Diabetes medication

Non-insulin anti diabetic medications

Mechanism of Action:
↓ insulin resistance
↓  hepatic glucose output
↑  peripheral glucose utilisation
↑ glucose turnover between intestine and liver

Main elimination route: Renal

Precautions: GI intolerance Lactic acidosis (rare) Renal impairment, any hypoglycaemic condition



Name: Metformin

Starting dose: 500mg bd

Max dose: 1g bd

Mechanism of Action:
Directly ↑insulin secretion Binds to SUR1 – stimulates β-cells by closure of K+-ATP channels

Main elimination route: Renal 60%

Precautions: Hypoglycaemia Selection restricted by severe liver or renal disease, or porphyria


Name: Gliclazide

Starting dose: 40mg od

Max dose: 320mg/24hrs


Name: Gliclazide SR

Starting dose: 30mg od

Max dose: 120mg od

Mechanism of Action:
Directly ↑ insulin secretion Binds to benzamido site on SUR1 – stimulates βcells by closure of K+- ATP channels Rapid onset, short duration of action

Main elimination route: Hepatic, Heptatic

Precautions: Lesser risk of hypoglycaemia (fewer and less severe than with sulphonylureas) Liver or severe renal disease


Names: Nateglinide

Starting dose: 60 mg with each meal

Max dose: 540mg


Names: Repaglinide

Starting dose: 0.5g with meals

Max dose: 16g

Mechanism of Action:
↑ insulin secretion Inhibition of DPP-4 allows increased t½ for incretins, which potentiate nutrientinduced insulin secretion

Main elimination route: Renal, Faecally excreted (Sharon to check)

Precautions: Small risk of hypoglycaemia (seldom severe), mostly when used with other glucose lowering agents Substantial renal or liver disease


Names: Sitagliptin

Starting dose: 50mg od

Max dose: 100mg od


Names: Linagliptin

Starting dose: 5mg od

Max dose: n/a (Sharon to check)

Mechanism of Action:
↑ insulin action Stimulate PPARγ ↑adipogenesis Alter glucose-fatty acid cycle

Main elimination route: Hepatic

Precautions: Heart failure, oedema, fluid retention, anaemia, fractures Cardiac disease, severe liver or renal disease


Names: Pioglitazone

Starting dose: 30mg od

Max dose: 45mg od

Mechanism of Action:
Inhibiting the digestion of carbohydrates by inhibiting a-glucosidase

Main elimination route: Renal 35%

Precautions: The major drawback of acarbose is the fact that it is often associated with a lot of flatulence.


Names: Acarbose

Starting dose: 50mg od

Max dose: 100mg tds

Mechanism of Action:
Reversibly inhibits SGLT2 to reduce glucose reabsorption and increase urinary glucose excretion

Main elimination route: Hepatic and Renal

Precautions: Risk of DKA, use with caution conditions leading to restricted food intake. Renal impairment.


Names: Canagliflozin

Starting dose: 100mg OD

Max dose: 300mg OD


Names: Dapagliflozin

Starting dose: 10mg OD

Max dose: n/a (Sharon to Check) 


Names: Empagliflozin

Starting dose: 10mg OD

Max dose: 25mg OD

Mechanism of Action:
↑glucose dependent insulin secretion ↓gastric emptying

Main elimination route: Renal

Precautions: CCF, pancreatitis, Renal impairment


Names: Albiglutide

Starting dose: 30mg weekly

Max dose: 50mg weekly


Names: Exenatide

Starting dose: 5mcg BD

Max dose: 10mcg BD


Names: Liraglutide

Starting dose: 0.6mg OD

Max dose: 3mg OD


Names: Lixisenatide

Starting dose: 10mcg

Max dose: 20mcg

Types of Insulin (Paul to convert)

Simplifying an insulin regime

Simplifying an insulin regime by converting from a twice daily mixed insulin to once daily long-acting insulin is done by understanding the proportion of intermediate-acting insulin in it. For example Novomix 30 has 70% intermediate-acting insulin. Humalog 25 has 75% intermediate acting insulin. Calculate the total daily amount of intermediate-acting insulin and give 80%of this amount as LA insulin analogue such as Lantus once daily. If blood glucose is low i.e. 4.0- 6.0 mmol/L, use 50% of the original intermediate-acting dose.

For example

If the patient normally takes 20 units BD Novomix30, this totals 40 units of insulin in 24 hours as it is a BD preparation. This is a mixture of intermediate and short acting insulin. 70% of Novomix30 is intermediate-acting, so the patient takes 28 units of intermediate-acting insulin daily (0.70 x 40 units).

To calculate the new dose, we want 80% of the existing intermediate-acting daily insulin dose, which is 22 units (0.80 x 28 units = 22 units). If hypoglycaemic we need to give 50% of the daily intermediate-acting insulin dose. This equals 14 units (0.50 x 28 units = 14 units)

Disclaimer (SPAGG - Rewrite)

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.