ($208, $377) $234 ($166, $303)\nConcentrated human\nregular insulin/C15U-500 human regular insulin U-500 vial $178 $142\nU-500 pre filled pen $230 $184\nLong-acting /C15Detemir U-100 vial; U-100 pre filled pen $370 $295\n/C15Degludec U-100 vial $142 † $327\nU-100 pre filled pen $142 † $114 †\nU-20... | [
0.0015089657390490174,
0.08880554139614105,
-0.03049837425351143,
0.0036388409789651632,
-0.03292565047740936,
-0.016396498307585716,
0.10328207910060883,
0.08664827793836594,
-0.04422930255532265,
0.004040271043777466,
-0.02565673552453518,
-0.05675385147333145,
-0.08212733268737793,
0.05... |
U-100 pre filled pen $142 † $114 †\nU-200 pre filled pen $85† $113 †\n/C15Glargine U-100 vial; U-100 pre filled pen $136 † $109 †\nU-300 pre filled pen $363 $290\n/C15Glargine biosimilar/\nfollow-on productsU-100 pre filled pen $190 ($74, $323) $95 †\nU-100 vial $118 † $95†\nPremixed insulin products /C15Aspart 70/30 U-100 ... | [
-0.01940583810210228,
0.060991957783699036,
-0.03868364542722702,
0.0028876455035060644,
-0.024592200294137,
-0.008203391917049885,
0.07035782933235168,
0.11380372196435928,
-0.01771412044763565,
-0.01827714964747429,
-0.006312516052275896,
-0.062044888734817505,
-0.0820005014538765,
0.070... |
Premixed insulin products /C15Aspart 70/30 U-100 vial $180 † $145 †\nU-100 pre filled pen $224 † $179 †\n/C15Lispro 50/50 U-100 vial $342 $274\nU-100 pre filled pen $424 $341\n/C15Lispro 75/25 U-100 vial $342 $274\nU-100 pre filled pen $127 † $102 †\n/C15NPH/regular 70/30 U-100 vial $172 ($165, $178)‡ $138 ($132, $143) ‡ | [
0.0047921971417963505,
0.036428552120923996,
-0.03692525252699852,
0.02103654108941555,
-0.0027853352949023247,
0.00030043511651456356,
0.074920654296875,
0.10984843969345093,
-0.029386276379227638,
-0.01361236721277237,
-0.028428934514522552,
-0.051556654274463654,
-0.06735064834356308,
0... |
U-100 pre filled pen $208 ($208, $377) $234 ($166, $302)\nPremixed insulin/GLP-1\nRA products/C15Degludec/liraglutide 100/3.6 mg pre filled pen $991 $795\n/C15Glargine/lixisenatide 100/33 mg pre filled pen $679 $543\nAWP , average wholesale price; GLP-1 RA, glucagon-like peptide 1 receptor agonist; NA, data not available;... | [
-0.001813584822230041,
-0.015552498400211334,
-0.031545575708150864,
0.03512311726808548,
-0.029770242050290108,
-0.00783457700163126,
0.08790585398674011,
0.1034904196858406,
0.04246120527386665,
0.01333603635430336,
-0.02191857062280178,
-0.0026541308034211397,
-0.07550443708896637,
0.03... |
quisition Cost. AWP (116) and NADAC (117) prices as of July 2023. *AWP or NADAC calculated as in Table 9.3 .†Unbranded product prices\nused when available. ‡AWP and NADAC data presented do not include vials of regular human insulin and NPH available at Walmart for ap- | [
-0.04899606108665466,
0.00589048583060503,
-0.029246052727103233,
-0.013274546712636948,
0.031993985176086426,
0.02337060682475567,
0.03450609743595123,
0.11620799452066422,
0.026831071823835373,
0.09048182517290115,
0.022792771458625793,
-0.0365380197763443,
-0.043879903852939606,
-0.0300... |
proximately $25/vial; median listed alone when only one product and/or price.diabetesjournals.org/care Pharmacologic Approaches to Glycemic Treatment S173\n©AmericanDiabetesAssociation | [
0.024758385494351387,
0.0035618243273347616,
-0.06670570373535156,
-0.020806502550840378,
-0.048486173152923584,
-0.05139307305216789,
0.03091217391192913,
0.1503257304430008,
-0.017094017937779427,
-0.014321060851216316,
-0.04649841785430908,
-0.021048326045274734,
-0.009248042479157448,
... |
Combination Injectable Therapy\nIf basal insulin has been titrated to an ac-\nceptable fasting blood glucose level (or if\nt h ed o s ei s >0 . 5u n i t s / k g / d a yw i t hi n d i -\ncations of need for other therapy) and\nA1C remains above goal, consider ad-\nvancing to combination injectable ther-apy ( Fig. 9.4 ).... | [
-0.08874620497226715,
0.00157009472604841,
-0.08434253931045532,
0.03138791769742966,
-0.049458105117082596,
-0.006549188867211342,
0.0769573375582695,
0.06287480890750885,
-0.07891235500574112,
0.04031630605459213,
0.036250997334718704,
0.03316111117601395,
-0.020232588052749634,
0.063708... |
GLP-1 RA or dual GIP and GLP-1 RAadded to basal insulin or multiple dosesof insulin (114,147). The combination of\nbasal insulin and GLP-1 RA (administered\nvia separate injections of individual prod-ucts or single injection of a fixed-ratio | [
-0.02927982062101364,
-0.009385096840560436,
-0.09857550263404846,
0.039927102625370026,
-0.07743562757968903,
-0.02856016531586647,
0.09394578635692596,
0.11428887397050858,
-0.02317066304385662,
-0.003953593783080578,
0.0677831843495369,
0.0390390083193779,
-0.01294148713350296,
0.010099... |
product) has potent glucose-lowering ac-tions and less weight gain and hypoglyce-mia compared with intensifi ed insulin plans\n(148). Two different once-daily, fixed dual\ncombination products containing basal in-sulin plus a GLP-1 RA are available: insulin\nglargine plus lixisenatide (iGlarLixi) and in- | [
-0.08200593292713165,
0.0066485716961324215,
-0.1070268452167511,
0.04376213252544403,
-0.019720008596777916,
-0.003375060623511672,
0.0804782435297966,
0.13836628198623657,
-0.013112396001815796,
-0.03985514119267464,
-0.004872703459113836,
0.029480790719389915,
-0.040867604315280914,
-0.... |
glargine plus lixisenatide (iGlarLixi) and in-\nsulin degludec plus liraglutide (IDegLira). Inselect individuals with type 2 diabetes,\ncomplex insulin plans can also be simpli fied\nwith fixed-ratio GLP-1 RA-insulin product\n(149).\nIntensi fication of insulin treatment can\nbe done by adding doses of prandial insu- | [
-0.037468887865543365,
-0.007301670964807272,
-0.09728268533945084,
-0.0032524913549423218,
-0.04612782597541809,
-0.05564159154891968,
0.0761052668094635,
0.11628804355859756,
-0.043109308928251266,
-0.008288239128887653,
0.001884539844468236,
0.06492774188518524,
-0.0612991638481617,
0.0... |
be done by adding doses of prandial insu-\nlin to basal insulin. Starting with a singleprandial dose with the largest meal of the\nday is simple and effective, and it can be\nadvanced to a plan with multiple prandialdoses if necessary (150). Alternatively, for\nan individual on basal insulin in whom ad- | [
0.01017625443637371,
0.0731939971446991,
-0.07221458852291107,
-0.0115009481087327,
-0.07294485718011856,
-0.024069858714938164,
0.06566952168941498,
0.06066024675965309,
-0.1039995402097702,
0.007022297475486994,
0.05038388818502426,
-0.02058798260986805,
-0.03083690255880356,
-0.00974549... |
an individual on basal insulin in whom ad-\nditional prandial coverage is desired butadministering insulin prior to one or more\nmeal(s) is not feasible, the medication\nplan can be converted to two doses of apremixed insulin. Each approach has ad-\nvantages and disadvantages. For example,\nbasal-prandial plans offer g... | [
-0.04005562141537666,
0.06070965528488159,
-0.09749661386013031,
-0.00608277739956975,
-0.0042278035543859005,
0.014994989149272442,
0.1156652569770813,
0.09730704128742218,
-0.035843584686517715,
0.016314014792442322,
0.0456734262406826,
0.0422905758023262,
-0.018895629793405533,
0.007536... |
basal-prandial plans offer greater flexibility\nfor individuals who eat on irregular sched-\nules. On the other hand, two doses of\npremixed insulin is a simple, convenientmeans of spreading insulin across the day.\nMoreover, human insulins, separately, self-\nmixed, or as premixed NPH/regular (70/30)formulations, are l... | [
0.01520669087767601,
-0.0001352046092506498,
-0.061709050089120865,
0.013850084505975246,
-0.013603254221379757,
0.01171024888753891,
0.07219026982784271,
0.09897936880588531,
0.0017596156103536487,
0.03540201857686043,
0.04843118041753769,
0.02232062816619873,
-0.04743114113807678,
-0.006... |
to insulin analogs. Figure 9.4 outlines these\noptions as well as recommendations for\nfurther intensi fication, if needed, to achieve\nglycemic goals. When initiating intensifi ca-\ntion of insulin therapy, metformin, SGLT2inhibitors, and GLP-1 RA (or dual GIP and\nGLP-1 RA) should be maintained, while | [
-0.06445896625518799,
-0.035726066678762436,
-0.0901481956243515,
0.04243040457367897,
-0.09350532293319702,
-0.023933090269565582,
0.0983637198805809,
0.08067861199378967,
-0.05868442356586456,
-0.04737679660320282,
-0.020512647926807404,
-0.010010951198637486,
-0.0512496642768383,
0.0316... |
GLP-1 RA) should be maintained, while\nsulfonylureas and DPP-4 inhibitors aretypically weaned or discontinued. In indi-\nviduals with suboptimal blood glucose | [
-0.03766024485230446,
-0.007473223842680454,
-0.08135034143924713,
0.0032755977008491755,
-0.0030704024247825146,
-0.0402328297495842,
-0.0645219087600708,
0.11184129118919373,
0.005397610832005739,
-0.042650189250707626,
-0.016093965619802475,
0.0823996365070343,
-0.13130635023117065,
0.0... |
management, especially those requiringlarge insulin doses, adjunctive use of athiazolidinedione or an SGLT2 inhibitormay help to improve control and reducethe amount of insulin needed, althoughpotential side effects should be consid-ered. Once a basal-bolus insulin plan is ini-tiated, dose titration is important, witha... | [
-0.015524767339229584,
0.0470251701772213,
-0.09672398120164871,
0.04719683527946472,
-0.03673088923096657,
-0.01993289776146412,
0.09420584887266159,
0.10425616055727005,
-0.04964269697666168,
-0.02248246967792511,
0.046275544911623,
0.06358975917100906,
-0.001651660306379199,
0.047086797... |
ini-tiated, dose titration is important, withadjustments made in both mealtime andbasal insulins based on the blood glucoselevels and an understanding of the phar-macodynamic pro file of each formulation | [
-0.062130119651556015,
0.036666806787252426,
-0.08591233193874359,
0.007932160049676895,
-0.024726292118430138,
-0.024639515206217766,
0.13450312614440918,
0.09049743413925171,
0.03128618746995926,
-0.026714898645877838,
-0.011353249661624432,
0.007418945897370577,
-0.004057513549923897,
0... |
(also known as pattern control or patternmanagement). In some people with type 2diabetes with signi ficant clinical complex-\nity, multimorbidity, and/or treatment bur-den, it may become necessary to simplifyor deintensify complex insulin plans to de-crease risk of hypoglycemia and improvequality of life (see Section 13... | [
-0.04426547884941101,
0.016492927446961403,
-0.08773089945316315,
0.021433139219880104,
-0.07147905230522156,
-0.02688300795853138,
0.029792536050081253,
0.0497683510184288,
-0.04663487523794174,
0.004782507196068764,
0.026057392358779907,
0.08478040248155594,
-0.04848960041999817,
0.01139... |
Adults ”).\nReferences\n1. Diabetes Control and Complications Trial\n(DCCT)/Epidemiology of Diabetes Interventionsand Complications (EDIC) Study Research Group.Mortality in type 1 diabetes in the DCCT/EDICversus the general population. Diabetes Care\n2016;39:1378– 1383\n2. Lachin JM, Bebu I; DCCT/EDIC Research Group. | [
0.007531919050961733,
0.02079872041940689,
-0.012900002300739288,
0.065666563808918,
-0.05285414308309555,
0.008523272350430489,
-0.025581102818250656,
0.09564774483442307,
-0.054113663733005524,
0.00814971886575222,
-0.0141545245423913,
0.017732048407197,
-0.07377117872238159,
-0.04058821... |
2016;39:1378– 1383\n2. Lachin JM, Bebu I; DCCT/EDIC Research Group.\nThe bene ficial effects of earlier versus later\nimplementation of intensive therapy in type 1diabetes. Diabetes Care 2021;44:2225 –2230\n3. Lachin JM; DCCT/EDIC Research Group.Understanding metabolic memory: the prolongedinfluence of glycemia during th... | [
0.013583951629698277,
0.008337557315826416,
-0.08615702390670776,
0.12978489696979523,
0.01170910894870758,
0.05700220167636871,
0.0024795278441160917,
0.13959474861621857,
-0.06466715037822723,
-0.01051776111125946,
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0.15601147711277008,
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and Complications Trial (DCCT) on future risks of\ncomplications during the study of the Epidemiology\nof Diabetes Interventions and Complications (EDIC).Diabetes Care 2021;44:2216– 2224 | [
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4. Holt RIG, DeVries JH, Hess-Fischl A, et al. Themanagement of type 1 diabetes in adults. aconsensus report by the American DiabetesAssociation (ADA) and the European Associationfor the Study of Diabetes (EASD). Diabetes Care2021;44:2589– 2625 | [
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5. Tricco AC, Ashoor HM, Antony J, et al. Safety,effectiveness, and cost effectiveness of longacting versus intermediate acting insulin forpatients with type 1 diabetes: systematic reviewand network meta-analysis. BMJ 2014;349:g5459\n6. Bartley PC, Bogoev M, Larsen J, Philotheou A.\nLong-term ef ficacy and safety of ins... | [
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-0.0052... |
Long-term ef ficacy and safety of insulin detemir\ncompared to neutral protamine Hagedorn insulin\nin patients with Type 1 diabetes using a treat-to-\ntarget basal-bolus regimen with insulin aspart atmeals: a 2-year, randomized, controlled trial.Diabet Med 2008;25:442– 449 | [
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7. DeWitt DE, Hirsch IB. Outpatient insulintherapy in type 1 and type 2 diabetes mellitus:scienti fic review. JAMA 2003;289:2254– 2264\n8. Aronson R, Biester T, Leohr J, et al. Ultra rapidlispro showed greater reduction in postprandial\nglucose versus Humalog in children, adolescents | [
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0.08397553116083145,
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0.0... |
glucose versus Humalog in children, adolescents\nand adults with type 1 diabetes mellitus. DiabetesObes Metab 2023;25:1964– 1972 | [
-0.019844509661197662,
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0.06802897155284882,
-0.12067861109972,
0.012100... |
9. Heise T, Pieber TR, Danne T, Erichsen L, HaahrH. A pooled analysis of clinical pharmacologytrials investigating the pharmacokinetic andpharmacodynamic characteristics of fast-actinginsulin aspart in adults with type 1 diabetes. Clin\nPharmacokinet 2017;56:551 –559\n10. Bode BW, McGill JB, Lorber DL, Gross JL, Chang | [
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0.032... |
10. Bode BW, McGill JB, Lorber DL, Gross JL, Chang\nPC; Af finity 1 Study Group. Inhaled technosphere\ninsulin compared with injected prandial insulin in\ntype 1 diabetes: a randomized 24-week trial.\nDiabetes Care 2015;38:2266 –2273\n11. Russell-Jones D, Bode BW, De Block C, et al. | [
0.02015269547700882,
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-0.0... |
11. Russell-Jones D, Bode BW, De Block C, et al.\nFast-acting insulin aspart improves glycemic controlin basal-bolus treatment for type 1 diabetes: results\nof a 26-week multicenter, active-controlled, treat-\nto-target, randomized, parallel-group trial (onset 1).Diabetes Care 2017;40:943 –950 | [
-0.053913459181785583,
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-0.08245456218719482,
... |
12. Klaff L, Cao D, Dellva MA, et al. Ultra rapidlispro improves postprandial glucose control\ncompared with lispro in patients with type 1\ndiabetes: results from the 26-week PRONTO-T1Dstudy. Diabetes Obes Metab 2020;22:1799– 1807\n13. Lane W , Bailey TS, Gerety G, et al.; Group\nInformation; SWITCH 1. Effect of insul... | [
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-0.10157618671655655,
-0.03956653... |
Information; SWITCH 1. Effect of insulin degludec\nvs insulin glargine U100 on hypoglycemia inpatients with type 1 diabetes: the SWITCH 1randomized clinical trial. JAMA 2017;318:33– 44\n14. Home PD, Bergenstal RM, Bolli GB, et al.\nNew insulin glargine 300 units/mL versus glargine | [
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0.005791787523776293,
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0.0... |
New insulin glargine 300 units/mL versus glargine\n100 units/mL in people with type 1 diabetes: arandomized, phase 3a, open-label clinical trial\n(EDITION 4). Diabetes Care 2015;38:2217– 2225\n15. Yeh HC, Brown TT, Maruthur N, et al. | [
-0.00994760449975729,
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0.05932322144508362,
-0.0664985403418541,
0.... |
15. Yeh HC, Brown TT, Maruthur N, et al.\nComparative effectiveness and safety of methodsof insulin delivery and glucose monitoring fordiabetes mellitus: a systematic review and meta-\nanalysis. Ann Intern Med 2012;157:336– 347\n16. Speight J, Choudhary P, Wilmot EG, et al. | [
0.0031061838380992413,
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-0.07107314467430115,
0.061158377677202225,
-0.051639165729284286,
0.0164... |
16. Speight J, Choudhary P, Wilmot EG, et al.\nImpact of glycaemic technologies on quality oflife and related outcomes in adults with type 1diabetes: a narrative review. Diabet Med 2023;\n40:e14944\n17. Barnard K, Skinner T. Cross-sectional study\ninto quality of life issues surrounding insulinpump use in type 1 diabet... | [
-0.02593856304883957,
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-0.022048603743314743,
0.10564912855625153,
-0.05826986953616142,
-0.020... |
2008;25:194– 200\n18. Mulinacci G, Alonso GT, Snell-Bergeon JK,\nShah VN. Glycemic outcomes with early initiation\nof continuous glucose monitoring system inr\necently diagnosed patients with type 1 diabetes.\nDiabetes Technol Ther 2019;21:6– 10 | [
-0.05305706709623337,
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-0.061841025948524475,
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-0... |
Diabetes Technol Ther 2019;21:6– 10\n19. Elbalshy M, Haszard J, Smith H, et al. Effectof divergent continuous glucose monitoringtechnologies on glycaemic control in type 1\ndiabetes mellitus: a systematic review and meta-\nanalysis of randomised controlled trials. DiabetMed 2022;39:e14854\n20. Champakanath A, Akturk HK... | [
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-0.08862871676683426,
-0... |
20. Champakanath A, Akturk HK, Alonso GT ,\nSnell-Bergeon JK, Shah VN. Continuous glucose\nmonitoring initiation within first year of type 1\ndiabetes diagnosis is associated with improved\nglycemic outcomes: 7-year follow-up study. Dia-betes Care 2022;45:750– 753 | [
-0.015950527042150497,
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0.00720... |
21. Weinstock RS, Xing D, Maahs DM, et al.; T1DExchange Clinic Network. Severe hypoglycemiaand diabetic ketoacidosis in adults with type 1diabetes: results from the T1D Exchange clinic\nregistry. J Clin Endocrinol Metab 2013;98:3411–\n3419\n22. Tamborlane WV, Beck RW, Bode BW, et al.; | [
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0.015004914253950119,
-0.11128156632184982,
0.011... |
3419\n22. Tamborlane WV, Beck RW, Bode BW, et al.;\nJuvenile Diabetes Research Foundation ContinuousGlucose Monitoring Study Group. Continuous\nglucose monitoring and intensive treatment of\ntype 1 diabetes. N Engl J Med 2008;359:1464–1476S174 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Volume 47, Supp... | [
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©AmericanDiabetesAssociation | [
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10. Cardiovascular Disease and\nRisk Management: Standards of\nCare in Diabetes— 2024\nDiabetes Care 2024;47(Suppl. 1):S179 –S218 |https://doi.org/10.2337/dc24-S010American Diabetes Association\nProfessional Practice Committee *\nThe American Diabetes Association (ADA) “Standards of Care in Diabetes ”includes | [
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the ADA ’s current clinical practice recommendations and is intended to provide the\ncomponents of diabetes care, general treatment goals and guidelines, and tools to\nevaluate quality of care. Members of the ADA Professional Practice Committee, an in-\nterprofessional expert committee, are responsible for updating the... | [
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0.0... |
annually, or more frequently as warranted. For a detailed description of ADA stand-ards, statements, and reports, as well as the evidence-grading system for ADA’ sc l i n i - | [
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-0.0... |
cal practice recommendations and a full list of Professional Practice Committeemembers, please refer to Introduction and Methodology. Readers who wish to com-ment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.\nFor prevention and management of diabetes complications in children and adol... | [
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0... |
cents, please refer to Section 14, “Children and Adolescents .”\nAtherosclerotic cardiovascular disease (ASCVD) —defined as coronary heart disease\n(CHD), cerebrovascular disease, or peripheral artery disease (PAD) presumed to be of\natherosclerotic origin —is the leading cause of morbidity and mortality for individuals | [
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with diabetes and results in an estimated $39.4 billion in cardiovascular-related spend-\ning per year associated with diabetes (1). Common conditions coexisting with type 2\ndiabetes (e.g., hypertension and dyslipidemia) are clear risk factors for ASCVD, and dia-\nbetes itself confers independent risk. Numerous studie... | [
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controlling individual cardiovascular risk factors in preventing or slowing ASCVD in peo-ple with diabetes. Furthermore, large bene fits are seen when multiple cardiovascular\nrisk factors (glycemic, blood pressure, and lipid control) are addressed simultaneously,\nwith evidence for legacy benefi ts (2–4). Under the curr... | [
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factor modi fication in people with diabetes, there is evidence that measures of\n10-year CHD risk among U.S. adults with diabetes have improved signi ficantly over\nthe past decade (5) and that ASCVD morbidity and mortality have decreased (3,6).\nHeart failure is another major cause of morbidity and mortality from cardi... | [
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disease. The American Diabetes Association (ADA) has developed a consensus reportto summarize guidance for the screening, diagnosis, and treatment of people with di-\nabetes (7). Recent studies have found that rates of incident heart failure hospitaliza-tion (adjusted for age and sex) were twofold higher in people with... | [
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compared with those without (8,9). People with diabetes may present with a wide\nspectrum of heart failure, including heart failure with preserved ejection fraction(HFpEF), heart failure with mildly reduced ejection fraction (HFmEF), or heart failure\nwith reduced ejection fraction (HFrEF). Hypertension is often a prec... | [
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ure of either type, and ASCVD can coexist with either type of heart failure (10),\nwhereas prior myocardial infarction (MI) is often a major factor in HFrEF. Recent trials\nincluding people with type 2 diabetes, most of whom also had ASCVD, have shown*A complete list of members of the American | [
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Diabetes Association Professional Practice Committeecan be found at https://doi.org/10.2337/dc24-SINT.\nDuality of interest information for each author is\navailable at https://doi.org/10.2337/dc24-SDIS.\nThis section has received endorsement from the\nAmerican College of Cardiology.\nSuggested citation: American Diabe... | [
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Suggested citation: American Diabetes Asso-\nciation Professional Practice Committee. 10.Cardiovascular disease and risk management:S t a n d a r d so fC a r ei nD i a b e t e s —2024 .D i a b e t e s\nCare 2024;47(Suppl. 1):S179– S218 | [
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Care 2024;47(Suppl. 1):S179– S218\n© 2023 by the American Diabetes Association.Readers may use this article as long as thework is properly cited, the use is educationaland not for pro fit, and the work is not altered. | [
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More information is available at https://www.diabetesjournals.org/journals/pages/license.10. CARDIOVASCULAR DISEASE AND RISK MANAGEMENTDiabetes Care Volume 47, Supplement 1, January 2024 S179\n©AmericanDiabetesAssociation | [
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that rates of heart failure hospitalization\nsignifi cantly decreased with use of\nsodium –glucose cotransporter 2 (SGLT2)\ninhibitors (11 –14).\nA recent meta-analysis indicated that | [
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inhibitors (11 –14).\nA recent meta-analysis indicated that\nSGLT2 inhibitors reduce the risk of heartfailure hospitalization, cardiovascular mor-tality, and all-cause mortality in peoplewith (secondary prevention) and without(primary prevention) cardiovascular dis-\nease (15).\nFor prevention and management of\nboth A... | [
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both ASCVD and heart failure, cardio-\nvascular risk factors should be systemati-cally assessed at least annually in all\npeople with diabetes. These risk factors\ninclude duration of diabetes, obesity/overweight, hypertension, dyslipidemia,smoking, a family history of premature\ncoronary disease, chronic kidney diseas... | [
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coronary disease, chronic kidney disease\n(CKD), and the presence of albuminuria.Modi fiable abnormal risk factors should\nbe treated as described in these guide-\nlines. Notably, the majority of evidence | [
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