DIABETIC MEDICATIONS: ONE PART OF THE TRIAD

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DIABETIC MEDICATIONS ONE PART OF THE TRIAD

• Swedish Family Medicine
• PAT BORMAN, M.D.

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THE DIABETIC TRIAD

• Think of diabetes as a three legged stool
• DIET
• EXERCISE
• MEDICATIONS
• Optimal Care Requires Balance of all Three

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DIABETIC DIET

• Timing of Meals
• Content of Meal
• Protein 10-20
• Carbohydrates and MonoFats 60-70
• Saturated and Poly Fats lt10
• Exchange Systems for Carbohydrate Counting
• High Fiber, Weight Loss as Indicated

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EXERCISE AND DIABETES

• Aids glucose utilization
• Promotes weight loss
• Regular intervals and consistent duration of work
  outs lend optimal control

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DIABETIC MEDICATIONS

• FIVE CLASSES OF MEDICATIONS
• SULFONYLUREAS
• MEGLITINIDES
• BIGUANIDES
• THIAZOLIDINENDIONE
• ALPHA-GLUCOSIDASE INHIBITOR

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SULFONYLUREAS

• Glyburide Diabeta, Micronase 16-81
• Micronized Glyburide 16-81
• Glipizide Glucotrol 18-76
• Slow Release Glucotrol XL 10-42
• Glimepiride Amaryl 7-42

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SULFONYLUREAS

• Mechanism of action
• Increase insulin secretion from beta cells
• Mild decrease in insulin resistance peripherally
• Lower HbA1C 0.8-2.0
• Side Effects
• Hypoglycemia, Weight gain
• Cautions
• Renal failure increases hypoglycemia

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MEGLITINIDES

• Repaglinide Prandin 51-199
• Nateglinide Starlix 83-86

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METIGLITINIDES

• Mechanism of Action
• Increase insulin secretions from beta cells, very
  short onset and half life, dose right before
  meals , Lower HbA1C 0.5-2.0
• Side Effects
• Less hypoglycemia than sulfonylureas
• Cautions
• Skip meal skip dose, Extra meal extra dose
  flexibility for those who eat irregularly

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BIGUANIDES

• Metformin Glucophage 58-99
• Glucophage XR 39-74

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BIGUANIDES

• Mechanism of Action
• Reduces hepatic glucose excretion and enhances
  insulin sensitivity peripherally, Reduces HbA1C
  1.5-2.0
• Side Effects
• GI upset, Metallic taste, potentiate hypoglycemia
• Caution
• lactic acidosis 3/100,000, avoid in renal dz,

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THIAZOLIDINEDIONES

• Pioglitazone Actos 85-148
• Rosiglitazone Avandia 75-136

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THIAZOLIDINEDIONES

• Mechanism of Action
• Enhance insulin sensitivity in muscle and fat,
  Inhibit hepatic glucose production, Lower HbA1C
  0.5-1.5 , alter lipids favorably
• Side Effects
• Weight gain, metabolized in liver
• Cautions
• Idiosyncratic Liver toxicity, monitor LFT every
  other month for first year

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ALPHA-GLUCOSIDASE
INHIBITORS

• Acarbose Precose 46-60
• Miglitol Glyset 51-59

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Alpha-Glucosidase Inhibitors

• Mechanism of Action
• Inhibit absorption of carbohydrates from
  intestines
• Side Effects
• GI upset, bloating, flatulence, elevate LFTs
• Caution
• Avoid with renal failure, reduces effective po
  treatment of hypoglycemia

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Management of Type II DM

• 1. Confirm diagnosis
• 2. 3 month trial diet and exercise
• 3. Initiate monotherapy
• Check triad for balance
• 4. Initiate Combination therapy
• Check triad for balance
• 5. Consider insulin /- oral agent
• Check triad for balance

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REFERENCES

• Luna B, Feinglos MN Oral Agents in the
  management of type II DM, AFP 639 1747-1756, May
  2001.
• Davidson MB Diabetes Mellitus Diagnosis and
  Treatment, 4th Ed.,W.B.Saunders Co.
• Feinglos MN, Bethel MA Treatment of Type II DM,
  Medical Clinics of NA 824, 757-803, July 1998.