diabetes part 3
TRANSCRIPT
1
What to do?DIABETES TREATMENT
2
TREATMENT TRIAD
01
0203DIET
EXERCISE
PHARMACOTHERAPY
3
What are we looking forCLINICAL EXAMINATION
4
put your great subtitle hereClinical Examination
Hands
Blood Pressure
Eyes
Injection Sites
Feet
5
The Cure for Type 2 DM?DIET AND EXERCISE
6
Exercise
HOW WILL YOU SPEND YOUR DAY?
7
WHAT YOU EAT IN PRIVATE YOUR WEAR IN PUBLIC
8
The old and new.ORAL PHARMACOTHERAPY
9
BIGUANIDE CLASS
PLACE IN THERAPYIncreases insulin sensitivity, Reduces hepatic glucose production; 1-2% HbA1C reduction
ADVANTAGESClinical experience, rare hypoglycemia, improved lipid profile, weight loss, low cost
DISADVANTAGESGI intolerance, lactic acidosis, vitamin B12 deficiency
AGENTSMetformin (Glucophage)
10
SULFONYUREA CLASS
PLACE IN THERAPYIncreases insulin secretion; 1-1.5% HbA1C reduction
ADVANTAGESClinical experience, low cost
DISADVANTAGESHypoglycemia, weight gain, beta cell exhaustion
AGENTSGlyburide (Diabeta), Gliclazide (Diamicron), Glipizide (Glucotrol), Glimepiride (Amaryl)
11
MEGLITINIDE CLASS
PLACE IN THERAPYIncreases insulin secretion; 0.5-1% HbA1C reduction
ADVANTAGESShort duration of action, hepatic clearance, glucose dependent postprandial action
DISADVANTAGESLow efficacy, hypoglycemia, weight gain, high cost
AGENTSNateglinide (Starlix), Repaglinide (Prandin)
12
THIAZOLIDINEDIONE CLASS
PLACE IN THERAPYIncreases insulin sensitivity, Reduces hepatic glucose production; 0.5-1.5% HbA1C reduction
ADVANTAGESRare hypoglycemia
DISADVANTAGESEdema, heart failure, weight gain, increased risk of long-bone fracture, risk of bladder cancer and CV events, high cost
AGENTSRosiglitazone (Avandia), Pioglitazone (Actos)
13
DPP-IV INHIBITOR CLASS
PLACE IN THERAPYReduces hepatic glucose production, increased insulin sensitivity, improve incretin effect ; 0.5-0.8% HbA1C reduction
ADVANTAGESRare hypoglycemia, low side effect profile
DISADVANTAGESAngioedema, unknown long term safety, risk of pancreatitis
AGENTSSaxagliptin (Onglyza), Linagliptin (Tradjenta), Vildagliptin (Galvus), Sitagliptin (Januvia)
14
ALPHA-GLUCOSIDASE INHIBITOR CLASS
PLACE IN THERAPYReduces carbohydrate absorption; 0.5-0.9% HbA1C reduction
ADVANTAGESRare hypoglycemia, low side effect profile
DISADVANTAGESAngioedema, unknown long term safety, risk of pancreatitis
AGENTSMiglitol (Glycet), voglibose (Volix), acarbose (Precose)
15
D2 DOPAMINE-RECEPTOR AGONIST CLASS
PLACE IN THERAPY; 0.5% HbA1C reduction
ADVANTAGESRare hypoglycemia
DISADVANTAGESGI side effects, side effect profile low efficacy, high cost,
AGENTSBromocriptine (Cycloset)
16
The old and newINJECTABLE PHARMACOTHERAPY
17
GLP-1 RECEPTOR AGONIST CLASS
PLACE IN THERAPYReduced glucagon secretion, Increased insulin secretion, reduced rate of gastric emptying, reduced appetite, improved incretin effect ; 0.5-1.5% HbA1C reduction
ADVANTAGESRare hypoglycemia, weight loss, protective CV effect
DISADVANTAGESSide effect profile low efficacy, risk of pancreatitis, thyroid C-cell hyperplasia, tumors, high cost,
AGENTSExenatide (Byetta), Exenatide extended release (Bydureon), liraglutide (Victoza)
18
AMYLIN ANALOGUE CLASS
PLACE IN THERAPYReduced glucagon secretion, Increased insulin secretion, reduced rate of gastric emptying, reduced appetite, improved incretin effect ; 0.5-1% HbA1C reduction
ADVANTAGESControl of postprandial glycemia, weight loss
DISADVANTAGESSide effect profile, hypoglycemia with insulin, high cost
AGENTSPramlintide (Symlin)
19
INSULIN PROFILES
Peak DurationOnset
Rapid Act 5-20 minsShort Act 30 minsIntermed Act 1-3 hrsLong Act
Insulin
1-2 hrs4-6 hrs2 hrs
45-90 mins 3-5 hrs3-5 hrs
12-16 hrs20-24 hrs
20
Where do we startDIABETES TREATMENT ALGORITHM
21
22
Guidelines versus realityGlycemic Management
23
Hypoglycemia risk/ADR
Patient/Disease Features
HYPERGLYCEMIA MANAGEMENT
Disease Duration
Life Expectancy
ComorbiditiesEst. Vascular Complications
Patient’s Attitude
Resources and Support
Target HbA1C
7%
More stringent Less stringent