Diabetes Part 3

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What to do?DIABETES TREATMENT

2

TREATMENT TRIAD

01

0203DIET

EXERCISE

PHARMACOTHERAPY

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What are we looking forCLINICAL EXAMINATION

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put your great subtitle hereClinical Examination

Hands

Blood Pressure

Eyes

Injection Sites

Feet

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The Cure for Type 2 DM?DIET AND EXERCISE

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Exercise

HOW WILL YOU SPEND YOUR DAY?

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WHAT YOU EAT IN PRIVATE YOUR WEAR IN PUBLIC

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The old and new.ORAL PHARMACOTHERAPY

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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)

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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)

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The old and newINJECTABLE PHARMACOTHERAPY

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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)

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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

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Where do we startDIABETES TREATMENT ALGORITHM

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22

Guidelines versus realityGlycemic Management

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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