1. 1
What to do?
DIABETES TREATMENT

2. 2
TREATMENT TRIAD
01
0203
DIET
EXERCISE
PHARMACOTHERAPY

3. 3
What are we looking for
CLINICAL EXAMINATION

4. 4
put your great subtitle here
Clinical Examination
Hands
Blood Pressure
Eyes
Injection Sites
Feet

5. 5
The Cure for Type 2 DM?
DIET AND EXERCISE

6. 6
Exercise

7. 7

8. 8
The old and new.
ORAL PHARMACOTHERAPY

9. 9
BIGUANIDE CLASS
PLACE IN THERAPY
Increases insulin
sensitivity, Reduces
hepatic glucose
production; 1-2%
HbA1C reduction
ADVANTAGES
Clinical experience, rare
hypoglycemia,
improved lipid profile,
weight loss, low cost
DISADVANTAGES
GI intolerance, lactic
acidosis, vitamin B12
deficiency
AGENTS
Metformin
(Glucophage)

10. 10
SULFONYUREA CLASS
PLACE IN THERAPY
Increases insulin
secretion; 1-1.5%
HbA1C reduction
ADVANTAGES
Clinical experience, low
cost
DISADVANTAGES
Hypoglycemia, weight
gain, beta cell
exhaustion
AGENTS
Glyburide (Diabeta),
Gliclazide (Diamicron),
Glipizide (Glucotrol),
Glimepiride (Amaryl)

11. 11
MEGLITINIDE CLASS
PLACE IN THERAPY
Increases insulin
secretion; 0.5-1%
HbA1C reduction
ADVANTAGES
Short duration of
action, hepatic
clearance, glucose
dependent postprandial
action
DISADVANTAGES
Low efficacy,
hypoglycemia, weight
gain, high cost
AGENTS
Nateglinide (Starlix),
Repaglinide (Prandin)

12. 12
THIAZOLIDINEDIONE CLASS
PLACE IN THERAPY
Increases insulin
sensitivity, Reduces
hepatic glucose
production; 0.5-1.5%
HbA1C reduction
ADVANTAGES
Rare hypoglycemia
DISADVANTAGES
Edema, heart failure,
weight gain, increased
risk of long-bone
fracture, risk of bladder
cancer and CV events,
high cost
AGENTS
Rosiglitazone (Avandia),
Pioglitazone (Actos)

13. 13
DPP-IV INHIBITOR CLASS
PLACE IN THERAPY
Reduces hepatic glucose
production, increased
insulin sensitivity,
improve incretin effect ;
0.5-0.8% HbA1C
reduction
ADVANTAGES
Rare hypoglycemia, low
side effect profile
DISADVANTAGES
Angioedema, unknown
long term safety, risk of
pancreatitis
AGENTS
Saxagliptin (Onglyza),
Linagliptin (Tradjenta),
Vildagliptin (Galvus),
Sitagliptin (Januvia)

14. 14
ALPHA-GLUCOSIDASE INHIBITOR CLASS
PLACE IN THERAPY
Reduces carbohydrate
absorption; 0.5-0.9%
HbA1C reduction
ADVANTAGES
Rare hypoglycemia, low
side effect profile
DISADVANTAGES
Angioedema, unknown
long term safety, risk of
pancreatitis
AGENTS
Miglitol (Glycet),
voglibose (Volix),
acarbose (Precose)

15. 15
D2 DOPAMINE-RECEPTOR AGONIST CLASS
PLACE IN THERAPY
; 0.5% HbA1C reduction
ADVANTAGES
Rare hypoglycemia
DISADVANTAGES
GI side effects, side
effect profile low
efficacy, high cost,
AGENTS
Bromocriptine (Cycloset)

16. 16
The old and new
INJECTABLE PHARMACOTHERAPY

17. 17
GLP-1 RECEPTOR AGONIST CLASS
PLACE IN THERAPY
Reduced glucagon
secretion, Increased
insulin secretion,
reduced rate of gastric
emptying, reduced
appetite, improved
incretin effect ; 0.5-1.5%
HbA1C reduction
ADVANTAGES
Rare hypoglycemia,
weight loss, protective
CV effect
DISADVANTAGES
Side effect profile low
efficacy, risk of
pancreatitis, thyroid C-
cell hyperplasia, tumors,
high cost,
AGENTS
Exenatide (Byetta),
Exenatide extended
release (Bydureon),
liraglutide (Victoza)

18. 18
AMYLIN ANALOGUE CLASS
PLACE IN THERAPY
Reduced glucagon
secretion, Increased
insulin secretion,
reduced rate of gastric
emptying, reduced
appetite, improved
incretin effect ; 0.5-1%
HbA1C reduction
ADVANTAGES
Control of postprandial
glycemia, weight loss
DISADVANTAGES
Side effect profile,
hypoglycemia with
insulin, high cost
AGENTS
Pramlintide (Symlin)

19. 19
INSULIN PROFILES
Peak DurationOnset
Rapid Act 5-20 mins
Short Act 30 mins
Intermed Act 1-3 hrs
Long Act
Insulin
1-2 hrs
4-6 hrs
2 hrs
45-90 mins 3-5 hrs
3-5 hrs
12-16 hrs
20-24 hrs

20. 20
Where do we start
DIABETES TREATMENT ALGORITHM

21. 21

22. 22
Guidelines versus reality
Glycemic Management

23. 23
Hypoglycemia
risk/ADR
Patient/Disease Features
HYPERGLYCEMIA MANAGEMENT
Disease Duration
Life Expectancy
Comorbidities
Est. Vascular
Complications
Patient’s Attitude
Resources and
Support
Target
HbA1C
7%
More stringent Less stringent