Diabetes mellitus amol

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  • In 1997 and 203, The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus 1,2 recognized an intermediate group of individuals whose glucose levels, although not meeting criteria for diabetes, are nevertheless too high to be considered normal This group was defined as having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) IFG: fasting plasma glucose (FPG) of 100 – 125 mg/dL (5.6 – 5.9 mmol/L) * IGT: 2-hour plasma glucose (2-h PG) on the 75-g oral glucose tolerance test (OGTT) of 140 – 199 mg/dL (7.8 – 11.0 mmol/L) Individuals with IFG and/or IGT have been referred to as having prediabetes, indicating a relatively high risk for future development of diabetes IFG and IGT should not be viewed as clinical entities in their own right but rather risk factors for diabetes as well as cardiovascular disease (CVD) IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension Individuals with an A1C of 5.7 – 6.4% should be informed of their increased risk for diabetes as well as CVD and counseled about effective strategies to lower their risks (see Section IV. Prevention/Delay of Type 2 Diabetes ) *The World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dL (6.1 mmol/L) References Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-1197. Genuth S, Alberti KG, Bennett P, et al., for the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160-3167. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S13. Table 3.
  • Sitagliptin Has a Generally Weight Neutral Profile Body weight did not increase from baseline with sitagliptin in either the 18-week or 24-week monotherapy study, compared with a small reduction in the body weight of patients given placebo. 1,2 A slight but similar decrease in body weight of patients was observed in both treatment groups of the add-on study with metformin. 2 There was no significant difference between sitagliptin and placebo in body weight change in the add-on study with pioglitazone. 3 Overall, sitagliptin appeared to have a neutral effect on body weight. 4 Purpose: To review the body weight profile for sitagliptin. Take-away: Sitagliptin has a generally weight neutral profile. Reference 1. Aschner P, Kipnes MS, Lunceford JK, Sanchez M, Mickel C, Williams-Herman, DE, for the Sitagliptin Study 021 Group. Effect of the dipeptidyl peptidase-4 inhibitor sitagliptin as monotherapy on glycemic control in in patients with type 2 diabetes. Diabetes Care. 2006;29:2632–2637. 2. Charbonnel B, Karasik A, Liu J, Wu M, Meininger G, for the Sitagliptin Study 020 Group. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor sitagliptin as monotherapy on glycemic control in in patients with type 2 diabetes. Diabetes Care. 2006;29:2632–2637. 3. Rosenstock J, Brazg R, Andryuk PJ, Lu K, Stein, P, for the Sitagliptin Study 019 Group. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor sitagliptin added to ongoing pioglitazone therapy in patients with type 2 diabetes: a 24-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. Clin Ther. 2006;28:1556–1568. 4. Nauck MA, Meininger G, Sheng D, et al, for the Sitagliptin Study 024 Group. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor, sitagliptin, compared with the sulfonylurea, glipizide, in patients with type 2 diabetes inadequately controlled on metformin alone: a randomized, double-blind, non-inferiority trial. Diabetes Obes Metab. 2007;9:194–205.
  • -Recommendations for the prevention/delay of type 2 diabetes 1 are summarized on this slide -Individuals at high risk for developing type 2 diabetes (i.e., those with impaired fasting glucose [IFG], impaired glucose tolerance [IGT] or both) can be given interventions that significantly decrease rate of onset of diabetes -Based on results of clinical trials and known risks of progression of prediabetes to diabetes, person with an A1C of 5.7%–6.4%, IGT or IFG should be counseled on lifestyle changes: 7% weight loss and moderate physical activity of at least 150 minutes/week -Regarding drug therapy for diabetes prevention, a consensus panel believed that metformin should be the only drug considered 2 Metformin may be recommended for very high-risk individuals (those with a history of GDM, the very obese, and/or those with more severe or progressive hyperglycemia) Of note, in the Diabetes Prevention Program (DPP), metformin was not significantly better than placebo in those over age 60 years For other drugs, issues of cost, side effects, and lack of persistence of effect in some studies 3 require consideration 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • -Recommendations for the prevention/delay of type 2 diabetes 1 are summarized on this slide -Individuals at high risk for developing type 2 diabetes (i.e., those with impaired fasting glucose [IFG], impaired glucose tolerance [IGT] or both) can be given interventions that significantly decrease rate of onset of diabetes -Based on results of clinical trials and known risks of progression of prediabetes to diabetes, person with an A1C of 5.7%–6.4%, IGT or IFG should be counseled on lifestyle changes: 7% weight loss and moderate physical activity of at least 150 minutes/week -Regarding drug therapy for diabetes prevention, a consensus panel believed that metformin should be the only drug considered 2 Metformin may be recommended for very high-risk individuals (those with a history of GDM, the very obese, and/or those with more severe or progressive hyperglycemia) Of note, in the Diabetes Prevention Program (DPP), metformin was not significantly better than placebo in those over age 60 years For other drugs, issues of cost, side effects, and lack of persistence of effect in some studies 3 require consideration 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • In 1997 and 2003, The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus 1,2 recognized an intermediate group of individuals whose glucose levels, although not meeting criteria for diabetes, are nevertheless too high to be considered normal This group was defined as having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) IFG: fasting plasma glucose (FPG) of 100–125 mg/dL (5.6–5.9 mmol/L) * IGT: 2-hour plasma glucose (2-h PG) on the 75-g oral glucose tolerance test (OGTT) of 140–199 mg/dL (7.8–11.0 mmol/L) Individuals with IFG and/or IGT have been referred to as having prediabetes, indicating a relatively high risk for future development of diabetes IFG and IGT should not be viewed as clinical entities in their own right but rather risk factors for diabetes as well as cardiovascular disease (CVD) IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension Individuals with an A1C of 5.7–6.4% should be informed of their increased risk for diabetes as well as CVD and counseled about effective strategies to lower their risks (see Section IV. Prevention/Delay of Type 2 Diabetes ) *The World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dL (6.1 mmol/L) A1C In 2009, an International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended the use of the A1C test to diagnose diabetes, with a threshold of ≥6.5% 1 , and ADA adopted this criterion in 2010 2 The diagnostic test should be performed using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay 3 Point-of-care A1C assays, for which proficiency testing is not mandated, are not sufficiently accurate at this time to use for diagnostic purposes 3 The A1C has several advantages to the FPG and OGTT, including greater convenience (since fasting is not required), evidence to suggest greater preanalytical stability, and less day-to-day perturbations during periods of stress and illness These advantages must be balanced by greater cost, the limited availability of A1C testing in certain regions of the developing world, and the incomplete correlation between A1C and average glucose in certain individuals In addition, HbA1C levels may vary with patients’ race/ethnicity 4,5 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • Meta-analyses 2 suggest that overall, each new class of noninsulin agents added to initial therapy lowers A1C around 0.9–1.1% 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • 2 nd generation is more potent than 1 st generation 1 st generation (tolbutamide, chlorpropamide, tolazamide) Glimepiride is most potent, 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • Insulin secretion is glucose dependent Use with sulfonylureas is duplicate therapy 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • Due to risks of MI restrict use of rosiglitazone to those currently using or those whose blood sugar is not controlled with any other meds and prefer not to use actos Avandia is available only through a restricted distribution program – prescriber would call 1800avandia 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • DPP4 enzyme is known to suppress some cancer growth 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • 8/8/2012 Lafayette Medical Education Foundation Inc. Anita Schwartz, Pharm D, BCPS Franciscan St. Elizabeth Health
  • Slide 6-20 MIMICKING NATURE WITH INSULIN THERAPY The Basal/Bolus Insulin Concept Insulin is capable of restoring glycemia to nearly normal in most patients with type 2 diabetes. The basal/bolus insulin concept attempts to mimic, with insulin therapy, the patterns that normally control glucose in persons without diabetes. Basal insulin suppresses glucose production so that the levels remain nearly constant between meals and overnight. Basal insulin meets about half of the patient’s daily need for insulin and may be sufficient when considerable endogenous insulin remains. Bolus insulin (10% to 20% of the total daily insulin requirement given at each meal) limits hyperglycemia after meals. This tends to smooth the peaks of glucose that occur in response to these meals. Frequent glucose monitoring aids in determining the candidates for basal or mealtime regimens. Ideally, each component of insulin replacement therapy should come from a different type of insulin with a specific profile to fit the patient’s needs. Practical methods to accomplish this basal/bolus strategy will be illustrated later in this module. Edelman SV, Henry RR. Insulin therapy for normalizing glycosylated hemoglobin in type II diabetes: applications, benefits, and risks. Diabetes Reviews . 1995;3:308-334; Kelley DB, ed. Medical Management of Type 2 Diabetes . 4th ed. Alexandria, Va: American Diabetes Association; 1998:56-72.
  • Insulin cartridges, disposable pens and vials not in use should be stored in the fridge. Injecting cold insulin may be more uncomfortable than injecting insulin at room temperature. Insulin pens and cartridges in use may be kept at room temperature (max 25 C) for up to 4 weeks. They should not be kept in the fridge when in use. Some insulin vials, when in use , may be kept out of the fridge (max 25 C) for up to 6 weeks.
  • Diabetes mellitus amol

    1. 1. Drug Management of Diabetes Mellitus Dr. Amol Diwan SKNMC, Pune
    2. 2. Diabetes Mellitus• Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.• The name diabetes mellitus derives from: Greek: diabetes – “siphon” or “to pass through” Latin: mellitus – “honeyed” or “sweet”**• Two major types : Type 1 and Type 2• There is either ABSOLUTE or RELATIVE deficiency of insulin
    3. 3. Classification• Type 1 diabetes• Type 2 diabetes• Other 1. Genetic defects of beta cell function 2. Genetic defects in insulin action 3. Diseases of the exocrine pancreas 4. Endocrinopathies 5. Drug/ chemical - induced 6. Infections 7. Uncommon forms of immune-mediated diabetes 8. Genetic syndromes sometimes associated with diabetes• Gestational diabetes mellitus
    4. 4. Criteria for the diagnosis of diabetes mellitusA. Random plasma glucose concentration ≥200 mg/dl (11.1 mmol/l), with or without classic symptoms Random is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, polyphagia and unexplained weight loss.ORB. Fasting Plasma Glucose is ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.ORC. 2-h post glucose load is ≥ 200 mg/dl (11.1 mmol/l) during an OGTT. Oral Glucose Tolerance Test should be performed as described by WHO, taking a glucose load of 75 g glucose dissolved in waterAny of these criteria establishes the diagnosis but needs to be confirmed on a later dayHbA1c• It measures the amount of glycosylated hemoglobin in blood• It is not useful for the diagnosis of diabetes mellitus• It is often used for monitoring long-term glycemic control and reflect glycemia for the previous 3 months• Its recommended level for a good glycemic is less than 6.5%.
    5. 5. Prediabetes: IFG, IGT, Increased A1C Categories of increased risk for diabetes (prediabetes)* FPG 100–125 mg/dL: IFG OR 2-h plasma glucose in the 75-g OGTT 140–199 mg/dL: IGT OR A1C 5.7–6.4% ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S13. Table 3.
    6. 6. Therapeutic aims• Glycemic control• Treatment of conditions associated with DM – Obesity – Hypertension – Dyslipidemia – Ischemic heart disease• Detection / treatment of DM related complications – renal – cardiovascular – retinal and – neuropathic
    7. 7. Therapeutic strategies• Diabetes management should begin with Medical Nutrition Therapy (MNT) (A typical day’s meals and snacks should provide 1,500–2,000 calories with 50% of the calories from carbohydrate, 20% from protein, and 30% from fat)• An exercise regimen to increase insulin sensitivity and promote weight loss should also be started.• If the patient’s glycemic target is not achieved after 3 to 4 weeks of MNT & exercise regimen, pharmacologic therapy is indicated.
    8. 8. Pharmacologic (DRUG) management• Pharmacologic management of for Type 1DM is only insulin• Pharmacologic management of Type 2 DM includes both oral glucose lowering agents or/ plus insulin (As Type 2 DM is a progressive disorder, it ultimately requires multiple therapeutic agents and often insulin)
    9. 9. Recap of Drugs
    10. 10. Oral Glucose Lowering Agents, also called Oral Hypoglycemic Agents (OHA)Based on their mechanisms of action, oral glucose lowering agents are subdivided into those: 1. Increase insulin secretion ( Insulin Secretagogues) 2. Reduce glucose production 3. Decrease glucose absorption from GIT 4. Increase insulin sensitivity
    11. 11. 1.Insulin Secretagogues (hypoglycemic agents) Sulfonylureas Meglitinides1st. Generation:AcetohexamideChlorpropamide Rapaglinide (0.25 - 4 mg tid/ qid)Tolazamide NateglinideTolbutamide(rarely used now )2nd. Generation:Glibenclamide (Glyburide)GlipizideGlicazideGlimepiride
    12. 12. Second generation sulfonylureaMore potent have fewer adverse effects have fewer drug interactions has longer duration (24 h) e.g. Glipizide, glyburide (Glibenclamide),glimepiride Contraindicated in hepatic impairement orrenal insufficiency
    13. 13. Second generation sulfonylureaExamples Starting dose Max. daily doseGlibenclamide 1.25 mg – 2.5 mg 15 mg (5 mg)Glipizide 2.5 mg – 5 mg 40mg (5 mg)Gliclazide 20 mg – 40 mg 320 mg(80 mg)Glimepride 1 - 2 mg 6 – 8 mg
    14. 14. Unwanted Effects:• Hyperinsulinemia & Hypoglycemia:• More in chlorpropamide & glibenclamide• Less in tolbutamide.• More in elderly and patients with renal disease.• Weight gain due to increase in appetite• GIT upset.• Dilutional hyponatremia, water intoxication (Chlorpropamide) vasopressin effect.• Disulfiram-like reaction with alcohol (chlorpropamide).• Tachyphylaxis (secondary failure).
    15. 15. Drugs which decrease hypoglycemic effect:• Microsomal inducers.• Thiazide diuretics• Corticosteroids.• Diazoxide.CONTRAINDICATIONS:• Pregnancy (use insulin)• Hepatic or renal insufficiency• Type I diabetes
    16. 16. Insulin Secretagogues (Sulfonylureas)• Mechanism of action: These drugs stimulate insulin secretion by interacting with the ATP sensitive K+ channel on the beta cells of pancreas - must have functional beta cells -• 1st generation sulfonylureas have a longer plasma half-life which causes a greater incidence of hypoglycemia• 2nd generation sulfonylureas are generally preferred, because they cause much less hypoglycemia due to their shorter half-life
    17. 17. Sulfonylureas1. ADRs: hypoglycemia, weight gain2. Contraindications: Type 1 DM, liver or kidney disease, sulfa allergy, pregnancy3. Clinical advantage: Lean patients with high blood glucose3. Drug interactions Drugs which can increase hypoglycemic effects of sulfonylureas 1. NSAIDs, 2. Sulfonamides 3. Warfarin 4. Beta -blockers Drugs which can decrease hypoglycemic effects of sulfonylureas 1. Thiazides, 2. Hydantoins 3. Oral contraceptives 4. Corticosteroids
    18. 18. Oral Antidiabetic Agents • Insulin secretagoguesHypoglycemia, is a side effectcommon to almost ALL these drugs – Sulfonylureas – MeglitinidesAlmost ALL of them are • Biguanides: Metformincontraindicated in severe liver, renal • ThiazolidinedionesandAlpha glucosidase inhibitors should be • cardiac disease andused with extreme caution in elderly
    19. 19. Insulin Secretagogues (Meglitinides) Repaglinide / Nateglinide• Mechanism of Action: also interact with the ATP-sensitive K+ - channel and increase insulin secretion from β-cell of pancreas.• They have – Fast onset of action (<1h.) – short half-lives (1h.) – short duration of action(4h.)• So these agents are taken immediately before each meal• Clinical advantage: Effective in reducing post prandial hyperglycemia and hypoglycemia is rare• Dose: 0.25 – 4.0 mg (repaglinide) & 60-120 mg (nateglinide) tid / qid• ADR: They should be cautiously used in hepatic & renal dysfunctions
    20. 20. Meglitinides• Examples• Rapaglinide - Starting dose 0.5 mg 3 times before meal• Max. daily dose 8 mg• Nateglinide - Starting dose 120 mg 3 times before meal• Max. daily dose 360 mg
    21. 21. Adverse effects of Meglitinides• Less incidence than sulfonylureas• Hypoglycemia (if meal is delayed)• Weight gain• Drug interactions - Repaglinide has recently been contraindicated in patients taking gemfibrozil due to the risk of severe/prolonged hypoglycemia- Clarithromycin, itraconazole, ketoconazole, MAOIs- Due to CYP2C8 and CYP3A4 interactionsContraindications• Hepatic and renal impairment.
    22. 22. 2. BIGUANIDES1. Metformin is the only drug used2. Mechanisms of action: – Reduced hepatic gluconeogenesis – Increased glycolysis in peripheral tissues – Reduced absorption of glucose from GIT – Decreased plasma glucagon level3. The initial starting dose is 500 mg OD/ BID, upto 1000 mg BID4. ADR: Metallic taste in the mouth, diarrhea, anorexia, nausea, and loss of appetite The major ADR of metformin is lactic acidosis5. Clinical Advantage: No hypoglycemia and No weight gain Useful in OBESE diabetics with not very high Blood Glucose6. Metformin is contraindicated in patients with – renal / liver diseases – Lactic acidosis-any form of acidosis – congestive heart failure – Use of contrast radiography (should be stopped 48 hrs. before) – Long term use interferes with B12 absorption – Pregnancy
    23. 23. BIGUANIDES• Metformin 500 mg• Starting dose 500 mg 1-3 doses with meals• 1000 mg ER od• Maximum dose 3000 mg• Tablets to be taken with or just after meal.
    24. 24. 3. α-GLOCUSIDASE INHIBITORSExamples: acarbose, miglitol and VogliboseM.O.A.: Reversible inhibitors of intestinal alpha- glucosidases in intestinal brush border responsible for degradation of oligosaccharides to monosaccharides.include sucrase, maltase, dextranase, glycoamylase.Dose: start with a low dose (25 mg of acarbose or miglitol) and may be increased over weeks to monthsADRs: diarrhea, flatulence, abdominal distentionClinical advantage: Pre-diabetic, obese persons
    25. 25. α-GLOCUSIDASE INHIBITORS• Acarbose 25/50 mg• Start with 25 – 50 mg 1 – 3 times with first bite of meal• Max dose - 300 mg in divided dose
    26. 26. Kinetics of α-glucosidase inhibitors• Acarbose• Given orally, poorly absorbed.• Metabolized by intestinal bacteria.• Excreted in stool and urine.• Miglitol• well absorbed, no systemic effects.• Excreted unchanged in urine.• 6 times more potent inhibitor for sucrase
    27. 27. Uses of alpha-glucosidase inhibitors• Type II diabetics inadequately controlled by diet with or without other agents ( SU, Metformin) alone or combined with insulin or sulfonylurea.
    28. 28. Contraindications of α-glucosidase inhibitors• Inflammatory bowel disorders (IBD).• Renal disease.• Hepatic disease (used with caution).• Intestinal obstruction.
    29. 29. 4. THIAZOLIDINEDIONES (glitazones) Rosiglitazone and Pioglitazone (Tro / Ciglitazone)• These drugs bind to the PPAR–y (peroxisome proliferators-activated receptor-y) nuclear receptor in adipose tissues• They correct insulin resistance• The first drug of this group, troglitazone, was withdrawn due to hepatotoxicity• For rosiglitazone and pioglitazone, liver function tests are recommended before starting and at regular intervals• These drugs are contraindicated in patients with liver disease or congestive heart failure• The safety of thiazolidinediones in pregnancy is not established.
    30. 30. Glitazones• Rosiglitazone 4 mg/ 8 mg• 4 mg once daily morning• Max Dose - 8 mg• - Pioglitazone 15 mg / 30 mg• 15 mg once daily morning• Max Dose - 45 mg
    31. 31. Adverse effects of pioglitazone• Fluid retention (Edema).• Weight gain.• Headache.• Liver function tests for 1st year of therapy.• Failure of estrogen-containing oral contraceptives. • Clinical benefits are not observed until 6-12 weeks
    32. 32. Incretin -mimetic (Exenatide / Liraglutide)• It mimicks the endogenous incretin, glucagon-like peptide-1 (GLP-1) and thus it stimulates glucose- dependent insulin release• As opposed to insulin secretagogues, which may cause non–glucose-dependent insulin release and hypoglycemia• Patients may attain modest weight loss.• This drug requires twice daily injections and is more expensive than high-dose glitazone therapy.Pramlintide : Synthetic amylin that reduces glucagon secretion and delays gastric emptying [s/c] Useful in type 1 and type 2 DM
    33. 33. DPP- 4 inhibitors• The newest oral hypoglycemic agents is Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin• A dipeptidyl peptidase IV (DPP-4) inhibitor• DPP-4 degrades numerous biologically active peptides including the endogenous incretins, GLP-1 and glucose-dependent insulinotropic peptide (GIP).• They can be used as a monotherapy or in combination with metformin or the glitazones• It is given orally and once daily
    34. 34. Dipeptyl- peptidase inhibitors Sitagliptin Vildagliptin Saxagliptin Septagliptin Allogliptin
    35. 35. Sitagliptin Has a Weight Neutral Profile• Monotherapy studies – No increase in body weight from baseline with sitagliptin compared with a small decrease in the placebo group• Add-on to metformin – A similar decrease in body weight for both treatment groups• Add-on to pioglitazone – No significant difference in body weight between treatment groups• Noninferiority vs Sulfonylurea A significant reduction in body weight with sitagliptin versus weight gain with glipizide 46
    36. 36. Clinical uses• Type 2 DM as an adjunct to diet & exercise as a monotherapy or in combination with other antidiabetic drugs.• Adverse effects: Nausea, abdominal pain, diarrhea• Nasopharyngitis
    37. 37. Indications for oral antidiabetics:  NIDDM not controlled by diet and exercise alone  Maturity onset diabetes > 40yrs age, duration <5yrs  BSL < 300mg%  Use Repaglinide or Nateginide for post-prandial hyperglycemia  In obese individuals prefer Metformin or Glyclazide a  One drug combine drugs from each class if inadequate response Add TZDs Switch over to insulin
    38. 38. Prevention, Prevention, Prevention!• Refer patients with IGT, IFG, or A1C 5.7–6.4% to ongoing support program – Target weight loss = 7% of total body weight – Minimum of 150 min/week of moderate physical activity• Follow-up counseling important for success• Based on cost-effectiveness of diabetes prevention, third-party payers should cover such programs• In those with pre-diabetes, monitor for development of diabetes annually ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2012;35(suppl 1):S16
    39. 39. Prevention, Prevention, Prevention!• Medications shown to delay progression of IGT/IFG to T2DM – Metformin (US DPP, NEJM 2002) – Acarbose (STOP-NIDDM, Lancet 2002) – Piaglitazone (ACT NOW, presentation 2008)• Consider metformin for prevention of type 2 diabetes if IGT, IFG, or A1C 5.7–6.4% – Especially for those with BMI >35 kg/m 2, age <60 years, and women with prior GDM• None are FDA approved for Diabetes Prevention
    40. 40. Easy A1c Correlation• NOTE: This is an estimate only• (A1C -2) x 30 – i.e. A1C= 7%; (7-2) x30 = 150mg/dL
    41. 41. How to treat Type 2 DM
    42. 42. Diagnostic Criteria Fasting Glucose 2-h OGTT Random Glucose A1c mg/dL mg/dL mg/dLNormal <100 <140 <200 <5.7%Prediabetes 100-125 140-199 5.7-6.4% (IFG) (IGT)Diabetes ≥ 126 ≥ 200 ≥ 200 ≥ 6.5%Note: In the absence of unequivocal hyperglycemia, result(s) should beconfirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S12. Table 2.
    43. 43. Determinants of selection of drugs for Type 2 DMEfficacy Safety Cost
    44. 44. Choice of Initial Glucose-Lowering Agent• The level of hyperglycemia should influence the initial choice of therapy.• mild to moderate hyperglycemia [FPG < (200–250 mg/dL)] often respond well to a single, oral glucose-lowering agent.• more severe hyperglycemia [FPG > (250 mg/dL)] -stepwise approach "Combination Therapy"• Insulin can be used as initial therapy in individuals with severe hyperglycemia [FPG > (250–300 mg/dL)• Insulin secretagogues, biguanides, -glucosidase inhibitors, thiazolidinediones, and insulin are approved for monotherapy of type 2 DM
    45. 45. What is the role of an ideal oral hypoglycaemic agent?Conserve islet cell function - delay the subsequent use of insulin.Improve patient compliance- single daily dosing.Reduce the incidence of hypoglycaemic events
    46. 46. Efficacy of Oral Hypoglycemic Agents• Sulfonylureas are not much helpful in patients with moderate glucose intolerance and pancreatic β -cell loss• Thiazolidinediones (glitazones) do not demonstrate much efficacy in patients who don’t have much insulin resistance
    47. 47. Side effects• The benefits of combination therapy must be weighed against the risk of side effects.• For sulfonylureas, the major side effect has been the frequency and severity of hypoglycemia.• However, for many patients, weight gain is also unacceptable• Renal disease• Hepatic disease Risk of lactic acidosis• Pregnancy – OHAs are contraindicated• Meglitinides are safe at higher levels of serumCr than sulfonylureas• Drug interactions
    48. 48. CostMetformin and 2nd Generation Sulfonylureasare LESS EXPENSIVENewer drugs are MORE EXPENSIVE
    49. 49. Initial Treatment of Type 2 Diabetes• Diet and exercise are the most effective treatments for type 2 diabetes !• Diet for approx 12 weeks• Then if control is poor (HbA1C > 7%) – Overweight (BMI > 25) - metformin – If not controlled then sulphonylureas, metaglitinides, amino acid derivatives• Contraindicated in pregnancy and when breast feeding• Used in conjunction with diet and exercise
    50. 50. Spectrum of Oral Hypoglycaemic Agents•Biguanides •Metformin (Biguanides)•Sulphonylureas •Glybenclemide, Glicliazide Glipizide, Glimepiride∀α-Glucosidase • Acarbose , Miglitol, Voglibosinhibitors • Repaglinide, Nateglinide•Meglitinide analogues • Rosiglitazone , Pioglitazone•Thiazolidinediones • Sitagliptin, Vildagliptin, DPPV-4 Inhibitors Saxagliptin
    51. 51. Combination therapy in the treatment of Diabetes Mellitus1. Suphonylurea + Biguanides2. Sulphonylurea + Insulin3. Insulin + Biguanides4. Insulin + Biguanides + Sulphonylurea5. Non-sulphonylurea + Biguanide + Glitazone6. Sulphonylurea + Acarbose7. Metformin + Acarbose8. Acarbose + Insulin9. Repaglinide + Pioglitazone/Rosiglitazone (FDA approved).
    52. 52. Guideline for combination therapy• Obese Type 2 DM - Start first with biguanides – if fails with maximum dose add Sulphonylurea or any insulin secretagogue or glitazone or acarbose• or minimum amount of insulin.• Normal weight Type 2 DM - Start with sulphonylurea if fails with moderate dose of OHA or• you may add biguanide/glitazone add insulin in moderate dose
    53. 53. Guideline for combination therapy• Under-weight Type 2 DM - Start with insulin then add minimum sulphonylurea• - Never use biguanides.
    54. 54. Determinants of OAD usage1)Body Mass Index : Metformin, Gliptins BMI> 22kg/m22)Presence of GI symptoms: Sulpho, Gliptins, Glitazones3)Renal Dysfunction: Gliptins,Glitazones(+/-),Sulpho (variable)4) Aging Meglitinides, Gliptins(?)5) Hepatic Dysfunction Nateglinide, Saxagliptin(?)6) Compliance Gliptins, Glitazones,7) Cost Metformin, Sulphas, Glitazones
    55. 55. Glycemic Control Algorithm for Type 2 Diabetes Mellitus Goals Hb A1C ≤ 6.0%, Fasting BG ≤100 mg/Dl, 2-hr PP BG ≤140 mg/dL Avoid hypoglycemia; i.e. glucose <60 mg/dL or <70 mg/dL if IHD Initial Intervention 1. Diabetes Education 2. Medical Nutrition, Weight Control, Exercise If NOT CONTROLLED 3. Consider Monotherapy (Metformin, if OBESE) Goals not met after 3 monthsGoals Achieved• Continue Therapy• A1C every 3-6 months • Add additional oral agent if A1C ~7% Goals not met after 3 Months • Add insulin (see Insulin Algorithm) • Consider referral to endocrinologist
    56. 56. Type 2 Diabetes Recommendations• Metformin + lifestyle changes at diagnosis providing no contraindication – Medications are ALWAYS to be used in combination with healthy meal planning and regular physical activity (150 minutes per week)• If marked elevation of A1c /blood glucose and/or symptomatic consider insulin (+ or – other agents) from the outset• If noninsulin monotherapy at maximal tolerated dose does not achieve /maintain the A1c goal over 3–6 months, add a second oral agent, a GLP-1 receptor agonist, or insulin ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S21
    57. 57. Non-Insulin Hypoglycemic Agents Oral Parenteral•Biguanides • Amylin analogs•Sulfonylureas • Incretin mimetics•Meglitinides•Thiazolidinediones•Alpha Glucosidaseinhibitors•Incretin Enhancers•(DPP-IV inhibitors)
    58. 58. Pharmacology - BiguanidesClass BiguanidesCompound MetforminMechanism Activates AMP-kinaseAction(s) • Hepatic glucose production ↓ • Intestinal glucose absorption ↓ • Insulin action ↑Glucose Lowering • FastingEffect • Post PrandialAdvantages • No weight gain • No hypoglycemia • Reduction in cardiovascular events and mortality (UKPDS f/u)Disadvantages • Gastrointestinal side effects (diarrhea, abdominal cramping) • Lactic acidosis (rare) • Vitamin B12 deficiency • Contraindications: reduced kidney functionCost Low – free at Marsh ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University
    59. 59. Pharmacology - SulfonylureasClass Sulfonylureas (2nd generation)Compound • Glibenclamide/Glyburide • Glipizide • Gliclazide • GlimepirideMechanism Closes KATP channels on β-cell plasma membranesAction(s) ↑ Insulin secretionAdvantages • Generally well tolerated • Reduction in cardiovascular events and mortality (UKPDS f/u)Disadvantages • Relatively glucose-independent stimulation of insulin secretion: Hypoglycemia, including episodes necessitating hospital admission and causing death • Weight gain • Primary and secondary failureCost Low – free at Marsh ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University.
    60. 60. Pharmacology – MeglitinidesClass MeglitinidesCompound • Repaglinide (Prandin®) • Nateglinide (Starlix®)Mechanism Closes KATP channels on β-cell plasma membranesAction(s) Insulin secretion ↑Advantages Accentuated effects around meal ingestionDisadvantages • Hypoglycemia, weight gain • Dosing frequencyCost Medium ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University.
    61. 61. Pharmacology – Thiazolidinediones (TZD)Class Thiazolidinediones (Glitazones)Compound Pioglitazone (Actos®)Mechanism Activates the nuclear transcription factor PPAR-γAction(s) Peripheral insulin sensitivity ↑Advantages • No hypoglycemia • HDL cholesterol ↑ • Triglycerides ↓Disadvantages • Weight gain • Edema • Heart failure (CI with stage III and IV) • Bone fracturesCost High ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University.
    62. 62. Pharmacology – Thiazolidinediones (TZD)Class Thiazolidinediones (Glitazones)Compound Rosiglitazone (Avandia®)Mechanism Activates the nuclear transcription factor PPAR-γAction(s) Peripheral insulin sensitivity ↑Advantages No hypoglycemiaDisadvantages • LDL cholesterol ↑ • Weight gain • Edema • Heart failure (CI with stages III and IV) • Bone fractures • Increased cardiovascular events (mixed evidence) • FDA warnings on cardiovascular safetyCost High ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University.
    63. 63. Pharmacology – Alpha- Glucosidase InhibitersClass α-Glucosidase inhibitorsCompound • Acarbose • MiglitolMechanism Inhibits intestinal α-glucosidaseAction(s) Intestinal carbohydrate digestion and absorption slowedAdvantages • Nonsystemic medication • Postprandial glucose ↓Disadvantages • Gastrointestinal side effects (gas, flatulence, diarrhea) • Dosing frequencyCost Medium ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University.
    64. 64. Pharmacology – Incretin EnhancersClass DPP-4 inhibitors (incretin enhancers)Compound • Sitagliptin (Januvia®) • Vildagliptin (available in Europe) • Saxagliptin (Onglza®) • Linagliptin (Tradjenta®)Mechanism Inhibits DPP-4 activity, prolongs survival of endogenously released incretin hormonesAction(s) • Active GLP-1 concentration ↑ • Insulin secretion ↑ • Glucagon secretion ↓Advantages • No hypoglycemia • Weight “neutrality”Disadvantages • Occasional reports of urticaria/angioedema • Cases of pancreatitis observed • Long-term safety unknown (cancer ?)Cost High ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S23. Adapted with permission from Silvio Inzucchi, Yale University.
    65. 65. Pharmacology – Incretin MimeticsClass GLP-1 receptor agonists (incretin mimetics)Compound • Exenatide (Byetta®) • Liraglutide (Victoza®)Mechanism Activates GLP-1 receptors (β-cells/endocrine pancreas; brain/autonomous nervous systemAction(s) • Insulin secretion ↑ (glucose-dependent) • Glucagon secretion ↓ (glucose-dependent) • Slows gastric emptying • Satiety ↑Advantages • Weight reduction • Potential for improved β-cell mass/functionDisadvantages • Gastrointestinal side effects (nausea, vomiting, diarrhea) • Cases of acute pancreatitis observed • C-cell hyperplasia/medullary thyroid tumors in animals (liraglutide) • Injectable • Long-term safety unknownCost High ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S23. Adapted with permission from Silvio Inzucchi, Yale University.
    66. 66. Pharmacology – Amylin AnalogClass Antihyperglycemic Synthetic AnalogCompound • Pramlintide (Symilin®)Mechanism • AmylinomimeticAction(s) • Glucagon secretion ↓ (glucose-dependent) • Slows gastric emptying • Satiety ↑Advantages • Potential weight lossDisadvantages • Meal time injections • Nausea • Hypoglycemia in combination with insulinCost High Lexi-Drugs Online [Internet]. Hudson (OH) : Lexi-Comp, Inc. 1978-2012[cited 2012 August 1].
    67. 67. Pharmacology – Bile Acid SequestrantsClass Bile acid sequestrantsCompound Colesevelam (Welchol®)Mechanism Binds bile acids/cholesterolAction(s) Bile acids stimulate receptor on liver to produce glucoseResults • Lowers fasting and post prandial glucoseAdvantages • No hypoglycemia • LDL cholesterol ↓Disadvantages • Constipation • Triglycerides ↑ • May interfere with absorption of other medicationsCost High ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S23. Adapted with permission from Silvio Inzucchi, Yale University.
    68. 68. Typical A1c Reductions Monotherapy Route of Administration A1c (%) ReductionSulfonylurea PO 1.5-2.0Metformin PO 1.5Glitazones PO 1.0-1.5Meglitinides PO 0.5-2.0α -glucosidase inhibitors PO 0.5-1.0DPP-4 PO 0.5-0.7GLP-1 agonists Injectable 0.8-1.5Amylin analogs Injectable 0.6Insulin Injectable Open to target Unger J et al. Postgrad Med 2010; 122: 145-57
    69. 69. Fasting vs. Postprandial Effect Mostly targets FASTING Mostly targets POSPRANDIAL hyperglycemia hyperglycemiaInsulin (long and intermediate Insulin (regular, rapid-action)action)Colesevelam α-glucosidase inhibitorsSulfonylureas MeglitinidesTZD PramlinitideMetformin DPP-4 inhibitors GLP-1 agonist
    70. 70. Considerations When Selecting Therapy• How long has the patient had diabetes (duration of disease – preservation of β-cell function)?• Which blood glucose level is not at target (fasting, postprandial, or both)?• Patient preference for route of administration (oral, injection)?• The degree of A1c lowering effect required to achieve goal?• Side effect profile and the patients tolerability?• Co – existing conditions ( CVD, osteoporosis, obesity, etc)?
    71. 71. Drug PearlsMedication PRO CONMetformin Low cost, A1c lowering, + CV Renal or hepatic impairment effects, weight loss, PCOSSulfonylurea Low cost, A1c lowering Hypoglycemia, treatment failureMeglitinides Erratic meals, renal insufficiency Hypoglycemia, treatment failurePioglitazone Insulin resistance, decrease in Edema, wt gain, CI with HF adipose tissue, TG reduction class III and IVα -glucosidase inhibitors Patients with constipation Long duration of T2DM, patients with GI problemsDPP-4 Well tolerated ? long term safetyGLP-1 agonists Obese patients GI side effectsAmylin analogs Poor PPG control despite GI side effects insulin therapyInsulin Flexible treatment (basal, basal Hypoglycemia, weight gain bolus, etc)
    72. 72. Dyslipidemic Agents• Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels – with overt CVD – without CVD >40 years who have one or more other CVD risk factors• For patients at lower risk (without overt CVD, <40 years, etc.) – Consider statin therapy in addition to lifestyle therapy if LDL cholesterol remains >100 mg/dL – In those with multiple CVD risk factors ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S30-31
    73. 73. InsulinInsulin is essential for patients with:• Type I Diabetes mellitus• Type II DM poorly controlled with OHA s• Some secondary diabetes• Diabetes associated with pregnancy• Surgery (Perioperative)• In some serious concurrent diseases, AMI• Ketoacidosis• Along with glucose to treat hyperkalemia
    74. 74. Chemistry of insulin:• Polypeptide hormone MW 5808.• Contains 51 amino acids arranged in• two chains A (21) & B (30) linked by two disulphide bridges.• B cells of pancreatic islets synthesize insulin from a precursor called proinsulin.• Proinsulin is hydrolyzed into insulin & C-peptide.• Insulin and C-peptide are secreted in equimolar amounts in response to all insulin secretagogues.• Proinsulin might have mild hypoglycemic action but C- peptide is inactive.• One milligram contains 28 units.
    75. 75. Types of insulin• Rapid-acting: Insulin aspart,- lispro, - glulisine (1-2h. onset / 4-6h. duration of action)• Short-acting: Regular Insulin, inhaled insulin (2-4h. onset / 6-12h. duration of action)• Intermediate-acting: NPH Insulin, Lente insulin (3-8h. onset / 12-20h. duration of action)• Long-acting: Insulin glargine, Insulin detemir ( Myristoylated insulin ) (6-12 onset / 16-30h. duration of action)• Pre-mixed insulins: NPH 70%+ Insulin aspart 30%
    76. 76. Ultra-short rapid-acting insulins• Insulin lispro, insulin aspart, insulin glulisine (injection)• Do not aggregate or form complexes• Fast onset of action (5-15 min)• Short duration of action (3-5 h)• Reach peak level 30-90 min after injection.
    77. 77. Short acting insulins regular insulins• Regular huminsulin R• Recombinant DNA technology• Clear solutions at neutral pH.• Hexameric analogue.• Onset of action 30-45 min (s.c.).• Peak 2-4 h.• Duration 6-8 h.
    78. 78. Short acting insulins regular insulins• I.V. emergency.• – Management of ketoacidosis• – After surgery• – During acute infection•  2-3 times/day.•  Control postprandial hyperglycemia &• ketoacidosis.•  Pregnancy
    79. 79. Intermediate acting insulins• Isophane (NPH), a neutral protamine hagedorn in phosphate buffer is combination of protamine & crystalline zinc insulin (1: 6 molecules). proteolysis release insulin.• Turbid suspension at neutral pH• Given S.C. only• Onset of action 1-2 h.• Insulin mixtures 75/25 - 70/30 - 50/50 (NPH/regular)
    80. 80. Intermediate acting insulins• Lente insulin• Mixture of 30% semilente insulin (amorphous precipitate of insulin with zinc in acetate buffer) + 70% ultralente insulin (poorly soluble crystal of zinc insulin)• Turbid suspension at neutral pH• Given S.C.• onset of action (1-3 h)• Peak serum level 4-8 h.• Duration of action 13-20 h.• Lente and NPH insulins are equivalent in activity.• Lente and NPH are Not used in emergencies (diabetic ketoacidosis).• Require several hours to reach therapeutic levels
    81. 81. Long acting insulin Insulin glargine (lantus)• Slow onset of action 2 h.• Clear solution• Forms precipitate (depot) at injection site.• absorbed less rapidly than NPH & Lente insulin.• Given s.c.- Maximum effect after 4-5 h• produce broad plasma concentration plateau (low continous insulin level).• Prolonged duration of action (24 h)- suitable Once daily• Should not be mixed with other insulin• Advantages over intermediate-acting insulins:• Constant circulating insulin over 24 hr with no pronounced peak.• More safe than NPH & Lente insulins ( reduced risk of hypoglycemia).
    82. 82. ADRs of insulin• Hypoglycemia• Lypodystrophy at the site of injection (atrophy or hypertrophy)• Weight gain• Hypersensitivity reactions.• Insulin resistance• Hypokalemia How to dose insulin • Sliding Scale Insulin It is the most frequent insulin regimen in hospitalized patients Otherwise, use • Basal- bolus insulin
    83. 83. The Basal/Bolus Insulin Concept• Basal Insulin – Suppresses glucose production between meals and overnight – Nearly constant levels – 50% of daily needs• Bolus Insulin (Mealtime or Prandial) – Limits hyperglycemia after meals – Immediate rise and sharp peak at 1 hour – 10% to 20% of total daily insulin requirement at each meal Ideally, for insulin replacement therapy, each component should come from a different insulin with a specific profile
    84. 84. Dosage• Usual Total Daily dose is 0.5 i.u. per kg BW• Higher doses are needed for those who: – have concurrent disease, AMI – have very high blood glucose levels – have ketoacidosis – are taking corticosteroids
    85. 85. Dosage (basal-bolus) Calculate the total daily dose of insulin (0.5 iu/kg) 2/3 rd before 1/3 rd before BREAKFAST EVENING MEAL 2/3 rd as 1/3 rd as 2/3 rd as 1/3 rd as intermediate or short-acting intermediate or short-actinglong-acting insulin Insulin long-acting insulin Insulin
    86. 86. Monitoring therapy1. Finger prick blood glucose testing Reagent strips and measuring instrument – Before each meal, before bed – Before meal blood glucose should be 70 – 120 mg/dl – After food level should be <180 mg/dl2. Urine glucose testing – Less accurate than blood glucose – Renal threshold may vary – Useful in stable patients – Useful in patients who can’t do finger-prick3. HbA1C measurement – Useful for measure of the degree of glycemia in the past 4-6 weeks – Good control if < 6 %
    87. 87. Increasing the dose of insulin• Any dietary error to be excluded and then the dose of insulin should be increased by 2-4 units.• Examples:• If breakfast and pre-lunch BG and/or urine glucose is high- add short acting insulin before breakfast• If post lunch and pre-dinner BG or urine is high –then increase morning dose of intermediate acting insulin by 2-4 units• If post dinner and late night BG or urine sugar is high, add short acting insulin 2-4 units before dinner• If fasting BG or urine sugar is high then increase pre- dinner intermediate acting insulin.
    88. 88. • Self-monitoring of blood glucose (individualized frequency)• HbAIC testing (2-4 times/year)• Medical nutrition therapy and education (annual)• Eye examination (annual)• Foot examination (1-2 times/year)• Screening for diabetic nephropathy (annual)• Blood pressure measurement (quarterly)• Lipid profile (annual)
    89. 89. Essential information for patients• What is hypoglycemia and how to treat it• Carry a diabetic card with details of drugs and patient information• Carry glucose (dextrose) or simple sugar (sucrose)• Careful while driving cars and handling heavy machine
    90. 90. Diabetic management “pearls”• When mixing insulins, draw up the regular insulin first• Allow mild hyperglycemia for the patient undergoing surgery—treat with short acting insulins• For elective surgery, schedule patient early in day to avoid prolonged fasting
    91. 91. “Pearls”• Use U-100 syringes for U-100 vials• In patients with insulin pumps, use regular insulin or insulin aspart. Generally will deliver one unit per hour w/bolus insulin before meals• Tight glycemic control can reduce the complications of diabetes.• Use ACE inhibitors to delay nephropathy• Limit dietary intake of protein
    92. 92. “Pearls”• Glitazones must suspect hepatotoxicity• Metformin cautiously with liver and renal impairment Concern that with hepatotoxicity, because risks of lactic acidosis are increased.• Rotate sites of injection of insulin to avoid development of lipodystrophy• Absorption of injected insulin in abdomen is not uniform with injections in arms or legs
    93. 93. Lypoatrophy andHyperlypotrophy
    94. 94. Injection Sites .. .. ArmsStomach Buttocks Thighs Site rotation is essential
    95. 95. Storage of insulin• Before use Store in fridge (2-8oC)• In-use vials Out of fridge to max 25oC (4-6 weeks)• In-use pens and cartridges Out of fridge at max 25oC (4 weeks)
    96. 96. Thank You

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