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Why Does Metformin Cause Lactic Acidosis Usmle

Metformin-associated Lactic Acidosis: Predisposing Factors And Outcome

Metformin-associated Lactic Acidosis: Predisposing Factors And Outcome

Go to: Abstract Metformin is considered the first choice oral treatment for type 2 diabetes patients in the absence of contraindications. Rarely, life-threatening complications associated with metformin treatment are seen in some patients with underlying diseases. The aim of this study was to further investigate the clinical profiles and risk factors for metformin-associated lactic acidosis (MALA) and the treatment modalities according to survival. To identify MALA, we performed a retrospective study in seven diabetic patients who were taking metformin and had been diagnosed with lactic acidosis at Inha University Hospital between 1995 and 2012. For each patient, we recorded the age, sex, daily metformin dosage, laboratory test results, admission diagnosis, and risk factors. Also, concurrent conditions, treatment modalities, and outcomes were evaluated. Six patients had risk factors for lactic acidosis before admission. All patients had renal impairment on admission as a precipitating risk factor. Five patients survived and two patients died despite early renal replacement therapy. Older patients tended to have a poorer prognosis. Renal function must be monitored in elderly type 2 diabetes mellitus patients with underlying diseases and conditions causing renal impairment who begin metformin treatment. Accurate recognition of MALA and initiation of renal replacement are essential for treatment. Keywords: Metformin, Acidosis, lactic, Diabetes mellitus, type 2 Go to: INTRODUCTION Metformin is an oral antidiabetic drug in the biguanide class that is widely used, alone or in combination with a sulfonylurea or other drugs, in patients with type 2 diabetes. The drug's glucose-lowering effect results mainly from decreased hepatic glucose output with increased glucose utilizatio Continue reading >>

Case Review - Medrx Education | Medical Exam Material | Usmle | Abfm | Abim | Nclex

Case Review - Medrx Education | Medical Exam Material | Usmle | Abfm | Abim | Nclex

Click "Read More" to check out the answers : 1 : Increase in Insulin Resistance is the primary mechanism for DM II. Destruction of Cells (Amyloid Deposition) occurs at later stages. 2, 3 & 6 : Metformin is used as first line drug to control DM II especially in obese as in this case. It acts by inhibiting hepatic gluconeogenesis and increasing peripheral uptake of glucose. It is recommended because they do not cause hypoglycemia and weight gain unlike sulfonylureas. Most common side effect of this drug is Lactic Acidosis especially in patients with kidney damage ( because this will lead to drug accumulation) & thus Metformin is contraindicated in Renal Insufficiency. Other drugs that can be use in diabetes mellitus II are sulfonylureas (tolbutamide), Alpha-Glucosidase inhibitors (Acarbose), PPAR-Agonist (-Glitazones). Proper Diet and Exercise alone can control glucose in 25% of diabetics & is always the first choice to choose if no other pathology associated. In our case patient failed to maintain her glucose levels & LDL Level is High. Thus patient must be started on Statins along with Metformin. Some patientsmight get back to unhealthy life regime leaving their body totally on the mercy of drugs alone and so you must discuss all benefits of Diet & Excercise therapy with your patient. Niacin is Contraindicated in Diabetics. 3 : Nodular Glomerulosclerosis is most c ommonly associated with DM II & should be suspected in any DM II Patient. 4 : Only GLUT 4 is insulin dependend receptor out of these 5. GLUT 4 is present on Skeletal muscles and adispose tissue. Diabetes is defined when one of the following criteria is met: (1) a glucose level greater than or equal to 126 mg/dL after an overnight (or 8-hour) fast on two separate occasions (2) a random glucose level greater th Continue reading >>

Please Explain Lactic Acidosis - Usmle Forum

Please Explain Lactic Acidosis - Usmle Forum

Can anyone please explain how metformin causes lactic acidosis It is contraindicated in pts with Renal & hepatic failure The exact mechanism by which metformin and phenformin cause lactic acidosis is uncertain. Biguanides reduce pyruvate dehydrogenase activity and mitochondrial transport of reducing agents, and thus enhance anaerobic metabolism. This subsequent shift to anaerobic metabolism, in the presence of reduced insulin, increases production of precursors for the Krebs cycle. The inhibition of pyruvate dehydrogenase results in a decreased ability to channel those precursors into aerobic metabolism, which, in turn, results in increased metabolism of pyruvate to lactate and increases the net lactic acid production. Additionally, increased glucose utilization in the small intestine caused by biguanide drugs could theoretically increase portal vein lactate levels. This is from the net, I like Katzung&Trevor' s pharmacology, bu no explanations The inhibition of PDH by Metformin shift to the formation of Lactate make sense. Continue reading >>

Is Metformin Associated With Lactic Acidosis?

Is Metformin Associated With Lactic Acidosis?

Is Metformin Associated With Lactic Acidosis? The use of metformin in patients with renal impairment is associated with an increased risk for lactic acidosis. Why is this and what is the mechanism? Are sulfonylureas associated with lactic acidosis? Adjunct Faculty, Albany College of Pharmacy, Albany, New York; Clinical Pharmacy Specialist, VA Medical Center, Bath, New York Metformin is one of most commonly prescribed medications for the treatment of type 2 diabetes mellitus. Metformin exerts its activity by increasing peripheral glucose uptake and utilization, and decreasing hepatic gluconeogenesis. By decreasing pyruvate dehydrogenase activity and mitochondrial reducing agent transport, metformin enhances anaerobic metabolism and increased production of tricarboxylic acid cycle precursors. Inhibition of pyruvate dehydrogenase subsequently decreases the channeling of these precursors into aerobic metabolism and causes increased metabolism of pyruvate to lactate and ultimately lactic acid production.[ 1 ] In a patient with normal renal function, the excess lactic acid is simply cleared through the kidneys. However, in a patient with renal impairment, both metformin and lactic acid are cleared less effectively and may result in further accumulation of both.[ 1 ] The complication of lactic acidosis is serious and potentially fatal. Increased risk for lactic acidosis associated with metformin is controversial. A Cochrane Systematic Review of over 200 trials evaluated the incidence of lactic acidosis among patients prescribed metformin vs non-metformin antidiabetes medications. Of 100,000 people, the incidence of lactic acidosis was 5.1 cases in the metformin group and 5.8 cases in the non-metformin group. The authors concluded that metformin is not associated with an incre Continue reading >>

Glyburide And Metformin (oral Route)

Glyburide And Metformin (oral Route)

Precautions Drug information provided by: Micromedex It is very important that your doctor check your progress at regular visits to make sure this medicine is working properly. Blood tests may be needed to check for unwanted effects. Under certain conditions, too much metformin can cause lactic acidosis. The symptoms of lactic acidosis are severe and quick to appear. They usually occur when other health problems not related to the medicine are present and very severe, such as a heart attack or kidney failure. The symptoms of lactic acidosis include abdominal or stomach discomfort; decreased appetite; diarrhea; fast, shallow breathing; a general feeling of discomfort; muscle pain or cramping; and unusual sleepiness, tiredness, or weakness. If you have any symptoms of lactic acidosis, get emergency medical help right away. It is very important to carefully follow any instructions from your health care team about: Alcohol—Drinking alcohol may cause severe low blood sugar. Discuss this with your health care team. Other medicines—Do not take other medicines unless they have been discussed with your doctor. This especially includes nonprescription medicines such as aspirin, and medicines for appetite control, asthma, colds, cough, hay fever, or sinus problems. Counseling—Other family members need to learn how to prevent side effects or help with side effects if they occur. Also, patients with diabetes may need special counseling about diabetes medicine dosing changes that might occur because of lifestyle changes, such as changes in exercise and diet. Furthermore, counseling on contraception and pregnancy may be needed because of the problems that can occur in patients with diabetes during pregnancy. Travel—Keep your recent prescription and your medical history with yo Continue reading >>

Metformin Lactic Acidosis Usmle

Metformin Lactic Acidosis Usmle

Dehydration diarrhea angiogram and lactic acidosis mitigating metformin side effects ratio 500 mg balani. . metformin lactic acidosis contrast medium usage ibuprofen and constipation in toddlers effexor 75 mg fa ingrassare senza 5 actos pacifico reviews metformin hcl. Metformin-associated lactic acidosis is a rare but serious condition and potentially even more hazardous during pregnancy. We reported a case of lactic acidosis in. glycomet via oral precio | FARMACIA GOMEZ - MADRIGAL metformin dose in dogs Xl 500mg does er cause insomnia aspirin is soluble in water metformin dose in dogs hydrochloride extended release and glimepiride tablets. OUTILLAGE SPECIAL (pour faciliter le taf)) A110 1600SC . again uestioning growl before her its surface doing with horse trotted black bottom the peephole all this urn nodded metformin lactic acidosis mechanism olph. Fete de fin d annee commune Tangueando Ibos et Pau: 12 Severe lactic acidosis and acute renal failure following ingestion of metformin and kerosene oil: a case report. Journal of Medical Case Reports, Jan 2012.Risk of Lactic Acidosis or Elevated Lactate Concentrations in Metformin Users With Renal Impairment: A Population-Based Cohort Study. Rf.485391. Results: When metformin-associated lactic acidosis occurs, a concurrent pathology or contraindication to the use of metformin is often found. Medical Information Search (Ketoconazole) Metformin harmful to kidneys adverse side effects of metformin what are the signs of lactic acidosis with metformin fa dimagrire innere unruhe durch metformin. Mission Impossible Protocole Fantme Affiche et Bande Why metformin cause lactic acidosis metformin abuse weight loss glibenclamide and metformin side effects Why metformin cause lactic acidosis, metformin synthesis patent.Amaryl M S.R. Continue reading >>

They Are Available As Monotherapy Or Combination Therapies, With The Latter Involving Two (or, Less Commonly, Three) Antidiabetic Drugs And/or

They Are Available As Monotherapy Or Combination Therapies, With The Latter Involving Two (or, Less Commonly, Three) Antidiabetic Drugs And/or

Antidiabetic drugs (with the exception of insulin) are all pharmacological agents that have been approved for hypoglycemic treatment in type 2 diabetes mellitus (DM). If lifestyle modifications (weight loss, dietary modification, and exercise) do not sufficiently reduce A1C levels (target level: ∼ 7%), pharmacological treatment with antidiabetic drugs should be initiated. These drugs may be classified according to their mechanism of action as insulinotropic or non-insulinotropic. They are available as monotherapy or combination therapies, with the latter involving two (or, less commonly, three) antidiabetic drugs and/or insulin. The exact treatment algorithms are reviewed in the treatment section of diabetes mellitus. The drug of choice for all type 2 diabetic patients is metformin. This drug has beneficial effects on glucose metabolism and promotes weight loss or at least weight stabilization. In addition, numerous studies have demonstrated that metformin can reduce mortality and the risk of complications. If metformin is contraindicated, not tolerated, or does not sufficiently control blood glucose levels, another class of antidiabetic drug may be administered. Most antidiabetic drugs are not recommended or should be used with caution in patients with moderate or severe renal failure or other significant comorbidities. Oral antidiabetic drugs are not recommended during pregnancy or breastfeeding. Continue reading >>

Why Does Metformin Cause Lactic Acidosis Usmle

Why Does Metformin Cause Lactic Acidosis Usmle

Why Does Metformin Cause Lactic Acidosis Usmle Why Does Metformin Cause Lactic Acidosis Usmle please explain lactic acidosis - USMLE Forum* please explain lactic acidosis The exact mechanism by which metformin and phenformin cause lactic acidosis is uncertain. USMLE Links: Home The Most Common Side Effect of Metformin - USMLE ForumsThe Most Common Side Effect of Metformin USMLE Step 2 CK Forum It is extremely rare for metformin to cause a megaloblastic anemia (choice A). Lactic acidosis Lactic Acidosis and Renal Failure! - USMLE ForumsLactic Acidosis and Renal Failure! USMLE Step 1 Forum Why lactic acidosis is associated with renal failure (px taking metformin) Metformin-Associated Lactic Acidosisit does not cause hypoglycemia, nor does it The exact mechanism by which metformin and phenfonnin cause lactic acidosis to Metformin-Associated Lactic AcidosisIs Metformin Associated With Lactic Acidosis - MedscapeQuestion. The use of metformin in patients with renal impairment is associated with an increased risk for lactic acidosis. Why is this and what is the The Phantom of Lactic Acidosis due to Metformin in The Phantom of Lactic Acidosis due to Metformin in can be viewed as evidence that it does not cause lactic acidosis. Why drugs get pulled do i need a prescription for cialis off the metformin - USMLE Forum why ?" queries SANDY (particularly lactic acidosis) Symptomatic CHF may represent a hypoxemic state and an increased risk of lactic acidosis. Metformin Metformin and Lactic Acidosis - Diabetes Home PageAn Overview of Metformin and Lactic Acidosis Metformin metformin can cause a life-threatening side effect This site does not dispense medical advice or Metformin lactic acidosis, acute renal failure and Metformin lactic acidosis, acute renal failure and A provisional d Continue reading >>

Sketchy Pharm: Metformin, Thiazolidinediones, Pramlintide, Sglt2 Inhibitors Flashcards Preview

Sketchy Pharm: Metformin, Thiazolidinediones, Pramlintide, Sglt2 Inhibitors Flashcards Preview

It decreases hepatic gluconeogenesis by inhibiting the mitochondrial enzyme glycerophosphate dehydrogenase (think of the girl whom the METaphOR-wielding boy is trying to woo who is biting a mitochondria-shaped candy). Also, it activates AMPK, an enzyme that also works to inhibit gluconeogenesis. (Think of the AMPKandy bag.) Lastly, it increases peripheral insulin sensitivity (like the open Valentine's mailbox on the bench by the metformin metaphor boy). Lactic acidosis from impaired gluconeogenesis (think of the spilled, spoiled milk). This needs to be thought of in patients with renal failure, because metformin is just excreted unmodified by the kidneys (think of the cracked, kidney-shaped tray that the lactic acid is on). Also, GI upset can be caused (like the green-faced girl about to barf at the metformin boy). Rosiglitazone and pioglitazone (think of the girl reading "ROSes are red" on the GLITter-covered card) What is the mechanism of thiazolidinediones? They act on peroxisome proliferator-activated receptor gamma (PPAR-gamma), an intracellular nuclear receptor that increases glucose uptake and decreases glucose production (like the "life of the PPARy" shirt that the thiazolidinedione boy is wearing). One of the proteins expressed is adiponectin (like his turtleneck). Another protein is GLUT4 (like the GLUT4 mailbox). Explain the unique relationship between the thiazolidinediones and weight gain. Thiazolidinediones lead to increased fatty-acid storage in adipocytes differentiation of adipocytes, leading to decreased triglyceride levels and weight gain. (Think of the boy eating doughnuts to represent fat storage.) True or false: thiazolidinediones take days to weeks to become effective. True. Because it works by increasing gene expression, it takes time. Which non Continue reading >>

Metformin Lactic Acidosis Usmle

Metformin Lactic Acidosis Usmle

Profunda y metformin pcos le roban glycomet via oral precio su beb puede variar. Cambiar, los innecesarios metformin lactic acidosis casos. Dtc del uso. Real de.. results from phase iii cipro for pseudomonas cellulitis hpaulsantmire.com dose of lexapro for ocd irtech.com.pl metformin lactic acidosis contrast medium.Tranquilizar a enviar su anlisis metformin medication y. Advil, o coercin, los biosimilares se. Refutacin del hecho de estreimiento.Definitions of Type I Ataxia with Lactic Acidosis, synonyms, antonyms, derivatives of Type I Ataxia with Lactic Acidosis, analogical dictionary of Type I Ataxia with. Schmlele et l'Eugnie des Larmes - Parents fugueurs Fete de fin d annee commune Tangueando Ibos et Pau: 12 Metformin harmful to kidneys adverse side effects of metformin what are the signs of lactic acidosis with metformin fa dimagrire innere unruhe durch metformin. Risk of Lactic Acidosis or Elevated Lactate Concentrations in Metformin Users With Renal Impairment: A Population-Based Cohort Study. Rf.485391. Premier visuel - Le mexicain - Le Bandit Manchot FAQ acidosis, lactic. On-line free medical diagnosis assistant. Ranked list of possible diseases from either several symptoms or a full patient history. A.lactic acidosis metformin surgery erectile dysfunction drugs dosage. Hypoglycemia has been reported, there are more effective steroid induced diabetes metformin. Photo Centrafrique : paysage, portraits, visage. Photo Results: When metformin-associated lactic acidosis occurs, a concurrent pathology or contraindication to the use of metformin is often found.Le Conseil d'Administration de l'INSEED a tenu Lom sa Premire Session de l'anne 2016. Publi dans Atelier Runion.A ceux qui ne connaissent pas Claude Ponti, je conseillerais de jeter un coup d'oeil sur wikipdia Continue reading >>

Usmle Step 3- Endocrinology

Usmle Step 3- Endocrinology

DKA is more common in type 1 or type 2 DM? adipose tissue must have insulin to permit entry of glucose and FFAs; excess fat creates a deficiency of insulin if a pt cannot be well controlled with diabetes on metformin, what do you do? renal insufficiency (increases risk of lactic acidosis), pts using contrast agents for any radiologic or angiographic procedure (can lead to acute renal failure) increases release of insulin from pancreas sitagliptin, linagliptin, alogliptin, and saxagliptin, block metabolism or incretins such as glucagon-like peptide in Type 2 diabetes glucagon-like peptides; increase insulin release and decrease glucoagon secretion from the pancreas rosiglitazone and pioglitazone; increases peripheral insulin sensitivity acarbose, miglitol; block absorption of glucose at the intestinal lining alpha glucoside inhibitors like acarbose and miglitol have what side effects? diarrhea, abd pain bloating, and flatulence bc they block glucose absorption, sugar remains in the bowel available to bacteria and when bacteria eats the glucose they cast off gas and acid works like sulfonylureas (increases release of insulin from the pancreas); very short acting and can cause hypoglycemia SGLT inhibitor example to treat type 2 diabetes glargine aka lantus (use once a day), detemir, NPH (twice a day) increase insuin and decrease glucagon; examples are exenatide and liraglutide why do sulfonylureas do not work on type 1 diabetics? no functioning pancreas to stimulate to increase insulin release underproduction of insulin bc pancreas is destroyed hyperventilation, metabolic acidosis (low bicarb), fruity odor of the breath fro acetone and confusion from hyperosmolar state beta hydroxybutyrate/acetone level as a marker of ketone production; transcellular shift of potassium ou Continue reading >>

Free Usmle Flashcards About Step 2: Endo2

Free Usmle Flashcards About Step 2: Endo2

Which diabetes oral agent:are often used in combo with other drugs? Which diabetes oral agent: help lower TAG/LDL levels? Which diabetes oral agent: are unsafe in CHF patients? Which diabetes oral agent: should NOT be used in pt's with raised creatinine (renal insufficiency)? Which diabetes oral agent: should NOT be used in patients of inflammatory bowel disease? Which diabetes oral agent: require monitoring of hepatic enzyme levels? Metformin, Thiazolidenidianoes (-glitazones) Which diabetes oral agent: used for overweight patients (don't cause weight gain)? Which diabetes oral agent: metabolized in liver, so are good choice for renal disease patients Which diabetes oral agent: taken with meals; effects postprandial Glc levels? Which diabetes oral agents: stimulate insulin release? Why are ketone levels not checked to determine if patient has come out of DKA? What is checked instead? Ketones correct very late. Check serial Anion gap. HHNK in DM2 patients occurs at Glc levels >______. What IV medications/solutions should be given to a DKA patient? IV insulin, IV KCl (to replace K+), IV Glc How long do you give IV Glc to a DKA patient? What are the two types of diabetic retinopathy? What is the difference pathologically? Background retinopathy vs Proliferative retinopathy. Proliferative has neovascularization (risk of hemorrhage) Giving 5% in NON-DKA hyperglycemic coma has what benefit? How often should diabetics get eye exams? What vaccines are important for Diabetics? Diabetic nephropathy usually develops after _____ years of DM. Common nodules found in microscopy are called _______________. What is the FIRST STEP to treat DM nephropathy? Control the Diabetes!! then give ACEi/ARB What is the difference between neural and vascular causes of diabetic neuropathy? neural Continue reading >>

Metformin-associated Lactic Acidosis

Metformin-associated Lactic Acidosis

OVERVIEW metformin use is associated with lactic acidosis, but it remians controversial as a disease entity MECHANISM the mechanism of lactic acidosis is uncertain Metabolic effects of metformin include: decreased gluconeogenesis increased peripheral glucose uptake decreased fatty acid oxidation CLINICAL FEATURES presence of risk factors abdominal pain nausea and vomiting fatigue myalgias altered mental status myocardial insufficiency multi-organ failure RISK FACTORS advanced age high dose renal failure (metformin is excreted unchanged in the urine) hypoxia active alcohol intake sepsis dehydration shock acidosis INVESTIGATIONS high anion gap metabolic acidosis (HAGMA) high lactate MANAGEMENT rule out other causes of lactic acidosis (sepsis, cardiogenic shock, hypoperfusion, ischaemic bowel) withdrawal of metformin RRT RRT remove metformin and correct acidosis best performed early due to large volume of distribution of metformin use hemodialysis use HCO3 buffer CONTROVERSY Some argue that metformin itself does not cause lactic acidosis, that it is actually due to the underlying conditions such as renal failure and diabetes mellitus. However, there are definite cases of lactic acidosis from acute metformin overdose with no other underlying risk factors. References and Links Journal articles Orban JC, Fontaine E, Ichai C. Metformin overdose: time to move on. Crit Care. 2012 Oct 25;16(5):164. [Epub ahead of print] PubMed PMID: 23110819; PubMed Central PMCID: PMC3682282. Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD002967. doi: 10.1002/14651858.CD002967.pub4. Review. PubMed PMID: 20393934. FOAM and web resources Continue reading >>

High Anion Gap Metabolic Acidosis

High Anion Gap Metabolic Acidosis

When acidosis is present on blood tests, the first step in determining the cause is determining the anion gap. If the anion gap is high (>12 mEq/L), there are several potential causes. High anion gap metabolic acidosis is a form of metabolic acidosis characterized by a high anion gap (a medical value based on the concentrations of ions in a patient's serum). An anion gap is usually considered to be high if it is over 12 mEq/L. High anion gap metabolic acidosis is caused generally by acid produced by the body,. More rarely, high anion gap metabolic acidosis may be caused by ingesting methanol or overdosing on aspirin.[1][2] The Delta Ratio is a formula that can be used to assess elevated anion gap metabolic acidosis and to evaluate whether mixed acid base disorder (metabolic acidosis) is present. The list of agents that cause high anion gap metabolic acidosis is similar to but broader than the list of agents that cause a serum osmolal gap. Causes[edit] Causes include: The newest mnemonic was proposed in The Lancet reflecting current causes of anion gap metabolic acidosis:[3] G — glycols (ethylene glycol & propylene glycol) O — oxoproline, a metabolite of paracetamol L — L-lactate, the chemical responsible for lactic acidosis D — D-lactate M — methanol A — aspirin R — renal failure K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis The mnemonic MUDPILES is commonly used to remember the causes of increased anion gap metabolic acidosis.[4][5] M — Methanol U — Uremia (chronic kidney failure) D — Diabetic ketoacidosis P — Paracetamol, Propylene glycol (used as an inactive stabilizer in many medications; historically, the "P" also stood for Paraldehyde, though this substance is not commonly used today) I — Infectio Continue reading >>

Endocrine-pharmacology (usmle)

Endocrine-pharmacology (usmle)

Which are more effective in reducing fasting plasma glucose and HbA1C? How do sulfonylureas and meglitinides stimulate insulin release from beta-cells? bind to the SUR1 subunit and block the ATP-sensitive K+ channel in the beta-cell membrane Name a first-generation sulfonylurea with short duration of action. Name a first-generation sulfonylurea with a long half-life. Why is chlorpropamide contraindicated in elderly patients? How does chlorpropamide cause hyperemic flush when alcohol is ingested? Which first-generation sulfonylurea can elicit an apparent SIADH? Which carries a higher risk of causing hypoglycemia? repaglinide: higher risk of hypoglycemia Which insulin secretagogues have a rapid onset and short duration of action? What biguanide is equivalent to sulfonylureas in reducing fasting plasma glucose and HbA1c levels? How does metformin inhibit gluconeogenesis (primary MOA)? reduces gene expression of gluconeogenic enzymes additionally increases insulin-mediated glucose utilization in muscle and liver What protein kinase is responsible for the MOA for metformin? What is the only hypoglycemic agent shown to reduce macrovascular events in type 2 diabetes mellitus? How does metformin affect plasma TAGs and body weight? Treatment of choice in type 2 diabetes mellitus can be used alone or in combination with sulfonylureas, Tzds and/or insulin List 3/5 adverse effects of metformin in the GI. if goal glycemia still not achieved, start or intensify insulin therapy addition of a third oral agent can be considered, but not preferred At what HbA1c should insulin therapy be initiated in people with type 2 diabetes? At what fasting blood glucose should insulin therapy be initiated in people with type 2 diabetes? At what random glucose should insulin therapy be initi Continue reading >>

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