Complete Diabetes Medications Table

• Alpha-Glucosidase Inhibitor
• Biguanide (Metformin)
• DPP-4 Inhibitors

• GLP-1 & Dual GLP-1/GIP Receptor Agonists (Incretin Mimetics)
• SGLT-2 Inhibitors
• Secretagogues

• Thiazolidinediones -TZDs
• Combination Medications
• Insulins  
• Glucagon

 Metformin extended release
Glumetza® (NB) $18-$74

• Monotherapy or in combination with metformin, sulfonylurea, pioglitazone or insulin.
• Use of DPP-4 inhibitors with SGLT-2 inhibitors may not be outlined in the product monograph(s), but is an acceptable combination according to research.

• Monotherapy or in combination with metformin , sulfonylurea, empagliflozin, basal insulin. 
• Use of DPP-4 inhibitors with other SGLT-2 inhibitors may not be outlined in the product monograph(s), but is an acceptable combination according to research.
• Boehringer 6m compassionate supply form for MDs.

• In combination with metformin, sulfonylurea or insulin. 
• Use of DPP-4 inhibitors with SGLT-2 inhibitors may not be outlined in the product monograph(s), but is an acceptable combination according to research.

• Monotherapy or in combination with metformin, sulfonylurea, pioglitazone, dapagliflozin or insulin.
• Use of DPP-4 inhibitors with SGLT-2 inhibitors may not be outlined in the product monograph(s), but is an acceptable combination according to research.

0.75 mg, 1.5 mg, 3 mg, 4.5 mg
(max 4.5 mg/week)

• Monotherapy or in combination with metformin, sulfonylurea, SGLT-2 or insulin. Sept 11, 2020 Health Canada approved to reduce the risk of non-fatal stroke in adults with type 2 diabetes with multiple CV risk factors or established CV disease.

• Monotherapy or in combination with metformin, sulfonylurea, SGLT-2  or basal insulin. 
• Add on combination in those with established CV disease & type 2 diabetes.
• Use of a GLP-1 with bolus insulin may not be outlined in product monographs, but is an acceptable combination in type 2 diabetes according to research.

• Discontinued
• Monotherapy or use with metformin, sulfonylurea, pioglitazone or basal insulin.
• Use of a GLP-1 with an SGLT-2 or bolus insulin may not be outlined in product monographs, but are acceptable combinations in type 2 diabetes according to research.

 0.25, 0.5 mg, 1 mg, 2 mg
(max 2 mg/week) 

• Monotherapy or in combination with metformin, sulfonylurea or basal insulin.
• Use of a GLP-1 with an SGLT-2 or bolus insulin may not be outlined in product monographs, but are acceptable combinations in type 2 diabetes according to research.
• For 1 mg pen about 74 clicks forward is 1 mg; 37 clicks forward is 0.5 mg. 
• 2 mg/wk is a newer dosing (2023). 
• For individuals on insulin +/- other antihyperglycemic agents with HgA1c < 8.0%, consider decreasing the insulin dose by 20% at onset of OZEMPIC treatment.
• As of Jan 2024, the current 1.5 mL pen which delivered 0.25 and 0.5 mg doses, will be replaced with a new 3 mL pen. HOWEVER, the larger pens contain the same number of 0.25/0.5 mg doses. The concentration has been changed (reduced) so that bigger pens can be used to address the shortage of the 1.5 mL pens. 

3mg, 7 mg, 14 mg tablet

• Monotherapy or in combination with other medicinal products for the treatment of diabetes (includes SGLT-2, secretagogues, metformin, insulins). 
• To be taken on an empty stomach, at least 30 min before eating, with no more than 120 mL water. Review rationale here. 

Tirzepatide injection
Mounjaro (NB) 

• Monotherapy or in combination with other medicinal products for the treatment of diabetes.
• Currently uses vial + syringe [training video here]. Multi-use pen is coming.
• Use of a Dual GLP-1/GIP Receptor Agonists with bolus insulin may not be outlined in product monographs, but is an acceptable combination in type 2 diabetes according to research.

• Monotherapy or in combination with metformin, sulfonylurea, pioglitazone, sitagliptin or insulin
• Use of an SGLT-2 with a GLP-1 or DPP-4 or bolus insulin may not be outlined in product monographs, but each is an acceptable combination in type 2 diabetes according to research.
• As add-on combination in patients with established cardiovascular disease and type 2 diabetes to reduce the risk of major adverse cardiovascular events.
• With type 2 diabetes and diabetic nephropathy to reduce the risk of end-stage kidney disease, doubling of serum creatinine, and cardiovascular (CV) death in adult patients with type 2 diabetes mellitus and diabetic nephropathy with albuminuria (>33.9 mg/mmol). 
• In patients with type 2 diabetes already initiated on treatment for diabetic nephropathy, the use of INVOKANA® 100 mg can be continued in patients with an eGFR <30 mL/min/1.73 m2. INVOKANA® 100 mg should be discontinued if dialysis is initiated. 

• Monotherapy or in combination with metformin, sulfonylurea, sitagliptin or insulin or to reduce the risk of hospitalization for heart failure in adults with type 2 diabetes and CV risk factors or established CV disease (with eGFR above 45 to impact glycemia). 
• Use of an SGLT-2 with a GLP-1 or other DPP-4 or bolus insulin may not be outlined in product monographs, but each is an acceptable combination in type 2 diabetes according to research.
• As an adjunct to standard treatment of heart failure (with or without diabetes) with reduced ejection fraction (HFrEF) to reduce the risk of cardiovascular (CV) death, hospitalization for heart failure and urgent heart failure visit.
• To reduce the risk of sustained eGFR decline  end-stage kidney disease, and cardiovascular and renal death in adults with chronic kidney disease (CKD, with or without diabetes). Can start if eGFR > 25. Can continue on the dose below this eGFR but discontinued if dialysis. 

• For Diabetes: Indicated as monotherapy or in combination with metformin, sulfonylurea, pioglitazone, linagliptin or insulin or as add-on combination in patients with established cardiovascular disease. May provide additional glycemic control at 25 mg if eGFR ≥30. (Use of an SGLT-2 with a GLP-1 or other DPP-4 may not be outlined in product monographs, but each is an acceptable combination in type 2 diabetes according to research.)
• For Heart Failure and/or Chronic Kidney Disease (CKD): The recommended dose of JARDIANCE is 10 mg taken once daily with an eGFR as low as 20 mL/min/1.73 m²
• Boehringer 6m compassionate supply form for MDs.

 Alone or in combination with sulfonylurea, pioglitazone or insulin (not premix).

Boehringer 6m compassionate supply form (MDs).

1 unit of Xultophy contains 1 unit of degludec and 0.04 mg liraglutide (fixed ratio)

Starting dose: 16 units
Maximum dose: 50 units

• Type 2 diabetes in combination with metformin, with or without sulfonylurea, when these combined with basal insulin (< 50 units daily) or liraglutide (less than or equal to 1.8 mg daily), do not provide adequate glycemic control.

• Type 2 diabetes, on basal insulin (< 60 units daily and > 15 units per day) alone or in combination with metformin OR inadquately controlled on GLP-1 in combination with metformin.
• Taken before the first meal.
• Starting Doses: 15 units Soliqua  (if current glargine dose < 30 units); 30 units Soliqua (if current glargine dose 30 to <60 units.)
• Take oral contraceptives at least 1 hour before or at least 11 hours after the dose of SOLIQUA.
• Suggested adjustments by fasting glucose of past 3 days:
  > 7.8 mmol/L add 4 units
  > 5.6 to < 7.8 mmol/L add 2 units
  4.4 to 5.6 mmol/L, no change
  < 4.4 mmol/L subtract 2 units

• Bolus
• Basal
• Mixed

Generic name
Brand names (*coverage) Cost/box

Aspart 
Novorapid® (B)
vial $30; cartridges $61; Prefilled pens no longer available.. 

10-20 min / 1-3 hrs / 3-5 hrs

• May inject up to 10 minutes before a meal 
• 1/2 unit NovoPen Echo available (re-usable)
• Prefilled pens no longer available. 

5-15 min / 1-3 hrs / 3-5 hrs

• May inject 2 mins before meal and up to 20 mins after starting meal
• Should not be mixed with other insulins
• Onset is 5 mins earlier than insulin aspart
• Time to peak is 11mins faster than insulin aspart
• Offset of effect occurs 12-14 mins earlier than insuilin aspart
• 1/2 unit NovoPen Echo available (re-usable)

• Biosimilar of insulin aspart from Sanofi-Aventis 

• Biosimilar of insulin aspart from Viatris

• Biosimilar of lispro from Sanofi-Aventis 
• Reusable pen is Star
• Reusable 1/2 unit pen is Junior Star
• Disposable pen is Solostar
• Use in all ages, pregnancy, pumps

Lispro 100 u/mL
Humalog® (B)
vial $29; cartridges $58; prefills $57

30-45 min / 1-3 hr / 3-5 hrs

• Available in 1/2 unit disposable pens with thebrand name "Humalog Junior KwikPen" 

Same as Lispro 100 u/mL 

30-45 min / 1-3 hr / 3-5 hrs

• Reserved for patients using > 20 units per day of rapid insulin.
• Not to be mixed with other insulins
• Not to be administered via SC infusion pump (not tested)
• Pre-filled pen is calibrated to give the dose dialled

20 min/ 1-3 hr /3-5 hours

10-15 min / 1-1.5 hrs / 3-5 hrs

• Must not be refrigerated once opened
• Patient can register for product cards at http://www.sanoficares.ca/

Refer to "regular insulin" line in the image Pharmacodynamic Action Profiles of Bolus Insulins 

30-60 min / 2-4 hrs / 6-8 hrs 

Refer to "regular insulin" line in the image Pharmacodynamic Action Profiles of Bolus Insulins 

30-60 min / 2-4 hrs / 6-8 hrs

1 hr / no peak / 42 hrs

• Pre-filled pen is calibrated to give the dose dialled, e,g.  80 units u100 = 80 units u200; the latter is contained in less volume. 
• U100 pen delivers doses in 1 unit increments up to 80 unit per dose
• U200 pen delivers doses in 2 unit increments up to 160 unit total dose
• Missed doses may be taken when remembered if at least 8 hrs between doses.
• Steady state serum concentration is reached after 3-4 days. 
• Diabetes Canada titration suggestions: 2 units every 3-4 days or 4 units a week. You may wish to use the  Tresiba titration handout
• Type 2, adult: If "taking once-daily long or intermediate-acting insulin, start TRESIBA® at the same unit dose. For patients transferring from twice daily long or intermediate-acting insulin, or insulin glargine (300 units/mL), it is recommended that the dose of TRESIBA® is reduced by 20% to lower the risk of hypoglycemia."
• Type 1: Reduce by 20% if patient has type 1 diabetes or if switching from bid basal
• Also available as the combination medication  Xultophy® (degludec + liraglutide). See combination medications section. 

 Conversion FROM degludec TO glargine is not standardized. (Eventually, 10-20% more glargine may be required.)  Consider either:

• Delaying the switch for 2 days e.g. no basal insulin for 48 hours to avoid overlap (Reference). 
  
  OR
  
  
• Day 1 of change (24 hr after degludec): Give 50% of basal as glargine (or less if worried about lows)
• Day 2 of change (48 hr after degludec): Give 75%-100% of basal as glargine depending on readings.
• If type 1, consider that the glargine dose may be divided between bedtime and morning. (Reference). 

1.5 hrs /  no peak / 16-24 hrs

• Prefilled pens no longer available.

Icodec
Awiqli® (NB)
1.5 mL pen: $78
3 mL pen: $156
U-700 FlexTouch® Pen 3 mL (2100u)
U-700 FlexTouch® Pen 1.5 mL (1050u)
U-700 FlexTouch® Pen 1 mL sample pen (700u)

• Once weekly basal injection.
• New to basal insulin:
  Starting dose is suggested as 70 units once per week (10u/day x 7 days). As per any new basal start, consider reducing if individual variables exist that may predispose to hypoglycemia. 
• Switching Basal insulin to icodec:
  1. The first weekly dose of icodec should be taken on the day following the last dose of once- or twice daily basal insulin (this includes degludec). 
  2. The weekly icodec dose is the previous daily basal insulin dose multiplied by 7, rounded to the nearest 10 units.
  3. For the first dose only (week 1 dose), there is the option to add an additional 50% of icodec, just this once above and beyond the calculation in point b. above. If this is not added, watch for higher glucose levels in the first 1-2 weeks. 
• The risk for lows is greatest between days 2-4.  Discuss initiation doses in those with type 1 diabetes with the specialist physician to minimize this risk. 
• Adjustment:
  • If the first dose contained an additional 50% dose (per comments above), wait until the third dose prior to making any necessary adjustments. 
  • If no additional 50% dose is given, then adjust weekly starting with dose 2 (week 2). 
  • Make to the nearest 10 unit increment
  • Due to the long half-life, adjustment of dose is not advised during acute illness nor if patients make short-term changes in their physical activity level or usual diet. In these situations, other applicable adjustments, e.g. glucose intake or changes to other (concomitant) glucose lowering medication, may be considered.
• Missed doses: Minimum 4 days between two consecutive doses,
• Accidental double dosing requires the next week's dose to be missed. 
• Steady state levels reached in 2-3 weeks if one-time 50% additional dose added; 3-4 weeks without the one-time additional dose.
• Caution: The pen can deliver up to 700 units in a single injection, in increments of 10 units. See page 52 here for instructions.

15 15 min / 4-8  hrs / 17-24 hrs

• Indicated for those requiring over 200 units insulin/day
• Onset similar to U-100
• Peak slightly lower than Humulin R U100
• Time to peak is delayed (vs. Humulin R)
• Dose 30 minutes before meal
• Given 2-3 times daily
• When switching to Entuzity and HbA1c < 8% reduce TDD by 20%
• Pre-filled pen is calibrated to give the dose dialled
• Pen delivers 5 unit increments

1-2 hrs / 5-8 hrs / 14-18 hrs

•  Still available as disposable pen as of July 2023

Refer to NPH line in the image Pharmacodynamic Action Profiles of Long-Acting Insulins 

1-2 hrs / 5-8 hrs / 14-18 hrs

•  Not available as disposable pen

1.5 hrs / no peak / 24 hrs

•  Reduce by 20% when switching from Toujeo to Lantus.
• Patient can register for product cards at http://www.sanoficares.ca/

1.5 hrs / no peak / 24 hrs

up to 6 hrs / no peak / up to 36 hrs

• The prescribed dose of TOUJEO should always be expressed in units of insulin.
• See Toujeo dosing handout.
• Pen dials up to 80 units. Dials in one unit increments.
• Patient can register for product cards at http://www.sanoficares.ca/

up to 6 hrs / no peak / up to 36 hrs

• The prescribed dose of TOUJEO should always be expressed in units of insulin.
• See Toujeo dosing handout.
• Pre-filled pen is calibrated to give the dose dialled
• Pen dials up to 160 units. Dials in two unit increments.

 Regular insulin (%Toronto) / insulin (%NPH)
Novolin® ge 30/70 (B)
vial $24, cartridges $46
3 mL cartridge to be discontinued Dec 2025

Novolin® ge 40/60 (B)
cartridges $46

Novolin® ge 50/50 (B) 
cartridges $46