Appendix 5: Diabetes Education and Medical Management
in Adults with Type 2 Diabetes
Oral Antihyperglycemic Agents

This directive will be implemented by the RPh, RN or RD with a Level 2b certification.

Type 1 CAPs (Controlled Acts and Procedures): All oral antihyperglycemic agents (OAA) can be
adjusted, held and discontinued and can be implemented by the RPh, RN, or RD as part of the
medically established plan of care, without specific discussion with the physician.
Note: Medications discontinued or placed on hold should be reviewed within 24-48 hours by the
RPh, RN, or RD in collaboration with the physician.
Type 2 CAPs: These can be performed by the RPh, RN, or RD. All OAA can be started after
discussion with the physician.
TABLE 1: List of Medications Implemented Under this Directive
with Detailed Indications/Contraindications
Oral Antihyperglycemic Agent /
Indications for
Alpha-Glucosidase Inhibitor
• Gastrointestinal side • Not recommended as initial Treat hypoglycemia with glucose tablets, milk or honey Biguanides
• Gastrointestinal side • Contraindicated in patients (creatinine clearance < 30 mL/min), congestive heart Oral Antihyperglycemic Agent /
Indications for
remains above target (7 mMol/L) consistently Insulin Secretagogues
Insulin Sensitizers
Thiazolidinediones (TZDs)
Oral Antihyperglycemic Agent /
Indications for
with insulin, may increase risk of edema and CHF. The combination of a TZD plus insulin is currently not an approved treatment in Canada approved for use alone to treat type 2 diabetes, except when Metformin use is contraindicated or not tolerated. approved for use with a sulfonylurea drug, except when metformin is contraindicated or not tolerated. used in combination with a sulfonylurea and metformin DPP4 Inhibitors
GLP-1 Analogues
Liraglutide (Victoza)
medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) Summary of Therapeutic Notes for Oral Antihyperglycemic
Agents/ Injectable Agents (CDA):

Key Adverse Effects
• Gastrointestinal upset, loose bowels (biguanide, alphaglucosidase inhibitor) • Hypoglycemia (secretagogues – less with gliclazide, glimepride, nateglinide • Edema, fluid retention (insulin sensitizers) • Moderate weight gain (insulin secretagogues, insulin sensitizers)
Key precaution/contraindications
• Hepatic disease (glyburide, biguanide, insulin sensitizers, DPP4I, GLP1 • Significant renal insufficiency (biguanide, sulfonylureas, DPP4I, GLP1 • Significant cardiac failure (biguanide, insulin sensitizers, DPP4I, GLP1 Analogues)


Oral ketamine/midazolam is superior to intramuscular meperidine, promethazine, and chlorpromazine for pediatric cardiac catheterization. Authors:Auden SM, Sobczcyk WL, Solinger RE, Goldsmith, LJ Anesthesia & Analgesia . 90(2):299-305, 2000 Feb. Reviewer(s): Joseph P. Cravero, MD, Dartmouth-Hithcock Medical Center Abstract: An IM combination of meperidine, promethazine, and c


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