Comorbidities
“I take a water pill for my heart failure.”
Consider
- ASCVD: GLP 1RA, SGLT2i
- HF or CKD: SGLT2i (adjust doses of all diabetes agents for renal function)
Avoid
- ASCVD: thiazolidinediones
- HF: thiazolidinediones , saxagliptin
- CKD: thiazolidinediones
Contraindications and Adverse Effects
“I get up to go to the bathroom several times each night.”
Consider
- ↓ Weight: GLP 1RA, SGLT2i
- ↓ Volume and blood pressure: SGLT2i
Avoid
- ↑ Weight: insulin, thiazolidinedione
- ↑ Diarrhea: metformin
- ↑ Urination: SGLT2i
- Pancreatitis: GLP 1RA and DPP 4i
- Thyroid tumors: GLP 1RA
Cost
“Sometimes I split tablets to save money.”
Consider
- Low-cost agents (metformin, thiazolidinediones, sulfonylureas, human insulin)
Avoid
- High-cost agents (GLP 1RA, SGLT2i, DPP 4i, insulin analogs)
Health Equity and Access
“I can’t drive to get healthy foods or to exercise classes.”
Consider
- Home exercise options, low-cost meal delivery services, low-cost transportation services, involve case manager or social worker
Avoid
- Recommending diet and exercise options that are not accessible to patient
Functional Status and Support
“My family member helps me take my medicines.”
Consider
- Cognitive or functional challenges: simple oral regimen, no blood glucose testing
- Fall risk: low hypoglycemia risk agents
- Assistance: involve others (ie, visiting nurse, paid caregiver, etc) in medication management
Avoid
- Regimen that is burdensome to patient and family or does not align with patient goals and support system
Notes:
ASCVD = atherosclerotic cardiovascular disease, HF = heart failure, CKD = chronic kidney disease