Drugs used in Diabetes

Dr Sally Hudson

BIGUANIDESreduce output of glucose from the liver and enhances uptake and use of glucose by

muscle cells

Example ADVANTAGES DISADVANTAGES COST Caution

Metformin500mg/850mg/1g

ORALWeight reductionNo hypo’sUKPDS evidenceHba1c 1.5%

Nausea, vomiting abdo. Pain, diarrhoea,anorexia/loss apetiteRisk lactic acidosisAvoid eGRF<30

CHEAP Renal failureHepatic failure and alcoholism as increase risk of lactic acidosis

Metformin M/R500mg,750mg,1g

ORALOnce dailyWeight reductionNo hypo’s

Still GI side effects Less than standard formulationRisk lactic acidosis

Moderate Renal failure

SULPHONYLUREASstimulate insulin release from the pancreas.

Example ADVANTAGES DISADVANTAGES COST Caution

GLICLAZIDE80MG

RAPID ONSET ACTIONORALHba1c

HYPO’SWEIGHT GAINGI SIDE EFFECTSLIVER FUNCTION

CHEAP ELDERLY DRIVERS

GLICLAZIDE m/R30MG

ONCE DAILYORAL

Postprandial glucose regulatorsPostprandial glucose regulators stimulate a rapid, short duration release of insulin

from the pancreas. This helps to restore the normal physiological insulin response to meals.

ExampleExample

Example ADVANTAGES DISADVANTAGES COST Caution

Repaglinide500mcg 30min before mealsUp to 4mg as single dose

Reduce post prandial BGReduce Hba1c up to 2%Suitable patient erratic lifestyle or hypo’s on sulphonylureas

Weight gainhypoglycaemia

cheap Renal impairment hepatic impairment

THIAZOLINDIONES(GLITAZONES)Thiazolidinediones reduce insulin resistance in adipose, skeletal, and hepatic tissues

by increasing transcription of insulin sensitive genes in these cells.

Example ADVANTAGES DISADVANTAGES COST Caution

PIOGLITAZONE15MG.30MG,45MG

ONCE DAILYORALIMPROVED LIPID PROFILE 0.5-1.5% Hba1c

WEIGHT GAINFracture riskRisk heart failureAnaemiamaculopathy

EXPENSIVE Ci HEARTFAILURE

DPP-4 INHIBITORSblock the action of DPP-4 which increases the availability of GLP-1.

Example ADVANTAGES DISADVANTAGES

COST Caution

SITAGLIPTIN(januvia)

WEIGHT NEUTRALONCE DAILY 100mgORALImproves fasting glucoseImproves B cell function(Triple therapy licence metformin,gliclazide,glitazone) Mono therapy licence if unable to take metformin.

GI SIDE EFFECTSNASOPHARYNGITIS

EXPENSIVE Adverse effects pancreatitis

Vildagliptin(galvus)Saxagliptin(onglyza)

INCRETIN MIMETICSBeta cells: Enhances glucose-dependent insulin secretion

Stomach: Helps slow gastric emptyingLiver: ↓ Glucagon which reduces hepatic glucose output

Alpha cells: ↓ Postprandial glucagon secretionPromotes satiety and reduces appetite.

Example ADVANTAGES DISADVANTAGES COST Caution

EXENATIDE LOW HYPO RISKWEIGHT LOSS

INJECTEDTWICE DAILYNAUSEA BLOATING

EXPENSIVE PANCREATITISSevere renal impairment

LIRAGLUTIDE ONCE DAILYLOW HYPO RISKWEIGHT LOSSBP REDUCTION

INJECTEDNAUSEA BLOATING

EXPENSIVE PANCREATITITSMEDULLARY THYROID CASevere renal impairment

INSULINExample ADVANTAGES DISADVANTAGES COST Caution

LONG ACTING ANALOGUESLANTUS AND LEVEMIR

EffectiveTailored regime

HYPO RISKWEIGHT GAINLantus cancer risk

moderate HGV/PSV DRIVERS

Short actingHumalognovorapid

Reduces postprandial glucoseRapidUse as part of basal bolus

Weight gainHypo’s

moderate

MixedHumalog mix 25Novomix 30

Only twice daily Less flexibleHypo’s

moderate

Erectile impotencePDE5 inhibitors

Name Dose duration Caution CI SE

SildenafilViagra

25-100mgSingle dose1 hour before intercourseTake on empty stomach

Onset action 25 min delayed if taking foodDuration action 4-5 hours

CVDAnatomical deformation penisPredisposition to priapism

Not in patients on nitrates.Within 4 hours of alpha blockesr

IndigestionHeadache facial flushing

TadalafilCialis

10mg-20mg at least 30min before max-20mg in 24 hours

Onset action 16-45 minDuration 36 hours

Not in patients on nitrates.Alpha blockers

IndigestionHeadache

Vardenafillevitra

5-20mg 25-60 min beforeCan eat/drink

Onset action 25 min. Delayed by fatty meal.Duration 4-5 hours

Not in patients on nitrates.Alpha blockers

Headache facial flushing