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Microsoft powerpoint - diabetes medications april 2011.ppt

“Making Clinical Sense of Diabetes
Types of Diabetes
Type 1 DM = Beta Cell Destruction, absolute insulin deficiency Type 2 DM = Ranges from predominantly insulin resistance with relative insulin deficiency to predominantly insulin deficiency with insulin Gestational DM (GDM) = glucose intolerance with Pre-Diabetes = Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT) Pathophysiology
Beta Cell Function & Glucagon
Insulin Deficiency + Insulin Resistance = Progressive Beta cell decline = inadequate insulin Hyperglycemia Type 2 DM, Gestational DM, Pre- Absolute Deficiency of Insulin = Hyperglycemia Glucagon is not suppressed during the post prandial Hepatic glucose production is increased during the fasting period Relative contributions of postprandial (□) and fasting (▪) hyperglycemia (%) to the overall diurnal hyperglycemia over quintiles of HbA1c Optimal Diabetes Medication
Glycemic Targets
Address patient concerns, i.e. hypo, weight gain, side Oral Medications
Question #1
• Drugs in the sulfoynlurea class are the drug of Pancreas – stimulate insulin production choice for newly diagnosed Type 2 diabetes Liver – decrease hepatic glucose production Intestines/gut – decrease absorption of CHO; gut Sulfonylureas
Efficacy: Reduce A1C 1-2%, decrease FPG 60 Work best in first 5-10 years of diabetes Meglinitides
Meglinitides (continued)
Take 0-15 min before meals and large snacks Efficacy: Reduce A1C 1-2%, Decrease FGB, PPG Question #2
Question #3
Which of the following is an important counseling Metformin is one of the best choices to target post c. May cause GI upsetd. If you skip a meal, skip Prandin Biguanides
Biguanides (continued)
Action: Decrease hepatic gluconeogenesis and Efficacy: Reduce A1C 1-2%, decrease FPG 60-70 mg/dl, weight loss, may decrease cholesterol Contraindicated if serum Cr > 1.4 mg/dl women, Thiazolidenediones (TZDs)
TZDs (continued)
Alpha-Glucosidase Inhibitors
AGIs (continued)
Action: Delay digestion and absorption of CHO Inhibit intestinal enzyme →slow breakdown of complex Decrease FBG (20-30 mg/dl) and PPG (40-50 mg/dl) DPP-4 Inhibitors
DPP-4 Inhibitors (continued)
Ingestion of food→release of incretin hormones GLP-1 and GIP→Beta & Alpha cell stimulation In DM, DPP-4 enzyme breaks down GLP-1 & GIP, so that the beta/alpha cells have decreased These inhibit the DDP-4 enzyme→prolongs life of GLP-1 Combination Meds
Incretin Mimetics
Action: increase insulin secretion, B-cell growth/replication, slows gastric emptying, may • Actosplus Met (pioglitazone/metformin) decrease food intake, suppresses glucagon secretion • Duetact (pioglitazone/glimepiride) • Janumet (sitagliptin/metformin) • Avandaryl (rosiglitazone/glimepiride) • Kombiglyze XR (metformin/saxagliptin) Incretin Mimetics (continued)
Question #4
Which medication(s) do not have the side effect of Risks: nausea, not with CrCL< 30mg/dl, not with Amylinomimetc
Amylinomimetic (continued)
Action: Hormone amylin co-secreted by beta cells in Dose T1DM 15 mcg→60mcg 4 step titration Dose T2 DM 60mcg→120 mcg 2 step titration Deficiencies relative to beta cell function Reduces food intake, appetite suppression Dopamine Agonist
Bile Acid Sequestrant
Used with diet & exercise in Type 2 DM GI side effects (constipation, dyspepsia, nausea) Insulin Therapy
Insulin: Basal/Bolus Regimen
NPH, detemir (Levemir), glargine (Lantus) Detemir & glargine more physiologic for basal Basal/Bolus Regimen
Bolus insulin targets meals/snacks and post prandial glucose • Add rapid insulin to next largest meal Insulin
Case Study #1
S.B. is a 42 yo AAF, 5 year hx Type 2 DM. PMH includes HTN, Ht 61 inches, wt 163 #; labs A1C 10.2%, HDL 55 mg/dl, LDL 83 mg/dl, TG 111, TC 167, SCr 0.9. Meds: lisinopril, metformin 1000 mg bid, glyburide 5 mg bid, asa 81 mg qd.
Q: Which of the following is the most effective approach to improve SBs glycemic control? Case Study #1
Case Study #2
T.L. is a 72 yo Caucasian male with 15 year hx DMT2. Meds: glipizide 10 mg bid, precose 25 mg tid ac, simvastatin. FBG 113-190, tests BG only in the am. BP 143/63, 6 ft 1 in, 220 #, SCr 1.7, HDL 26, LDL 79, TG 182, TC 120. A1C 8.2%. He reports he often forgets to take the precose.
Q: Which of the following is the most effective approach to improve TLs glycemic control? Case Study #2
Case Study #3
J.R. is a 40 yo AAM, 20 yr hx DMT2. Patient currently taking Lantus 20 units HS, glimepiride 4 mg qam, metformin 1000 mg bid, atenolol, lisinopril, pravachol, asa 81 mg. SMBG FBG 180s, before dinner or HS up to 200s-300s.
c. Decrease precose, add januvia 50 mg qd Ht: 5’8”, wt 177#. Review of diet indicates patient is not overeating. A1C 11.2, LDL 98, HDL 41, TG 144, TC 177. Q: Which of the following is the most effective approach to improve JRs glycemic control? Case Study #3
c. Increase Lantus 1 unit daily until FBG less than


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