DIABETES IS A PROGRESSIV DISEASE AND WE NEED TO STAY ONE STEP AHEAD OF THE DISEASE.WE HAVE TO TITRATE THE MEDICATIONS EVERY THREE MONTHS AND THE TIME IS NOT OUR FRIEND AS FAR AS THE MANAGEMENT OF DIABETES IS CONCERNED
Dipeptidyl peptidase inhibitors(DPP-IV): A deep insightRxVichuZ
This presentation deals with DPP-IV inhibitors, that are implicated for use in diabetes mellitus. Generalized pharmacology, including a precise insight into individual drugs have been elucidated.
EVALUATION OF GLYCEMIC RESPONSE OF ADDITION OF PIOGLITAZONE TO GLIBENCLAMIDE...Nani Karnam Vinayakam
Retrospective study of Antidiabetic drugs in Diabetes Mellitus patients. It help in for Pharmacy graduates, Pharm D Students, M Pharm -pharmacy practice students , hospital pharmacists & Clinical Pharmacists around the globe.
On DPP-Inhibitor ,case study on Linagliptin,Safe and affective class of drug for Management of Type II Diabetes as Monotherapy and add on therapy with OHA and Insulin,It can be added to SGLT2 Inhibitor also.
Slides to Guide Reducing Cardiovascular Risk in Type 2 Diabetes: What I Do an...hivlifeinfo
Slides to Guide Reducing Cardiovascular Risk in Type 2 Diabetes: What I Do and Why.2018
Zachary T. Bloomgarden, MD, MACE
Program Director
Mikhail N. Kosiborod, MD
Pamela Kushner, MD, FAAFP
Format: Microsoft PowerPoint (.ppt)
File Size: 923 KB
Released: June 29, 2018
Dipeptidyl peptidase inhibitors(DPP-IV): A deep insightRxVichuZ
This presentation deals with DPP-IV inhibitors, that are implicated for use in diabetes mellitus. Generalized pharmacology, including a precise insight into individual drugs have been elucidated.
EVALUATION OF GLYCEMIC RESPONSE OF ADDITION OF PIOGLITAZONE TO GLIBENCLAMIDE...Nani Karnam Vinayakam
Retrospective study of Antidiabetic drugs in Diabetes Mellitus patients. It help in for Pharmacy graduates, Pharm D Students, M Pharm -pharmacy practice students , hospital pharmacists & Clinical Pharmacists around the globe.
On DPP-Inhibitor ,case study on Linagliptin,Safe and affective class of drug for Management of Type II Diabetes as Monotherapy and add on therapy with OHA and Insulin,It can be added to SGLT2 Inhibitor also.
Slides to Guide Reducing Cardiovascular Risk in Type 2 Diabetes: What I Do an...hivlifeinfo
Slides to Guide Reducing Cardiovascular Risk in Type 2 Diabetes: What I Do and Why.2018
Zachary T. Bloomgarden, MD, MACE
Program Director
Mikhail N. Kosiborod, MD
Pamela Kushner, MD, FAAFP
Format: Microsoft PowerPoint (.ppt)
File Size: 923 KB
Released: June 29, 2018
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
ABSTRACT
Over the last decade, diabetes mellitus has emerged as an important clinical and public health
problem throughout the world. The aim of the study is perceive the Potentiality of a newer oral
Antihyperglycemic combination therapy over conventional therapy in type 2 diabetes. The
prospective study was conducted over a period of six months in the department of Medicine,
Guntur City Hospital. The prevalence of type2 diabetes was high in male 65.79 % than female
34.21%. Majority of the patients (23.68 %) belonged to age group of 51–55 years. Majority of
patients (55.26%) having a family history of Diabetes. Majority of patients receiving Combination
of Glibenclamide + Metformin (60.53%), evaluated for effect on FPG for both combinations. The
mean changes in FPG were noted. In the same way effect on HbA1c also noted. Mean changes in
for every month HbA1c will be noted. Our study reveals that Combination therapy with Metformin
plus Glimepiride is more effective than Glibenclamide plus Metformin; in improving glycemic
control in type 2 diabetes, while also allowing a reduction of the dosage of each drug.
Recently, several novel glucose-lowering targets have had drugs developed. This has resulted in several new drugs that have been approved for the local market to treat hyperglycaemia in patients with type 2 diabetes.
This presentation will attempt to provide:
A concise summary of these drugs for an Intensive Care Physician.
A pragmatic framework for what the non-Endocrinology Doctor should do with these drugs whilst the patient is in, and being discharged from, the Intensive Care Unit.
An outline of current trials evaluating glycaemia in the Intensive Care Unit.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
ABSTRACT
Over the last decade, diabetes mellitus has emerged as an important clinical and public health
problem throughout the world. The aim of the study is perceive the Potentiality of a newer oral
Antihyperglycemic combination therapy over conventional therapy in type 2 diabetes. The
prospective study was conducted over a period of six months in the department of Medicine,
Guntur City Hospital. The prevalence of type2 diabetes was high in male 65.79 % than female
34.21%. Majority of the patients (23.68 %) belonged to age group of 51–55 years. Majority of
patients (55.26%) having a family history of Diabetes. Majority of patients receiving Combination
of Glibenclamide + Metformin (60.53%), evaluated for effect on FPG for both combinations. The
mean changes in FPG were noted. In the same way effect on HbA1c also noted. Mean changes in
for every month HbA1c will be noted. Our study reveals that Combination therapy with Metformin
plus Glimepiride is more effective than Glibenclamide plus Metformin; in improving glycemic
control in type 2 diabetes, while also allowing a reduction of the dosage of each drug.
Recently, several novel glucose-lowering targets have had drugs developed. This has resulted in several new drugs that have been approved for the local market to treat hyperglycaemia in patients with type 2 diabetes.
This presentation will attempt to provide:
A concise summary of these drugs for an Intensive Care Physician.
A pragmatic framework for what the non-Endocrinology Doctor should do with these drugs whilst the patient is in, and being discharged from, the Intensive Care Unit.
An outline of current trials evaluating glycaemia in the Intensive Care Unit.
Memorias Conferencia Científica Anual sobre Síndrome Metabólico 2017 - Programa Científico
¿Hacia dónde van los algoritmos de la ADA/EASD, AACE y ALAD en el tratamiento DM2. Control glucémico y protección cardiovascular como objetivo?
Dr. Guillermo E. Umpiérrez
Professor of Medicine in the Division of Endocrinology at Emory University School of Medicine, Section Head, Diabetes and Endocrinology. USA. Editor en Jefe del BJM Open Diabetes Research and Care.
This Presentation Give You A brief Information About DPP4 And New Recommendations .This Presentation Guide You How To Treat Patients With Safety.
For Further Contact:03354999496
A Little Bit of Everything, Quick & Snappy: Probiotics to Advances in the Car...PASaskatchewan
As pharmacists, you are rarely faced with a consistent patient population with similar problems and questions. More likely, each patient you interact with has unique and varied concerns that you must be ready to address in an instant. This session reflects the diversity of patients a pharmacist will face in day-to-day practice and covers a range of topics in a quick and snappy format. This session will cover the evidence as it relates to concurrent probiotic and antibiotic use, second line treatment for patients with type 2 diabetes, and explore new utilization strategies of using drugs traditionally used in the treatment of type 2 diabetes for patients with type 1 diabetes.
Obesity context of type 2 diabetes and medication perspectivesApollo Hospitals
Drug therapy of obesity has harsh antecedent that many earlier introduced drugs are withdrawn from market. The drugs in present use lack sufficient long-term efficacy and safety data. The difficulty of reversing changing dietary habits and decline in physical activity, however, offers major scope for anti-obesity therapeutics, implied in managing the epidemic chronic inflammatory maladies and cardiovascular sequel. Metabolic syndrome, pre-diabetes and type 2 diabetes mellitus, commonly associate with obesity. Weight reduction is crucial to prevent and control type 2 diabetes. This emphasizes rational choice of therapeutic regimens that do not themselves cause weight gain, and better promote weight loss. Such an aspect is addressed briefly focusing upon the available newer anti-obesity drug options, in particular.
Intensification Options after basal Insulin RevisitedUsama Ragab
Intensification Options revisited
By Dr. Usama Ragab Youssif
Add an OAD
Add a short-acting insulin at mealtime
Switch to premixed insulins
Novel insulin combinations
Basal insulin/GLP-1 RA combinations
Royal Pharmaceutical Society UCL School of Pharmacy New Year Lecture 20193GDR
Diabetes and the Pharmacy Army
Philip Newland-Jones
Consultant Pharmacist Diabetes & Endocrinology
University Hospital Southampton NHS Foundation Trust
Obesity is a multifactorial disorder of energy balance, in which long-term calorie intake exceeds energy output. The generally accepted benchmark is the body mass index (BMI).
مدیریت و کنترل دیابت نوع دو (Management of diabetes)HalehChehrehgosha
این فایل جهت یادگیری بهتر دانشجویان پزشکی فراهم شده است.
دکتر هاله چهره گشا
فوق تخصص غدد و عضو هیات علمی دانشگاه ایران
بیمارستان حضرت رسول اکرم تهران
chehrehgosha.h@iums.ac.ir
Gestational Diabetes is the most common as well as the very prevalent medical disorder in females of reproductive age group. It has got significant impact on future development of T2D as well as CVD in women.
DYSPNOEA IS DEFINED AS THE UNDUE AWARENESS OF UNPLEASANT BREATHING.WHEN THERE IS AMIS MATCH BETWEEN THE AFFERENT VENTILATORY SIGNALS AND THE EFFERENT RESPIRATORY SIGNALS IN THE BRAIN WE MAY GET AN UNIGNORABLE FEELING FOR NEED OF MORE AND MORE OXYGEN.
Dyslipdaemia is common in diabetes and there is strong that cholesterl lowering improves cardiovascular outcomes ,even in patients with apparently unremarkable lipid profiles. The newly developed PCSK9 inhibitors are of great interest as they reduce LDL cholesterol by 50-70% independent of co medications and largely independent of the underlying dyslipidaemia.
Different types of vasculitis have characteristic patterns of blood vessel involvement.However vasculitis is a systemic illness.The symptoms of vasculitis depend on the particular blood vessels that are involved by the inflammatory process
Viruses are obligate intracellular parasites.Our arsenal of antivirals is dangerously small.Currently available antivirals are mainly against Herpes,Hepatitis and AIDS viruses.The treatment of HCV has shifted away from the use of Peg-IFN towards oral antivirals.Preventive vaccination is the key to global control of viral infections.
Pleural effusion may be defined figuratively as the juice, oozing from the leaky lingerie of the lung. However the text book definition is the abnormal accumulation of fluid in the pleural space due to disturbances in the forces that keep the pleural fluid economy in equilibrium...
SGLT2 INHIBITORS are very new therapeutic agents for the management of Type2 DM.They are very unique molecules and they donot cause hypoglycaemia or weight gain unlike many other OADs
The global epidemic and the d lightful vitaminRISHIKESAN K V
Roughly 1 billion people globally having low vitamin D levels. Scientists believe that lack of vitamin D is not only linked with rickets and osteomalacia but it plays a major role in heart disease ,Diabetes and cancers
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
India Diagnostic Labs Market: Dynamics, Key Players, and Industry Projections...Kumar Satyam
According to the TechSci Research report titled “India Diagnostic Labs Market Industry Size, Share, Trends, Competition, Opportunity, and Forecast, 2019-2029,” the India Diagnostic Labs Market was valued at USD 16,471.21 million in 2023 and is projected to grow at an impressive compound annual growth rate (CAGR) of 11.55% through 2029. This significant growth can be attributed to various factors, including collaborations and partnerships among leading companies, the expansion of diagnostic chains, and increasing accessibility to diagnostic services across the country. This comprehensive report delves into the market dynamics, recent trends, drivers, competitive landscape, and benefits of the research report, providing a detailed analysis of the India Diagnostic Labs Market.
Collaborations and Partnerships
Collaborations and partnerships among leading companies play a pivotal role in driving the growth of the India Diagnostic Labs Market. These strategic alliances allow companies to merge their expertise, strengthen their market positions, and offer innovative solutions. By combining resources, companies can enhance their research and development capabilities, expand their product portfolios, and improve their distribution networks. These collaborations also facilitate the sharing of technological advancements and best practices, contributing to the overall growth of the market.
Expansion of Diagnostic Chains
The expansion of diagnostic chains is a driving force behind the growing demand for diagnostic lab services. Diagnostic chains often establish multiple laboratories and diagnostic centers in various cities and regions, including urban and rural areas. This expanded network makes diagnostic services more accessible to a larger portion of the population, addressing healthcare disparities and reaching underserved populations. The presence of diagnostic chain facilities in multiple locations within a city or region provides convenience for patients, reducing travel time and effort. A broader network of labs often leads to reduced waiting times for appointments and sample collection, ensuring that patients receive timely and efficient diagnostic services.
Rising Prevalence of Chronic Diseases
The increasing prevalence of chronic diseases is a significant driver for the demand for diagnostic lab services. Chronic conditions such as diabetes, cardiovascular diseases, and cancer require regular monitoring and diagnostic testing for effective management. The rise in chronic diseases necessitates the use of advanced diagnostic tools and technologies, driving the growth of the diagnostic labs market. Additionally, early diagnosis and timely intervention are crucial for managing chronic diseases, further boosting the demand for diagnostic lab services.
For those battling kidney disease and exploring treatment options, understanding when to consider a kidney transplant is crucial. This guide aims to provide valuable insights into the circumstances under which a kidney transplant at the renowned Hiranandani Hospital may be the most appropriate course of action. By addressing the key indicators and factors involved, we hope to empower patients and their families to make informed decisions about their kidney care journey.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
PET CT beginners Guide covers some of the underrepresented topics in PET CTMiadAlsulami
This lecture briefly covers some of the underrepresented topics in Molecular imaging with cases , such as:
- Primary pleural tumors and pleural metastases.
- Distinguishing between MPM and Talc Pleurodesis.
- Urological tumors.
- The role of FDG PET in NET.
LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to CareVITASAuthor
This webinar helps clinicians understand the unique healthcare needs of the LGBTQ+ community, primarily in relation to end-of-life care. Topics include social and cultural background and challenges, healthcare disparities, advanced care planning, and strategies for reaching the community and improving quality of care.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
1. WHAT’S AFTER 3x PM
DR.RISHIKESAN K.V
SPECIALIST PHYSICIAN
VENNIYIL MEDICAL CENTRE
SHARJAH
2. Aims
To discuss the wide range of options for the sequence
of medications that should follow the ubiquitous
first – line use of Metformin in patients with
TYPE 2 DIABETES.
3. Learning Objectives
• Discuss the anti hyperglycaemic medications available
to physicians whose patients are not at their A1C goal
following Metformin and Lifestyle modification
• Learn the pros and cons of each medication.
• Select which medication we would prescribe to the fictional
patient mentioned here in this presentation
4. A 50 Y. old female visits your office to f/u her T2D. Her current medications include
Metformin 1000mg. BID, Lisinopril 10mg. and Atorvastatin 40mg. The most recent
HbA1C is 8.6 ; rest of her labs are within acceptable range. Which of the following
medications would you add to this patient’s regimen?
DPP-4 INHIBITORS
SULPHONYL UREA
BASAL INSULIN
TZD
SGLT-2 INHIBITORS
GLP-1 RA
5. Target HbA1c
American Diabetes Association (ADA) guidelines for
HbA1c targets
- <7% for most patients
- <6.5% for younger patients without comorbidities
- <8% for older patients with multiple comorbidities
The goal for our patient is 7%
https://doi.org/10.2337/dc15-S009
7. Is It easier to treat T2D today than it was 10 years ago ?
YES , it is easier now
NO, it has become harder
8. Background
• Nearly 50% of patients with T2D have an HbA1c above the target of
7%
• The combination of lifestyle management, with or without
metformin is recommended as the initial treatment for patients
with newly diagnosed T2D.
Inzucchi SE, et al .Diabetes Care.2015;38(1):140-19
9. Anti hyperglycaemic Therapy in T2D: General
Recommendations
• First-line therapy : Life style modification and
Diabetes self – education
• First-line medication: Metformin
• Metformin is a “No-Brainer”
• Even Metformin which is pretty much universally used first line is
not the ideal therapy for every one
10. For Profoundly Insulin Sensitive……
• For the patient who is profoundly insulin sensitive, Metformin may
not be the drug of choice
• Gastrointestinal tolerability is a clinical issue
• B12 Deficiency
11. Why Metformin?
• Metformin is safe
• Low risk of hypos
• Efficacious
• Affordable, low cost
But additional agents are often necessary to achieve adequate
glycaemic control
Skolnic N, Jaffa F, Kiriakov Y. J Fam Pract.2017;66(4)S4-S9
12. Metformin Advantages
• Metformin should remain a first-line therapy because its effect on
HbA1c is similar to other medications.
• Metformin has a long-term safety profile,
• It's weight neutral or helps people lose weight,
• It has gastrointestinal side effects but they are avoidable or tolerable
• Of course metformin looks better for cardiovascular mortality than
sulfonylureas
13. Metformin- FDA Label Update (2016)
• Contra indications of Metformin may be contradicted
• Expand metformin’s use in certain patients with reduced kidney
function
• Review of studies showed that metformin can be used safely in
patients with mild to moderate impairment in kidney function
14. Metformin and Renal Function
CKD STAGE eGFR, mL/min per 1.73sq.m Maximum total daily
dose, mg
1 More than or equal 90 2,550
2 60 -- < 90 2,550
3A 45 -- < 60 2,000
3B 30 -- < 45 1,000
4 15 -- < 30 Do not use
5 < 15 Do not use
15. The Continued Role of Metformin
Metformin remains as first line therapy if there are no
contraindications or intolerance .
- Extended release formulations may be better tolerated for some
patients
- Can be combined with other anti hyperglycaemic agents.
Favourable CV benefits seen with Metformin in UKPDS
ADA. Diabetes Care 2017;40(suppl 1):S1-S135
Garber AJ, et al. Endocr Pract 2017;23: 207-238
UKPDS Group. Lancet.1998;352:837-858
16. Clinical inertia
• It can take approximately 2 years to intensify therapy when patients
are not to goal on a single medication.
• An average of 7 years it may take ,when patients are not to goal on
2-3 oral medications.
Khunti K, et al. Diabetes Care.2013;36(11):3411-3417
17. ADA / EASD and AACE / ACE Guideline
Recommended several classes of antihyperglycaemic
medications for patients who have not achieved adequate
glycaemic control with metformin and life style management
alone
18. Criteria for Choosing Next Add-on Medications
• A1C Efficacy
• Hypoglycaemia Risk
• Weight Considerations
• Tolerable Side Effects and Adverse event Profiles
• Cost
These are the important attributes to second line therapy
Inzucchi S, et al.Diabetes Care.2015;38:140-149
19. Diabetes Oral Treatment Progression
ADA algorithm
-Metformin+ life style
-2nd oral agent based on patient profile
-3rd oral agent or injections
- Insulin by 1 year if not at goal
The favorable pattern
- Metformin + life style
- Cost is an issue – METFORMIN - SUs – PIOGLITAZONE
- Treatment preferences: Metformin-Pioglitazone-SGLT-2 inhibitor or
DPP-4 inhibitor
20. How many oral diabetes agents will you typically use before you
recommend an injection therapy for your patient ?
NONE , I START INJECTIONS DIRECTLY
ONE
TWO
THREE
I TRY TO AVOID USING INJECTION THERAPIES
21. The Sulfonylureas : better than nothing
• The most commonly prescribed second line agent for T2D
• If a patient still has lots of Beta cells , SUs can have nice effects in
lowering blood glucose
• But they cause
Weight gain
Hypoglycaemia
What really drives SU use is the cost
If a patient cannot afford anything else , they are better than nothing
22. SUs : Pros and Cons
HbA1C REDUCTION APPROXIMATELY 1%
GLYCAEMIC DURABILITY LIMITED
EFFECT ON WEIGHT INCREASE APPROX. 2.2KG
RISK OF HYPOGLYCAEMIA MODERATE
COST LOW
OTHER SAFETY CONCERNS
SULFONAMIDE HYPERSENSITIVITY , HYPOGLYCAEMIA,
HAEMOLYTIC ANEMIA, WEIGHT GAIN
Bolen S, et al. Agency for Healthcare Research and Quality.2016
25. Pioglitazone
This is not used much anymore, however IT IS NOT A TOTAL NON STARTER
It can be used in a patient population that is insulin resistant
It lowers TG
Raises HDL
It has benefits for NASH
May have some cardiovascular benefits
We know about its weight gain , and risk of heart failure, edema and fracture
risk
It is a potential add-on therapy that can have efficacy which outweighs safety
in some patients
26. TZDs
HbA1c REDUCTION APPROXIMATELY . 4 - . 9%
GLYCAEMIC DURABILITY GOOD
EFFECT ON WEIGHT INCREASE
RISK OF HYPOGLYCAEMIA LOW
COST LOW
ADVANTAGES ASSOCIATED WITH IMPROVEMENT IN HDL, TGs; MAY REDUCE THE RISK OF
RECURRENT CVA IN PATIENTS WITH INSULIN RESISTANCE BUT W/OUT DM
OTHER SAFETY CONCERNS HEART FAILURE, ISCHEMIC CARDIAC EVENTS, HEPATIC FAILURE, BLADDER CA,
EDEMA , WT.GAIN, FRACURES, MACULAR EDEMA, DECREASED Hb/Hct,
HYPOS WITH SU OR INSULIN
Bolen S, et al. Agency for Healthcare Research and Quality.2016
Lincoff AM, et al.JAMA2007;298(10):1180-1198
27. DPP-4 Inhibitors: MoA
• Inhibits the degradation of Glucose- dependent Insulinotropic
Polypeptide (GIP) and Glucagon-like peptide (GLP-1)
• Increases GIP and GLP-1 (INCRETIN) levels
• Inhibits glucagon release
• Increases Insulin secretion
• Decrease glucose levels
Thornberry NA, Gallwitz B. Clinical Endocrinology and Metabolism.2009;23(4):479-486
28. DPP-4 INHIBITORS
These are exceptionally tolerable agents
The efficacy may not be as great as the GLP-1 agonists
The risk of hypoglycaemia is low
They are weight neutral
29. DPP-4 Inhibitors
HbA1C REDUCTION APPROX . 0.4 – 0.5%
GLYCAEMIC DURABILITY GOOD
EFFECT ON WEIGHT NO CHANGE
RISK OF HYPOGLYCAEMIA LOW
COST HIGH
ADVANTAGES SAFETY AND TOLERABILITY
OTHER CONCERNS ACUTE PANCREATITIS, ARF, ALLERGIC AND HYPERSENSITIVITY
REACTIONS, ARTHRALGIA , CHF, HEPATIC FAILURE, HYPOS WITH SU
OR INSULIN
Skolnik N, Jaffa F, Kiriakov Y. J Fam Pract.2017;66(4):S4-S9
30.
31. DPP-4 Inhibitors are a good choice in Elderly
Vildagliptin 100 mg daily resulted in better glycemic control, tolerability,
and fewer adverse events compared with metformin 1,500 mg daily in
drug-naive elderly patients with type 2 diabetes .
Vildagliptin is effective and well-tolerated in type 2 diabetic patients aged
75 years or older .
Sitagliptin also provides similar glycemic improvement with less
hypoglycemia in the elderly with type 2 diabetes compared to sulfonylurea.
In older adults with type 2 diabetes, reductions in HbA1c after treatment
with a DPP-4 inhibitor were not different from those in younger patients.
Treatment with DPP-4 inhibitors in older diabetic adults was associated
with a low risk of hypoglycemia, and these agents were weight neutral .
33. The SGLT2 inhibitors
• They have got a non –insulin – dependent mechanism of action that is
highly applicable across the broad spectrum of Diabetes patients
• Their Glucose lowering efficacy is similar to the DPP-4 Inhibitors
• They have the benefit of promoting moderate weight loss
• They present “no hypoglycaemia risk”
• “Volume – related aspects” need to be considered when using these
agents
34. SGLT-2 Inhibitors: Summary of Physiologic Effects
Glucoretic effect of 60-80 grams of Glucose per day = 240-320
kcals/day
Typical weight reduction approx. 2-4 kg
Typical SBP reduction approx. 3-5 mmHg
2/3 of weight loss = adipose tissue
1/3 of weight loss = lean tissue
Of adipose tissue loss ½ = visceral fat; ½ = subcutaneous fat
DeFronzo RA, et al.DiabetesSpectrum.2014;27(2):100-112
36. EMPA-REG OUTCOME: Which outcomes were observed in the study of
7020 patients with median follow up of 3.1 years
> 30% reduction in all cause mortality
>30% reduction in CV mortality (primary outcome)
>30% reduction in hospitalisation for CHF
All of the above
37. EMPA-REG OUTCOME
• Empagliflozin , the game changer SGLT2 inhibitor has got an
exceedingly impressive mortality data.
• 60% of our diabetes patients die from cardiovascular disease
• The recent update by Canadian Diabetes Association clinical practice
schedule states that if your diabetes patient has CVD you should
consider a SGLT2 inhibitor as second-line after Metformin
• Preventing cardiovascular death trumps any other parameter.
38. SGLT-2 Inhibitors Precautions
Genital mycotic infection rate approx. 5% in males, approx. 10% in
females
Bacterial UTI minimally increased
Orthostatic symptoms more common in:
-Age > 75 years of age
- eGFR 30- < 60mL/min/1.73sqM
- Patients using loop diuretics
Taylor SR & Harris KB.Pharmacotherapy.2013;33(9):984-999
39. SGLT-2 Inhibitors
HbA1C REDUCTION APPROX 0.5 -1%
GLYCAEMIC DURABILITY EXCELLENT
EFFECT ON WEIGHT DECREASE APPROX . 2 - 4 KG
RISK OF HYPOGLYCAEMIA LOW
COST HIGH
ADVANTAGES WEIGHT LOSS, BP REDUCTION, CVO STUDY SHOWED A SIGNIFICANT
REDUCTION IN COMPOSITE MACE OUTCOME, AS WELL AS ALL CAUSE
MORTALITY
OTHER SAFETY CONCERNS SEVERE RENAL IMPAIRMENT, ESRD, DIALYSIS, HYPOTENSION, KETOACIDOSIS ,
AKI/RENAL IMPAIRMENT, HYPERKALAEMIA, UROSEPSIS/PYELONEPHRITIS,
GENITAL MYCOTIC INFECTIONS, LDL RISE, BLADDER CANCER, BONE FRACTURE,
HYPOS WITH SU OR INSULIN, LEG AND FOOT AMPUTATION (canagliflozin)
40. GLP-1 RAs
WHAT ARE THE GLP-1 RAs?
Class of injectable diabetes medications for T2D
What does GLP-1 RA stand for ?
Glucagon-Like Peptide -1 Receptor Agonist
Some times called
GLP-1 analogs
Incretin mimetics .
41. The Newer Kids on the
Block
• Their efficacy is high
• They are applicable across a broad
spectrum diabetes patients
• They have a tendency to promote weight
loss
• Got a positive favourable factor for a
patient with insulin resistance.
• They have got a promised Cardiovascular
benefits as hinted at by LEADER
• However GI tolerability is a major clinical
barrier
42. Key Things to Know about GLP-1 RAs
Stimulate Glucose Dependent insulin secretion
- Results in very low rates of hypoglycaemia
All injectable – tools vary by products
Important warnings
- Pancreatitis
- Medullary Thyroid Cancer/MEN 2 Syndrome
- Gastroparesis
- Renal disease
Brunton S. The International Journal of Clinical Practice.2014;68(5):557-567
43. Indications for GLP-1 Medications
Second-line or beyond for most with options for combinations
other medications, including basal insulin
AACE algorithm notes as preferred agent with efficacy and
weight loss
Used in T2D to improve blood glucose and A1c
44. Why not always insulin ?
When a patient is on oral and advances to an injection
- GLP-1 RAs are comparable to basal insulin
- GLP-1 RAs often outperform meal-time insulin
LESS HYPOS
WEIGHT LOSS RATHER THAN WEIGHT GAIN
- Cost and GI Side effects must be balanced.
45. GLP-1 RA : Advantages over Insulins
• Less Hypoglycaemias
• May be fewer injections
• Less weight gain
• Similar efficacy as Insulin but less side effects
46. Treatment Suggestions
High Fasting Blood sugar
GLP – 1 RA LONG ACTING
LIRAGLUTIDE DAILY (VICTOZA)
EXENATIDE WEEKLY (BYDUREON)
ALBIGLUTIDE WEEKLY (TANZEUM)
DULAGLUTIDE WEEKLY (TRULICITY)
High Post-Prandial Glucose
GLP-1 RA SHORT ACTING
EXENATIDE BID (BYETTA)
LIXISENATIDE
47. GLP-1 RAs
HbA1C REDUCTION APPROX . 5 - 1.3%
GLYCAEMIC DURABILITY EXCELLENT
EFFECT ON WEIGHT DECREASE APPROX 2.5 KG
RISK OF HYPOGLYCAEMIA LOW
COST HIGH
ADVANTAGES WEIGHT LOSS, GOOD DURABILITY, REDUCTION IN SBP AND DBP, DATA TO
SUPPORT REDUCTION IN MACE, MICROVASCULAR EVENTS, NEPHROPATHY(LIRA)
OTHER SAFETY CONCERNS MTC, MENS, THYROID C-CELL TUMORS, PANCREATITIS, RENAL IMPAIRMRNT,
GASTROPARESIS, HYPERSENSITIVITY, N & V, HYPOS WITH SU OR INSULIN, BILE
DUCT /GB DISEASE, DIARRHOEA, INJ.SITE REACTIONS
Bolen S,et al. Agency for Healthcare Research and Quality.2016
Marso SP, et al. NEJM.2016;375(4):311-322
48. Insulin : The Little Black
Dress of Diabetes Therapy
• Insulin remains the safest
alternative after Metformin
when the pancreas starts to tire
• Basal Insulin is a good choice
after Metformin
• We give Metformin to address
insulin resistance , and then we
can use insulin
50. BASAL INSULINS
HbA1C REDUCTION THEORETICALLY UNLIMITED
GLYCAEMIC DURABILITY EXCELLENT
EFFECT ON WEIGHT INCREASE
RISK OF HYPOGLYCAEMIA HIGH
COST HIGH
OTHER SAFETY
CONCERNS
HYPOGLYCAEMIA, HYPOKALAEMIA, ALLERGIC REACTIONS, FLUID
RETENSION WITH TZD
51. Individualization
Recognititon of the benefits and limitations of each
class of medications as well as differences among
medications within each class will help clinicians to
customise treatment and improve patient outcomes
52. So What are the Choices?
First: Metformin + Life Style
If HbA1C below 8%, may choose 2nd oral agent
- Pioglitazone, SGLT-2 Inhibitor or DPP-4 Inhibitor, or SU
If HbA1C 8- 10%
- Basal Insulin or GLP-1 RA
If HbA1C above 10%
- Basal Insulin
- Meal time insulin or GLP-1 RA to follow
53. Why not always insulin ?
When a patient is on oral and advances to an injection
- GLP-1 RAs are comparable to basal insulin
- GLP-1 RAs often outperform meal-time insulin
LESS HYPOS
WEIGHT LOSS RATHER THAN WEIGHT GAIN
- Cost and GI Side effects must be balanced.
54. Basal Insulin/ GLP-1 RA Combination Medications
Two Promising combinations have
received the FDA-approval
• IDegLira : Combination of degludec and
liraglutide
• IGlarLixi : Combination of glargine and
lixisenatide
These combinations are appealing
because of
• Their high efficacy
• They are weight neutral
• They won’t be fit for all
55. Basal Insulin/GLP-1 RA Combination Medications
Advantages
Highest efficacy
Weight loss
No added hypoglycaemic risk
compared to basal insulin
Fewer GI side effects than GLP-1 RA
Disadvantages
Hypoglycaemia
GI side effects - fewer than GLP-RA
Maximum basal insulin dose
(Fixed combination product)
56. Clinical Pearls from CVOT Data
TYPE 2 DIABETES
METFORMIN 1000mg.TWICE DAILY
DPP-4 INHIBITOR GLP-1 RA SGLT-2 INHIBITOR
WELL TOLERATED IN PATIENTS WITH CVD
(LIRAGLUTIDE)
IN PATIENTS WITH CVD
(EMPAGLIFLOZIN)
WEIGHT NEUTRAL WEIGHT LOSS H/o HEART FAILURE OR AT RISK
OF HEART FAILURE
LOWER BLOOD PRESSURE WEIGHT LOSS
LOWER BLOOD PRESSURE
58. Summary and Key points
Many reasonable choices for additional therapy when a patient
is not at goal on Metformin
Key point 1: Individualise additional therapy
• The mantra is to individualize
• It is called patient centric therapy
Key point 2: Do something rather than succumb to clinical inertia
• The delay in intensifying therapy when a therapeutic goal is not achieved
• May reflect confusion about the next medication.
• May be the misconceptions/ perceptions about risk , and side effects.
• The general hesitancy to escalate therapy
59. Take Home Message
• Diabetes is a very progressive disease
• Time is not our friend
• We need to stay one step ahead of the disease
• Many choices including complementary oral therapies
• Titrate every three months
• We typically take too long to intensify therapy
• Consider using injectables earlier
60. References
1.Inzucchi SE, et al .Diabetes Care.2015;38(1):140-19
2.Skolnic N, Jaffa F, Kiriakov Y. J Fam Pract.2017;66(4)S4-S9
3.ADA. Diabetes Care 2017;40(suppl 1):S1-S135
4.Garber AJ, et al. Endocr Pract 2017;23: 207-23
5.UKPDS Group. Lancet.1998;352:837-858
6.Khunti K, et al. Diabetes Care.2013;36(11):3411-3417
7.DeFronzo RA, et al.DiabetesSpectrum.2014;27(2):100-112
8.Taylor SR & Harris KB.Pharmacotherapy.2013;33(9):984-999
9.Bolen S, et al. Agency for Healthcare Research and Quality.2016
10.Bolen S,et al. Agency for Healthcare Research and Quality.2016
11.Lincoff AM, et al.JAMA2007;298(10):1180-1198
12.Bolen S,et al. Agency for Healthcare Research and Quality.2016
13.Marso SP, et al. NEJM.2016;375(4):311-322
14.Brunton S. The International Journal of Clinical Practice.2014;68(5):557-567
15.Thornberry NA, Gallwitz B. Clinical Endocrinology and Metabolism.2009;23(4):479-486