therapeutic management for diabetes mellitus, insulin therapy, oral hypoglycemic agents

1. Prepared for Dawacom Academy.
Presented by: PharmD Raed H. AL-Hweiyyan.
July-27-2016
CLINICALMANAGEMENT OF
DIABETES MELLITUS
Insulin Regimen For Treatment of Diabetes Mellitus

2. Objectives: • A brief definition and classification of
Diabetes Mellitus and Diabetes associated
phenomena anti diabetic agents.
• Diagnostic criteria of Diabetes mellitus.
• Goal of management of diabetes mellitus.
• Insulin regimen and Diabetes management
protocol.
• Complication management.
• Medical nutritional therapy.

3. Beat Diabetes!

4. Around the world, WHO estimates the number of people with
diabetes has remarkably increased between 1980 and 2014, as a
rise from 108 million to 422 million adults aged over 18 years
which is around four times higher, with a global prevalence growth
from 4.7% in 1980 to 8.5% in 2014.
An expected rise in the number of people with diabetes is
predicted to reach 592 million by 2035.
Diabetes numbers & figures
http://www.who.int/diabetes/global-report/en/

5. Lets have a look on Jordan!

6. Diabetes?
Diabetes is a disease characterized by high blood sugar levels
over a prolonged period of time caused by inability of human
body to metabolize glucose.
Frequent urination (polyuria), increased thirst (polydipsia),
and increased hunger (polyphagia) are typical symptoms of
diabetes.
If left untreated, it can cause many complications, such as:
(nephropathy, neuropathies, and retinopathy).

7. DM classification:
Caused by or classified to:
- Either the pancreas is not
producing insulin (Type 1
DM) "insulin-dependent diabetes
mellitus" (IDDM) or "juvenile
diabetes" with an unknown cause.
- Or the cells of the body not
responding appropriately to the
insulin produced or insulin
resistance, often combined with
insufficient insulin production(Type 2
DM).
- T2DM is a progressive metabolic
disorder, and upon progression of the
disease one may even develop lack of
insulin.

8. DM Associated phenomenon :
1- The Somogyi phenomenon ( Rebound Hyperglycemia ).
( 1-3 Am Hypoglycemia made by drugs ).
( 7- 9 AM Hyperglycemia reflex ).
2- The dawn phenomenon.
( 1-3 Am euglycemic clamp ).
( 7- 9 AM Hyperglycemia reflex ).

9. :
DM
2
Current antidiabetic medications for type
1-Sensitizers
A. Biguanides: Metformin(Glucophage),
B. Thiazolidinedions"glitazones"
Rosiglitazone (Avandia)
Pioglitazone (Actos).
2-Secretagogues:
Sulfonylureas:
1st gen.: Chlorpropamide(Diabens)
2nd gen.: Glimpiride(Amaryl)
Nonsulfonylurea secretagogues:
Repaglinide (Novonorm).
3-Alpha-glucosidase inhibitors:
Acarbose (Glucobay)
4-Glycosurics:
Canagliflozin (Invokana).
5-Peptide analogs:
(GLP-1 agonists and DPP-4 inhibitors).

11. Glucose
Level
Glucose
Level

12. Degludec

14. Diagnostic Criteria
Category Fasting plasma
glucose
2-hr 75-gm
OGTT
A1C
Normal < 100 mg/dL < 140 mg/dL < 5.7 %
Prediabetes 100–125 mg/dL 140–199 mg/dL 5.7–6.4 %
Diabetes ≥ 126 mg/dL ≥ 200 mg/dL ≥ 6.5 %

15. Glycemic Goals
ADA Goals AACE Goals
Preprandial capillary
plasma glucose
70– 130 mg/dL < 110 mg/dL
Peak postprandial
capillary plasma
glucose
< 180 mg/dL < 140 mg/dL
A1C < 7% < 6.5%

16. 1- IF the reading of A1C less than or equal 1.5% of the goal start with single agent .
2- IF the reading of A1C more than 1.5 % of the goal and less than ( A1C = 10 ), Give
combination ( of two or three agent according to the level of reading and its type.
Comprehensive Guide Line

17. Comprehensive Guide Line
3- IF the reading of A1C more than 10 % and less than ( A1C = 12 ) and not symptomatic
start with insulin initial doses and consider titration with shifting into oral hypoglycemic
drugs.
4- IF the reading of A1C more than 12 % or with A1C more than 10 less than ( A1C =
12 ) and symptomatic start with insulin maintenance doses and consider titration with
shifting into oral hypoglycemic drugs.

18. Initial Dose ( 0.3 - 0.5 IU / Kg ).
If A1c ( 10 – 12 )
Maintenance dose ( 0.7 – 2.5 IU / Kg).
If A1c ( More than 12 ).
Mixed Regimen :
Calculated dose
2/3
morning
1/3
evening

19. Dose ( 0.1 – 0.25 IU / Kg ). Of Total insulin regimen .
Basal – Bolus Regimen :
Calculated dose
50 % short
Acting
40%
30%
30 %
50% Long
Acting
Once daily

20. Dose Adjustment :
- Take pre-prandial reading before the evening dose by one hour to adjust the
morning dose.
- Take post prandial reading after evening dose by two hours and adjust the reading
according to it.
Decision according to the five days reading average.
Note : Change of dose By ( 25 – 35 % ) by increment or reduction.
Mixed Regimen :

21. Dose Adjustment :
- Long Acting according to the five days average of the morning reading :
1- ( 130 -140 ).add Two units.
2- ( 140 – 180 ). Add Four units.
3- ( More than 180 ). Add Six units
4- ( Less than 80 or hypoglycemia reduce two units )
- Rapid acting depend on the average of five days postprandial reading.
( Rule of 1800 ) = ( 1800 / patient doses ).
The result will be the amount of glucose reduced by 1 units of insulin.
The average of reading subtracted of the goal the act as proportional addition .
Basal – Bolus Regimen :

22. Conversion Between Mixed regimen and Basal- Bolus
Step 1
• Dose of intermediate insulin Type : its % as stated on the
products multiply by calculated insulin ).
Step 2
• Dose of long Acting : 80 % of intermediate insulin.
Step3
• Dose of short acting insulin : 80 % of Long acting insulin.
Step 4
• Distribute the dose of short acting .
Rule of ( 80 : 80 )

24. Easy EF

25. • Diabetic Retinopathy - Bilberry ( Grape Seed ) Extract : 40 – 80 mg three times
per day.
• Ginkgo Biloba Extract ( 24% Ginkgo Flavo- glycosides ) : 40- 80 mg three times
daily .
• Bitter melon ( Momordica charantia ) ( 1-2 oz fresh juice three times per day ).
• Defatted fenugreek powder : 50gm per day.
• Salt bush ( atriplex holimus ) : 3g per day .
• Fiber ( guar,pectin ,oat bran ) : 20 – 30 gm per day .
Medical Nutritional Therapy
‫ملحي‬ ‫رغل‬

26. • Vitamine C :500 -1000mg / day.
• Mixed Flavanoids : ( 1000 – 2000 mg / day ).
• Vitamine E : ( 800 – 1200 IU / day ).
• Flaxseed oil : 1 tablespoon per day.
• GLA source : ( 240 – 480 mg of GLA / day ).
• Magnesium : 250 mg two – three times per day.
• Methylcabal amine ( Active Vitamine B12 ) : 1000 mcg per day.
Medical Nutritional Therapy

27. THANK YOU FOR
LISTENING !
Any question?

28. References