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Therapeutic Approach to Diabetes Mellitus PowerPoint Presentation

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Description : It's an presentation provided by a team of medical students of Mazandran University of medical science from Iran to discuss about therapies of Diabetes mellitus.

Tags : iran,diabetes,therapeutic,diabetes,diabetes mellitus

Published on : Feb 16, 2021 | Views : 2132 | Downloads : 11

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In the name of God اعضای گروه 1. ارشیا زمانی 2. شمیم داداشی 3. آینور خرمالی 4. محمدمهدی منوچهری 5. علی فرهمند 6. باسط زیتونلی 7. سینا مظلومی 8. امیرحسین بابایی
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Therapeutic approach to diabetes mellitus Main Topics Injection therapy(Insulins) Short-acting Long-acting Medication Biguanides Sulfonylureas Meglitinides SGLT-2 inhibitors GLP-1 agonist DPP-V inhibitors α- Glucosidase inhibitors Thiazolidinediones Amylin agonist
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Diabetes Definition Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves. Types Diabetes insipidus(ADH disorder/Fluid imbalance) Diabetes Mellitus Type I Type II The most common is type II diabetes, usually in adults, which occurs when the body becomes resistant to insulin or doesn't make enough insulin. In the past three decades the prevalence of type 2 diabetes has risen dramatically in countries of all income levels. Type I diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin by itself.
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Insulins Insulin is a 51-amino acid peptide hormone that is formed from a molecule named preproinsulin. The lack of insulin in diabetes mellitus marks the need for insulin injection as a compensatory pathway to regulate plasma glucose. As a whole, there are two types of insulin molecules used for the treatment of diabetes, one with the native amino acid sequence as the human insulin, and another one with a recombinant sequence. Of all the types available today, regular and NPH insulins are those with native sequences, while others like lispro, glulisine, etc. are insulin analogues with slightly-modified molecules. Also, insulins are divided into two groups: short- and long-acting. The type of injection for the first one is called a “bolus dose”, and for the second is called a “basal dose”. * NPH: Neutral Protamine Hagedorn
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Short-acting Insulins aspart, glulisine, lispro, and regular are called short-acting insulins, for they have less than 6 hours of effective duration. Of all these, the first three are recombinant forms and have less tendency for self-aggregation, resulting in more rapid absorption and onset of action, and a shorter duration of action. This shorter duration of action results in fewer number of hypoglycemic episodes because the decay of the insulin action happens at the time of the decline of plasma glucose after a meal. One last type of short-acting insulin is a novel one, and is delivered to the body by inhalation to provide a meal-time insulin. This method is approved, but it’s not widely used as of now. An important note is that inhaled human insulin can cause bronchospasm and cough, and shouldn’t be used in smokers or those with a lung disease.
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Long-acting Sometimes referred to as intermediate-acting, NPH has a longer duration of action than short-acting insulins. Aside from NPH, there are some other types known as degludec, detemir, and glargine. These three have some modifications in the molecule of insulin that results in an even longer duration of action, and a minimal peak activity. The lack of a pronounced peak makes hypoglycemic episodes happen fewer times in these insulins than in NPH, especially at nights. Beyond these, some new types of long-acting insulins are in development; for example, one with a duration of action of several days.
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* For the basal insulin requirement, one daily injection of degludec in enough, but as for the rest, twice-daily injections of glargine and especially determir might be necessary.
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Long-acting Can you mix long-acting insulins with others? Mixing NPH with short-acting insulins is common practice. This may alter the insulin absorption profile (e.g. lispro absorption is delayed when mixing with NPH), but it doesn’t mean we should stop mixing them. There are some guidelines to be followed when mixing insulins: -Mix them immediately before injection -Don’t store the mixture -Never mix glargine, detemir, or degludec with others -Have the same routine for mixing to standardize the physiologic response Five common types of mixtures include: -70% NPH and 30% regular -50% NPH and 50% regular -70% protamine aspart and 30% aspart (Novomix) -75% protamine lispro and 25% lispro (Humalog Mix 25) -50% protamine lispro and 50% lispro (Humalog Mix 50)
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Insulin Regimens - In the Past The whole initial dosage required by patients is as followed: -For type 1 DM: 0.4-1 units/kg/day -For type 2 DM: 0.2-0.4 units/kg/day The mentioned amount of required insulin can be provided through different insulin regimens. In the past, one common regimen included NPH and regular with this pattern: The drawback to this regimen is that it forces a rigid schedule on the patient. If the patient’s meal pattern or content varies or if their activity is increased, hyperglycemia or hypoglycemia may result.
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Insulin Regimens - MDI MDI or Multiple Daily Injection is a newer regimen that consists of both basal and bolus injections. The timing and dose of short-acting ones are altered based on SMBG results and the amount of physical activity. One common type of this method is shown below and consists of a basal insulin with glargine, detemir, or degludec and preprandial lispro, glulisine, or aspart.
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Insulin Regimens - CSII CSII or Continuous Subcutaneous Insulin Injection is a very effective regimen for patients with type 1 DM. In this, basal insulin is injected continuously via the insulin infusion device, and multiple bolus doses before meals. This device can act as an open loop (the patient sets the timing) or a closed loop (in which the device detects the glucose in the blood and injects insulin when needed). However, these devices come with the risk of infection, or DKA/hypoglycemia in case they become unresponsive.
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Insulin pens in iran
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Medication Other than insulins and some other parenteral medications, there are different types of oral agents than help lower glucose levels in the body. These medications are almost always used for the treatment of type 2 DM; however, some variants of MODY, as well as some neonatal diabetes patients may respond to sulfonylureas. These non-insulin agents result in one or more of these effects: -Increasing insulin secretion -Reducing glucose production -Increasing insulin sensitivity -Enhancing GLP-1 action -Promoting urinary excretion of glucose
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Biguanides Mechanism: -Decreasing hepatic glucose production -Improving peripheral glucose utilization Advantages: -No weight gain -No hypoglycemia -Decreasing cardiovascular events Disadvantages: -Diarrhea, nausea -Lactic Acidosis -B12 deficiency Contraindications: -GFR < 45-(if already taking, reduce dose until 30) -Acidosis
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Sulfonylureas Mechanism: -Increasing insulin production Advantages: -Having a short onset Disadvantages: -Hypoglycemia -Weight gain Contraindications: -Renal/liver diseases -Some of them have significant interactions with alcohol, warfarin, aspirin, ketoconazole, fluconazole, and α-glucosidase inhibitors
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Meglitinides Mechanism: -Increasing insulin production Advantages: -Having a short onset Disadvantages: -Hypoglycemia Contraindications: -Renal/liver diseases * The duration of action for meglitinides is shorter than sulfonylureas. * When using meglitinides, a higher glucose level is required compared to sulfonylureas for beta cells to secrete insulin.
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SGLT-2 Inhibitors Mechanism: -Increasing renal glucose excretion Advantages: -No hypoglycemia -Weight loss -Lowering blood pressure Disadvantages: -Urinary and genital infections -Polyuria and dehydration -Hyperkalemia and euglycemic DKA Contraindications: -Moderate renal insufficiency -Insulin-deficient DM (type 1, MIDY, etc.) * Inhibition of SGLT-2 on α-cells may cause glucagon secretion, thus ↑ glucose & ketone production in the liver, causing DKA in infections and stress-induced hyperglycemia
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GLP-1 Agonists (Parenteral) Mechanism: -Increasing insulin, decreasing glucagon -Slowing gastric emptying -Inducing satiety Advantages: -No hypoglycemia -Weight loss -Decreasing cardiovascular events Disadvantages: -Nausea -Hypoglycemia (only if used with insulin secretagogues) Contraindications: -Renal/pancreatic diseases -Agents that slow GI motility -Medullary thyroid carcinoma, and MEN syndromes
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DPP-IV Inhibitors Mechanism: -Inhibiting GLP-1 degradation -(Same effects as GLP-1 agonists) Advantages: -No hypoglycemia Disadvantages: -Angioedema -Urticarial and other dermatological effects Contraindications: -Renal diseases (dose reduction required) * Level of GLP-1 in patients using DPP-IV inhibitors is lower than those using GLP-1 agonists. * DPP-IV is a peptidase that is not GLP-1 specific.
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α-Glucosidase Inhibitors Mechanism: -Decreasing glucose absorption* Disadvantages: -GI flatulence -Diarrhea Contraindications: -Renal/liver diseases -IBD -Creatinine > 2 mg/dL -Taking simultaneous bile acid resins / antacids * They inhibit the enzyme that cleaves oligosaccharides into simple sugars in the intestinal lumen. * In case of hypoglycemia, simple sugars should be taken as the breakdown of complex sugars is disrupted.
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Thiazolidinediones Mechanism: -Increasing glucose utilization -Decreasing insulin resistance Advantages: -Lowering insulin requirements Disadvantages: -Peripheral edema -CHF -Weight gain -Macular edema -Fractures Contraindications: -CHF -Liver diseases
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Amylin Agonists (Parenteral) Mechanism: -Decreasing glucagon secretion -Slowing gastric emptying Advantages: -Weight loss Disadvantages: -Nausea -Hypoglycemia (if used with insulin) Contraindications: -Agents that slow GI motility * The role of amylin in glucose homeostasis is uncertain. Seeing some insulin-deficient patients also have low amylin led to developing pramlintide. It has been effective.
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Summary of Diabetes treatment Injection Therapy Mechanism: prevent glucagon secretion *Any of these combined with hypoglycemia-cause drugs, will cause hypoglycemia.
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The End Thanks for your attention
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Question 1 Q: Which of the following diabetes drugs acts by decreasing the amount of glucose produced by the liver? a. Sulfonylureas b. Meglitinides c. Biguanides d. Alpha-glucosidase inhibitors Answer: c
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Question 2 Q: A 52-year-old woman begins pharmacotherapy after being diagnosed with type 2 diabetes mellitus. Four weeks later, her hepatic glucose output is decreased, and target tissue glucose uptake and utilization are increased. Which of the following drugs was most likely prescribed for this patient? a. Acarbose b. Glyburide c. Metformin d. Repaglinide Answer: c
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Question 3 Q: A 45-years-old woman with a 5-year history of diabetes type 2 undergoes medication therapy with Metformin 500mg/8h and Gelibenclamide 1.5 tablets/12h. Wich of the following medications preferred? On examination: BMI=32, FBS=154, HbA1c=8% a. Gliclazide b. Pioglitazone c. Acarbose d. Exenetide Answer: d
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Question 4 Q: Which of the following regimens offers the best blood glucose control for persons with type 1 diabetes? a.A single anti-diabetes drugs b.Once daily insulin injections c.A combination of oral anti-diabetic medications d.Three or four injections per day of different types of insulin. Answer: d
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Question 5 Q: Which of the following is true of oral diabetes medications? a. The most common side effect of metformin is lactic acidosis. b. Thiazolidinedione ion compounds increase insulin production by stimulating PPAR gamma. c. Sulfonylurea compounds are the treatment of choice for obese diabetics with a history of more than five years of diabetes. d. Rapaglinide due to its short half-life reduces postprandial blood sugar. Answer: d
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Question 6 Q: A 70-years-old man with diabetes undergoes treatment with 30-units NPH insulin before breakfast and 20-units NPH insulin before dinner. He complains of midnight weakness and sweeting. Which of the following is the proper therapeutic action base on his history and examination findings? On examination: FBS=235 mg/dl, BS 10am=180 mg/dl, HbA1c=6% a. Take NPH before sleep instead of dinner b. Increasing the morning NPH unit c. Increasing the NPH unit before dinner d. Decreasing the morning NPH unit Answer: a
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Question 7 Q: The benefits of using an insulin pump include all of the following except: a. By continuously providing insulin they eliminate the need for injections of insulin b. They help with weight loss c. They enable exercise without compensatory carbohydrate consumption d. They simplify management of blood sugar and often improve A1C Answer: b
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Question 8 Q: A 45-years-old man has presented due to a 10kg weight loss in recent weeks followed by Polyuria and polydipsia. His FBS was reported 300mg/dl. In addition to life style and nutritional status changing which of these following therapeutic strategies is preferred for him? a. Metformin b. Glyclazide c. Pioglitazone d. Insulin Answer: d
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Question 9 Q: A 65-years-old woman with a 26-year history of type 2 diabetes Treated with glibenclamide 20mg, metformin 2000mg, sitagliptin 50mg daily, has been referred to a diabetes clinic due to a lack of blood sugar control. The patient with a feeling of fullness in stomach, after examination, is treated with a diagnosis of diabetic gastroparesis. In the patient's history in the last 2 months, there are two crises of nocturnal hypoglycemia. What you suggest for his BS correction? On his last examination: FBS=210 mg/dl, BUN=18 mg/dl, Cr=0.6 mg/dl, 2hpp blood glucose=230 mg/dl, HbA1c=9.3% a. Increasing the dosage of Sitaglipin b. Increasing the dosage of morning Liraglotide c. Increasing night NPH d. Increasing night Glargine Answer: d
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Question 10 Q: A boy with type 1 diabetes has been suffering from cold and fever symptoms for the past two days. He is treated with 32-unit insulin geltergine per night, and 12-unit insulin aspart before each meal. The patient's pre-lunch blood glucose is 380 mg/dl. If blood glucose is to be corrected to 180 mg/dl before lunch, what dose of short-acting insulin corrector is required to be given base on the patient's weight of 30 kg? a. 2 b. 4 c. 6 d. 8 Answer: b