Drug therapy in DiabetesSee also: viagra online pharmacy | cialis online pharmacy |
 Aims of management ► To achieve near normal glycaemia - Short term- to prevent symptoms of hyper & hypo - Long term- to prevent complications ► Good quality of life, near normal life expectancy Types of Insulin ► Short acting - Soluble / Neutral insulin Insulin aspart Insulin lispro ► Intermediate acting - Isophane ► Long acting - Insulin Zinc suspension new insulin analogue - Glargine Detemir ► Biphasic- mixture of short and intermediate Biphasic lispro Biphasic Isophane Types of Insulin
Soluble insulin / neutral /clear ► Names - Human actrapid/ Humulin S ► Species- Bovine, porcine, human ► Following s/c injection Onset of action – 30 min Peak- 1-3 hours Duration- 4-8 hours ► Only insulin suitable for intravenous route –plasma half life < 5 min, required continuous infusion ► Used in diabetes Ketoacidosis Sites of injections - Subcutaneous ► Thighs ► Upper buttocks ► Abdomen ► Arms Important to rotate the site Rate of absorption may be significantly different – faster from arm and abdomen than from thigh and buttock Routes of Administration ► Subcutaneous for long term regular use ► Intravenous infusion in acute conditions- diabetes Ketoacidosis, Perioperative period, Hyperosmolar Nonketotic state ONLY NEUTRAL/ CLEAR INSULIN CAN BE USED ► Continuous subcutaneous insulin infusion via pump – neutral ► Intraperitoneal – Peritoneal dialysis patients ► Inhaled insulin- experimental Untoward effect of insulin ► Hypoglycaemia ► Weight gain- anabolic hormone ► Lipohypertrophy- injection to same site ► Insulin oedema ► Transient deterioration in retinopathy ► Insulin neuritis – actively regenerating neurone, uncommon ► Postural hypotension Recurrent Hypo ► ? Required dose adjustment ► ? Right insulin/ injection technique ► ? Meal/ fasting related ► ? Injections sites ► ? Exercise ► Unexplained - ?autonomic neuropathy Sick day rules never stop insulin monitor more frequently maintain your hydration Check for ketones Know when & how to call for help Oral Medications to Treat Type 2 Diabetes Major Classes of Medications sensitize the body to insulin +/- control hepatic glucose production stimulate the pancreas to make more insulin slow the absorption of starches Thiazolidinediones Biguanides Sulfonylureas Meglitinides Alpha-glucosidase inhibitors Thiazolidinediones ► ↓ insulin resistance by making muscle and adipose cells more sensitive to insulin. They also suppress hepatic glucose production. ► Efficacy ↓ fasting plasma glucose ~1.9-2.2 mmol/L Reduce A1C ~0.5-1.0% 6 weeks for maximum effect ► Other Effects Weight gain, oedema Hypoglycemia (if taken with insulin or agents that stimulate insulin release) Contraindicated in patients with abnormal LFT or CHF Improves HDL cholesterol and plasma triglycerides; usually LDL neutral ► Medications in this Class: pioglitazone (Actos), rosiglitazone (Avandia), [troglitazone (Rezulin) - taken off market due to liver toxicity] Biguanides ► Biguanides ↓ hepatic glucose production and increase insulin-mediated peripheral glucose uptake. ► Efficacy Decrease fasting plasma glucose 60-70 mg/dl (3.3-3.9 mmol/L) Reduce A1C 1.0-2.0% ► Other Effects Diarrhea and abdominal discomfort Lactic acidosis if improperly prescribed Cause small decrease in LDL cholesterol level and triglycerides No specific effect on blood pressure No weight gain, with possible modest weight loss Contraindicated in patients with impaired renal function Medications in this Class: metformin (Glucophage), metformin hydrochloride extended release (Glucophage XR) Sulfonylureas ► Sulfonylureas increase endogenous insulin secretion ► Efficacy Decrease fasting plasma glucose 3.3-3.9 mmol/L Reduce A1C by 1.0-2.0% ► Other Effects Hypoglycemia Weight gain No specific effect on plasma lipids or blood pressure Generally the least expensive class of medication ► Medications in this Class: First generation : chlorpropamide , tolazamide, acetohexamide , tolbutamide Second generation : glyburide , glimepiride , glipizide Meglitinides ► stimulate insulin secretion (rapidly and for a short duration) in the presence of glucose. ► Efficacy ↓ peak postprandial glucose ↓ plasma glucose 3.3-3.9 mmol/L ↓ HbA1C 1.0-2.0% ► Other Effects Hypoglycemia (may be less than with sulfonylureas if patient has a variable eating schedule) Weight gain No significant effect on plasma lipid levels Safe at higher levels of serum Cr than sulfonylureas ► Medications in this Class: repaglinide , nateglinide Alpha-glucosidase Inhibitors ► Alpha-glucosidase inhibitors block the enzymes that digest starches in the small intestine ► Efficacy ↓ peak postprandial glucose 2.2-2.8 mmol/L ↓ fasting plasma glucose 1.4-1.7 mmol/L Decrease A1C 0.5-1.0% ► Other Effects Flatulence or abdominal discomfort No specific effect on lipids or blood pressure No weight gain Contraindicated in patients with inflammatory bowel disease or cirrhosis ► Medications in this Class: acarbose , miglitol Combination Therapy for Type 2 Diabetes Sulfonylurea + Biguanide Glyburide + Metformin - Glucovance Glipizide + Metformin - Metaglip Thiazolidinedione + Biguanide Rosiglitazone + Metformin - Avandamet Chart Clinic Checklists ► Glycaemic control- home monitoring, HbA1c, inj site, hypo ► Diet, exercise, Smoking, alcohol ► BP ► Weight ► Macrovascular- CVA, IHD ► Microvascular- Retinopathy, microalbuminuria, neuropathy ► Foot ► Lipid profile, renal function, TSH Special circumstances ► Intercurrent illness ► Peri-operative period ► Pregnancy ► Childhood and adolescents ► Others- travelling across time zones Exercise Alcohol Driving Dr K S Myint Specialist Registrar | Other posts: | |||||||||||||||||||||||||||||
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