diabetes part 3
TRANSCRIPT
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What to do?DIABETES TREATMENT
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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)
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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)
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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)
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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)
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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)
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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)
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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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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