This document discusses oral anti-diabetic drugs and insulin therapy for treating diabetes. It describes different classes of oral drugs that enhance insulin secretion, overcome insulin resistance, or retard carbohydrate absorption. It also outlines 1-3 drug oral regimen plans based on HbA1c levels. For insulin therapy, it provides a history of insulin discovery and types including rapid, short, intermediate, and long acting varieties. Insulin therapy plans including once, twice, and thrice daily regimens are presented based on the number of daily injections.

1. RX
Dr. Kamal Kishore M.D.(AYU)

2. DIABETES RX
PART - 1
ORAL ANTI-DIABETIC
DRUGS
PART - 11
RX PLANS OF ORAL
DRUGS
PART - 111
INSULIN THERAPY
PART – 1V
RX PLANS OF INSULIN
THERAPY

3. PART - 1
ORAL ANTI-DIABETIC DRUGS

4. Oral Anti-Diabetic Drugs
Enhance
insulin
Secretion
“ides”
Sulfonyl ureas Meglitinides
“ins”
DPP-4
inhibitors
Overcome
insulin
Resistance
Biguanide
(Metformin)
Thiozolidinedione
(pioglitazone)
Retard
carbohydrate
absorption
Alpha
glucosidase
inhibitor

5. OVERCOME
INSULIN
RESISTANCE
Half life
Dosage
Dosage
Half life
Dosage
Dosage

6. ENHANCE
INSULIN
SECRETION
DPP-4 inhibitor
Sitagliptin 25-100 mg Single
Saxagliptin 2.5-5 mg Single
Linagliptin 5mg Single
Vildagliptin 50-100mg Single or divided

7. RETARD
CARBOHYDRATE
ABSORPTION

8. PART - 11
RX PLANS OF ORAL DRUGS

9. RX
PLANS OF ORAL DRUGS

10. ONE DRUG REGIMEN
U S E D F O R H B A 1 C  6 . 5 T O 7 . 5 %
• Metformin 500, 750, 850, 1000 mg twice or thrice daily
(not exceeding 2500mg)
• Lowers HbA1C by 1 to 1.5%
• Safer to use for lifelong (even with insulin dependency)
• Contraindicated with raised serum creatinine

11. TWO DRUGS REGIMEN
USED FOR HBA1C  7.5 TO 9%
Metformin + Glitazones*
(iR + iR)
*takes upto 12 weeks for max effect
*may cause fluid retention thereby contra in heart failure
Metformin + Sulfonyl urea*
(iR + iS)
*causes weight gain
*causes hypoglycemia (in such case meglitinides are used)
Metformin + Gliptins*
(iR + iS)
*expensive
*weight neutral
Sulfonyl urea + Glitazones
Sulfonyl urea + Gliptins

12. Metformin
+
Glitazones
(iR + iR)
Metformin
+
Sulfonyl urea
(iR + iS)
Metformin
+
Gliptins*
(iR + iS)

13. THREE DRUGS REGIMEN
USED FOR HBA1C  >9%
Metformin & Sulfonyl urea + Glitazones
Metformin & Sulfonyl urea + Gliptins
Metformin & Sulfonyl urea/Gliptins* +
INSULIN**
**Insulin in once daily regimen
*Gliptins to be used instead of SU, when risk of weight gain is
there
Metformin + Premixed insulin*
*Insulin in twice daily regimen
Metformin + Basal bolus Insulin*
*Insulin in thrice+ daily regimen

14. Metformin & Sulfonyl urea + Glitazones Three drug regimen

15. PART - 111
INSULIN THERAPY

16. HISTORY OF
INSULIN
Frederick Banting & Charles Best

17. • Canadian Surgeon Sir Frederick Banting and his Assistant Charles
Best prepared a crude extract (concoction) of Insulin from Dog
pancreas.
• When injected to diabetics, it helped to reduce blood glucose.
• Later insulin from Cattle and pig (Bovine insulin and Porcine
insulin) were commercially made. No longer used now a days.
1921

18. 1930
In order to reduce the number of insulin injections per day
Sir H.C. Hagedorn, prolonged the action (absorption) of
insulin by adding Protamine and zinc.
This added insulin acts for longer (14-16 hours) and is called
as:-
Neutral Protamine Hagedorn (NPH) or Isophane insulin.

19. 1978
First synthetic(artificial) copy of Human insulin was made by using DNA
recombinant technology in E.Coli (Adding human genes for insulin into
E.coli)
This artificial copy of human insulin is called as :-
HUMAN / REGULAR / SOLUBLE / NEUTRAL insulin

20. 1996
Insulin AnScientists modified the amino acids in
insulin and invented new insulin like peptides called
as
alogues
a) Rapid acting insulin analogues
Lispro (1996)
Aspart (2000)
Glulisine (2004)
b) Long acting insulin analogues
Glargine (2000)
Determir (2005)

21. 1921
1930
1978
1996
• Human / Regular / Soluble / Neutral insulin – Short
acting
• Insulin Analogues - Rapid acting & Long acting
• NPH / Isophane insulin – Intermediate acting

22. TYPES OF INSULIN
Type Time Duration Name Addnl name
Rapid acting
Insulin
with
meals /
just
after
meals
1-4 hours
Lispro, Aspart,
Glulisine
Insulin analogues
Short acting
Insulin
30 min
before
meals
6-8 hours
Regular / Soluble /
Neutral / Human
Insulin
Insulin/ Human
insulin
Intermediate
acting Insulin
30 min
before
meals
8-10 hours NPH / Isophane NPH/Isophane
Long Acting
Insulin
30 min
before
meals
16-24 hours Detemir, Glargine Insulin analogues

23. MEAL PATTERN IN
EXOGENOUS INSULIN
DEPENDENCY
• Morning breakfast
• Afternoon lunch
• Evening meal/snacks
• Night dinner/ bed time meal

24. PART – 1V
RX PLANS OF INSULIN THERAPY

25. RX
PLANS OF INSULIN THERAPY
(Based on number of injections per day )
(regimen are increased if blood sugar targets are not met)

26. ONCE DAILY REGIMEN
• Starting dose – 8-10 units or 0.2 units/kg OD
INTERMEDIATE ACTING INSULIN 30 min before breakfast
or
 LONG ACTING INSULIN 30 min before breakfast or dinner.
Given with Metformin and Sulfonyl Ureas (discontinue other oral anti diabetic
agents)
Increase insulin dose by 2 units every 3 days until blood sugar before breakfast is
under control.
Repeat HbA1c every three months. If not under control change to twice daily
regimen.

27. Morning AFTERNOON EVENING NIGHT
INTERMEDIATE ACTING INSULIN 30 min before breakfast
or
 LONG ACTING INSULIN 30 min before breakfast or dinner.

28. Intermediate acting insulin (before breakfast)
OR
Long acting insulin (before breakfast or before
dinner)

29. TWICE DAILY REGIMEN
(PREMIXED / BIPHASIC / MIXTARD REGIMEN)
• Starting dose – 6-10 units or 0.2 units/kg BD (divided doses)
PREMIXED RAPID ACTING INSULIN 30 min before breakfast & evening meal.
or
PREMIXED SHORT ACTING INSULIN 30 min before breakfast & evening meal.
Given with Metformin only (discontinue other oral anti diabetic agents)
Increase insulin dose of before breakfast by 2 units every 3 days until blood sugar
before lunch & evening meal is under control.
Increase insulin dose of before evening meal by 2 units every 3 days until blood
sugar before bed time meal & before breakfast is under control.
Repeat HbA1c every three months. If not under control change to twice daily
regimen.

30. Morning AFTERNOON EVENING NIGHT
PREMIXED RAPID ACTING INSULIN 30 min before breakfast & evening meal.
or
PREMIXED SHORT ACTING INSULIN 30 min before breakfast & evening meal.

31. PRE MIXED (before breakfast and evening
meals)
OR
PRE MIXED (before breakfast and evening meals)

32. THRICE+ DAILY REGIMEN
(BASAL BOLUS REGIMEN / BASAL PLUS REGIMEN)
• Starting dose of basal insulin – 8-10 units or 0.2 units/kg
• Starting dose of bolus insulin – 4 units
BASAL INSULIN 30 min before breakfast or before dinner
AND
BOLUS INSULIN 30 min before breakfast and before lunch and before evening
meal.
Given with Metformin only (discontinue other oral anti diabetic agents)
Increase basal insulin by 2 units every 3 days until blood sugar before breakfast/dinner is
under control.
Increase bolus insulin by 2 units every 3 days until blood sugar before lunch, evening
meal & dinner is under control.
Repeat HbA1c every three months. If not under control refer to
diabetologist/endocrinologist.

33. Morning AFTERNOON EVENING NIGHT
BASAL INSULIN 30 min before breakfast or before dinner
and
BOLUS INSULIN 30 min before breakfast and before lunch and before evening meal.

34. BASAL INSULIN
Intermediate acting insulin (before breakfast)
or
Long acting insulin (before breakfast or before
dinner)
BOLUS INSULIN
Rapid Acting Insulin (with brkfast & lunch & evening
meal)
or
Short Acting Insulin (before brkfast & lunch & evening
meal)

35. SITES OF INSULIN INJECTIONS

36. REFERENCES
• http://www.birminghamandsurroundsformulary.nhs.u
k/docs/acg/Insulin%20Guidelines%20for%20Adults%2
0and%20Children%20with%20Type%201%20and%20
Type%202%20Diabetes%20Mellitus%20V%201.0%20
%20February%202021.pdf
• ABC of diabetes (textbook) by Tim Halt and Sudesh
Kumar.
• Essential endocrinology and diabetes by Richard and
Neila.