2. depends on
• The type of diabetes you have
• The other medical problems you may have, which can
prevent the use of certain medicines
• The side effects you may experience with a particular
3. Medicines for Type 2 Diabetes
 SULFONYLUREAS, REPAGLINIDE, AND NATEGLINIDE
 ACARBOSE AND MIGLITOL (ALPHA-GLUCOSIDASE INHIBITORS)
 ROSIGLITAZONE AND PIOGLITAZONE
4. SULFONYLUREAS, REPAGLINIDE, AND
 These are oral medications that bind to receptors on the beta cell,
causing it to release insulin. The released insulin then lowers the
 Tolbutamide, chlorpropamide, acetohexamide, and tolazamide
are referred to as first-generation sulfonylureas, and, with the
exception of tolbutamide, are rarely used these days.
 The newer, second-generation drugs are glyburide, glipizide,
glimepiride, and gliclazide, and these are commonly used. They
vary in their duration of effect and how they are removed from the
5. SULFONYLUREAS, REPAGLINIDE, AND
 The risk of hypoglycemia with the sulfonylureas is higher in the
elderly and those with kidney failure. For these groups, it is better to
use lower doses and the fast-acting drugs—glipizide, repaglinide,
 People taking these medicines tend to gain some weight with time.
The reasons is that at times the medicine causes low glucose levels,
causing hunger so that the person overeats.
 Metformin works to reduce the glucose production by the liver.
 Unlike the sulfonylureas, metformin does not stimulate insulin release
from the beta cells, and so it does not cause hypoglycemia.
 The main side effects of metformin are nausea and occasionally
 Rarely, people taking metformin can develop lactic acidosis,
which can lead to death and so requires immediate
7. ACARBOSE AND MIGLITOL (ALPHA-
 These medications partially block the enzymes in the
small-bowel wall that break down starches, so that the
glucose rise after eating starchy foods is delayed and
the glucose peak is lower.
 When you take these medicines, more starch
breakdown products find their way to the lower part of
the bowel and the action of the intestinal bacteria on
these starches leads to production of gas (flatulence)
and abdominal discomfort.
8. ROSIGLITAZONE AND PIOGLITAZONE
 also called thiazolidinediones, TZDs, or glitazones.
 They work by making the tissues more sensitive to the effects of
 In addition to their glucose-lowering effect, thiazolidinediones
lower triglycerides and free fatty acid levels and raise total
cholesterol, LDL cholesterol, and HDL cholesterol.
 The main side effects of these medicines are weight gain and fluid
9. ROSIGLITAZONE AND PIOGLITAZONE
 Fluid retention can cause ankle swelling, and in
individuals with heart disease these medicines can
cause heart failure. (The symptoms of heart failure
include swelling of the legs and shortness of breath on
exertion.) The fluid retention is more of a problem if you
are also on insulin.
 The FDA has emphasized that these drugs should not be
used in people who are at risk for heart failure.
• It acts on the beta cells to cause insulin release.
• It decreases the glucagon release from alpha cells after
• It slows stomach emptying.
• It reduces appetite and promotes weight loss.
Nausea occurs in approximately 40 percent of individuals
Sitagliptin inhibits an enzyme (called dipeptidyl protease
IV, DPP IV) and so prolongs the action of the hormone
glucagon-like polypeptide 1 (GLP-1). The prolonged
activity of the released GLP-1 lowers glucose levels by
three different means:
• It stimulates the release of insulin from beta cells.
• It inhibits glucagon release from alpha cells.
• It slows down stomach emptying.
 Pramlintide limits the glucose rise after meals by slowing
stomach emptying and lowering the postmeal
glucagon levels. It also causes modest weight loss: two
to four pounds on average.
 Pramlintide is a modified form of IAPP. It is approved for
use by people with type 2 diabetes who are using insulin
and for people with type 1 diabetes
The goal of insulin therapy is to mimic the insulin secretion pattern that
is seen in people without diabetes through the use of injections or an
insulin pump. Normally there are two patterns of insulin release:
• Basal insulin, or background insulin, which is continuously released
from the beta cells and regulates the glucose production from the
• Bolus insulin, which is insulin released in response to food and
controls the glucose changes after meals
14. Types of insulin
• Fast-acting insulin covers the glucose level rise in
response to food
• Long-acting insulin provides the background insulin
16.  Regular insulin has to be injected thirty minutes before a meal so
that the insulin peak matches the glucose peak. Insulin analogs
get absorbed more quickly after injection, so that they can be
injected within fifteen minutes of starting a meal.
 However, there are some cautionary notes: first, because the peak
level of the insulin with the analogs is higher after a meal, it is
important for you to be more precise in counting the
carbohydrates you are consuming. Regular insulin is more forgiving
of errors in carbohydrate counting. Also, if you were to consume a
very fatty meal, which delays glucose absorption, you have to
inject these insulin analogs after a meal.
17. LONG-ACTING INSULIN PREPARATIONS
• NPH insulin
• Insulin glargine (brand name Lantus)
• Insulin detemir (brand name Levemir)
18. NPH insulin
 the effect on average lasts for about eight hours.
 The crystals of NPH insulin appear white to the naked
eye, and they tend to settle in the insulin vial. This is why
you should mix the NPH insulin (by rolling the bottle
between the palms of your hands) before drawing it up
in the syringe.
19. Insulin glargine
 Since it is acidic, the manufacturer recommends it should be given
as a separate injection and not mixed in the syringe with the
regular or fast-acting insulin analogs.
 Works for twenty-four hours.
20. Insulin detemir
 Lasts up to eighteen hours. It usually needs to be given twice a day
to cover the twenty-four hours.
21. INSULIN TIPS
 All insulin vials have a concentration of 100 units of insulin in 1 ml and are
therefore called U100 insulins.
 Do not “cook” them in a hot car or leave them in the sun, as this will affect
 Any spare insulin should be kept in the refrigerator (not the freezer) and
are good until the expiration date.
 All insulins, with the exception of NPH, are clear liquids, so you do not have
to mix them.
 When you mix NPH insulin, it is best to roll the bottle in the palm of your
hand and not to shake it vigorously, because that will introduce bubbles
and the dosing will be inaccurate.
22. Exubera (Inhaled Insulin)
 it is simply an old insulin (regular insulin) that is delivered into the
body in a different way. You use an inhaler (very much like an
asthma inhaler) to inhale the insulin powder, which is available in 1
mg and 3 mg blister packs.
 The 1 mg pack is equivalent to 3 units of insulin, and the 3 mg pack
is about 8 units of insulin. Three 1 mg inhalations are not equivalent
to one 3 mg inhalation—you get onethird more insulin with the
former. This is because three separate inhalations result in more
insulin being absorbed than one larger-dose inhalation.
23. USING AN INSULIN PUMP
 An insulin pump is a device the size of a pager. It contains a syringe
or reservoir filled with a fast-acting insulin, a battery-powered
syringe plunger, and a small computer to control the insulin
 The syringe is attached to tubing, which in turn is attached to a
small plastic tube (cannula) inserted under the skin.
24. Before you go to a pump clinic , you
should already have these skills:
• Be on a basal-bolus insulin regimen
• Counting carbohydrates.
• Know how to adjust food and insulin for exercise.
• Monitoring blood glucose levels frequently.
• Keeping written records.
25. Why doesn’t everyone with type 1
diabetes get a pancreas transplant?
1. There are only a limited number of donor pancreata available—a
few thousand—whereas there are about a million people with type
2. People who get an organ transplant have to be on medicines to
prevent the body’s immune system from attacking and rejecting
the organ. These immunosuppressive medicines have serious side
effects, such as making the individual more susceptible to
infections and increasing the risk of developing a cancer in the