TOC | ENDO | Diabetes Mellitus
Medications for Diabetes Mellitus REF: ACP PIER 2006 | ACP Med Best Dx/Best Rx 2006 | diabetesRx2007.pdf | DM_Meds_2011.pdf |
Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase)
Injectable medications:
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Sulfonylureas:
first choice for normal weight; hypoglycemia with monotherapy
- stimulate insulin secretion in response to glucose. Watch for weight gain.
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Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
Biguanides
- Primary action is reduction of excessive hepatic glucose output; it also has some activity on insulin resistance in skeleton muscle, though less than troglitazone. - Metformin may cause life-threatening lactic acidosis. - Takes about 2 wks to work well. Do not use in renal or hepatic dysfunction, dehydrated, or hospital patients. - Hold this med prior to IV contrast agents and for for 48 hours after. - Avoid if ethanol abuse, heart failure, hepatic or renal insufficiency (Cr >1.4-1.5), or hypoxic states.
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Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
Thiazolidinediones
TZD
(Glitazones) - enhance insulin action (sensitivity to insulin) in muscle, adipose tissue & liver; it also reduces excessive hepatic glucose output. It is for type II diabetes currently on insulin, yet not controlled (insulin >30 u/d) . - Side effects are weight gain and edema. Caution: Possible liver damage. Check LFT baseline & then every 1-2 months when clinically indicated thereafter.
__________________________________ Study continues controversy over rosiglitazone (Avandia)'s cardiovascular risks 6-8-2009 A new study found that rosiglitazone doubled the risk of heart failure among type 2 diabetes patients but did not raise overall cardiovascular hospitalizations or deaths compared with standard therapy.
The manufacturer-sponsored Rosiglitozone Evaluated for Cardiovascular Outcomes
in Oral Agent Combination Therapy for Type 2 Diabetes, or RECORD, trial's
results conflict with the findings of a 2007 study showing that rosiglitazone
significantly increased the risk of myocardial infarction. The RECORD trial
confirmed, however, earlier findings that rosaglitazone doubles the risk
of distal fracture in older women. The study results were presented at the
American Diabetes Association's annual scientific sessions over the weekend
and published online by the Lancet
(The
Lancet, Early Online Publication, 5 June
2009doi:10.1016/S0140-6736(09)60953-3). In the trial, 4,447 patients with type 2 diabetes on metformin or sulfonylurea monotherapy with mean hemoglobin A1c of 7.9% were randomly assigned to either add rosiglitazone to their existing regimen or take metformin and sulfonylurea alone. After 5.5 years follow up, HbA1c was lower in the rosiglitazone group than the standard therapy group, rosiglitazone did not increase the risk of overall cardiovascular morbidity or mortality, and rosiglitazone patients had a nonsignificant reduction in fatal and nonfatal stroke. However, heart failure causing admission to hospital or death was higher in the intervention group (hazard ratio [HR] 2.10; 95% confidence interval [CI] 1.35-3.27; risk difference per 1,000 person-years HR 2.6; CI 1.1-4.1) and upper and distal lower limb fracture rates were increased mainly in women taking rosiglitazone. The authors concluded that the data are inconclusive about rosiglitazone's effects on myocardial infarction and that the drug does not increase the risk of overall cardiovascular morbidity or mortality compared with standard glucose lowering drugs. In an interview with Modern Medicine, a study author noted that rosiglitazone should not be used by patients who have heart failure or who are at increased risk of fracture but could be considered in other type 2 diabetics, particularly obese patients. __________________________________
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Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
Meglitinides(Non-Sulfonylurea
Insulin Secretagogues) - stimulate insulin production in response to post-meal hyperglycemia. - Side effects include hypoglycemia, while repaglinide can bring on headaches.
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Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
Alpha-glucosidase
Inhibitor
- induce gastrointestinal carbohydrate absorption after a meal.
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Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
GLP
(Glucagon-Like Peptide)
Analogues:
Byetta (Exenatide)
5 mcg subc bid
Symlin (pramlintide) 15 mcg subc before
meal |
Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
DPP IV Inhibitors DDP-4 enzyme naturally breaks down the GI hormone called GLP-1 (Glucagon-Like Peptide), which promotes the synthesis and release of insulin when food is consumed, lowers levels of glucagon, induces satiety by slowing gastric emptying, and possibly stimulates beta-cell growth & neogenesis.
Januvia
(Sitagliptin) - recommended dose of JANUVIA is
100 mg PO once daily
Janumet (Sitagliptin/metformin) 50/500 or 50/1000 mg tab 1 tab bid PO |
Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
INSULIN
treatment
Rapid-Acting | Short-Acting | Intermediate-Acting | Long-Acting | Combination | New Inhaled Insulin | Non-insulin subc
RAPID-ACTING: as Humalog & Novolog insulin
Humalog insulin analog is faster but shorter duration action than Human regular insulin. Use within 15 min before meals. Injection, solution, aspart, human:
Injection, solution, lispro, human:
Injection, Apidra (insulin glulisine) given within 15 min premeal or within 20 min after starting a meal.
Injection, solution, regular, human:
Injection, solution, regular, human, buffered :
Injection, solution, regular, purified pork:
INTERMEDIATE-ACTING: NPH or Lente insulin
Injection, suspension, lente, human [zinc]:
Injection, suspension, NPH, human [isophane]:
Injection, suspension, NPH, purified pork [isophane]:
Injection, Levemir [insulin determir (rDNA origin)] subc once or twice daily
LONG-ACTING: Ultralente insulin Injection, suspension, Ultralente®, human [zinc]:
Injection, solution, glargine, human:
Pramlintide (Amylin) subc
COMBINATION, INTERMEDIATE-ACTING: Injection, aspart protamine human suspension 70% and rapid-acting aspart human solution 30%
Injection, lispro protamine human suspension 75% and rapid-acting lispro human solution 25%
Injection, NPH human insulin suspension 50% and short-acting regular human insulin solution 50%
Injection, NPH human insulin suspension 70% and short-acting regular human insulin solution 30%:
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Sulfonylureas
(as Glipizide/Glucotrol, Glyburide/Micronase) |
Biguanides
(Metformin/Glucophage) Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide, Starlix/Nataglinide) a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc) DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin (Exubera) |
Correlation of HgA1c to Average Blood
Glucose
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2006 General Guidelines for Management of Patients Presenting with High Blood Sugars See also Diabetic Ketoacidosis |
For blood glucose 300 - 500
mg/dl:
For blood glucose greater than 500 mg/dl (but glucose less than 700 mg/dL and serum CO2>20):
For blood glucose >700 mg/dl or C02 <20,
Endocrinology (KP Imperial Diabetic Clinic 2-2006) |