Pharmacological Treatment of Diabetes

Treatment of Type 2 Diabetes should be individualized and take into account of individuals lifestyle, patient’s wishes and financial abilities.

Type 2 Diabetes

Step One (Lifestyle intervention and metformin):

  • Lifestyle changes to limit Carbohydrate intake, decrease weight and increase activity is inexpensive and provides broad benefits
  • Metformin is 1st line pharmacotherapy in Type 2 Diabetes. Its generally inexpensive and not associated with weight gain or hypoglycemia and benefits i
  • The presenting glycemic status in newly diagnosed people with diabetes should be considered. If the fasting glucose is greater than 250mg/dl or random glucose over 300mg/dl, sulfonylurea is considered instead of Metformin, or combination of both, or initiation of insulin therapy at diagnosis.

Step Two (Additional Medication) which includes either:

Sulphonylureas (SU)

  • Inexpensive but may give rise to modest weight gain
  • Severe Hypoglycemia is relatively uncommon
  • Chlorpopamide and Glibencamide are more likely to cause hypoglycemia than Glimepiride, Gliclazide and Glipizide

Thiazolidinediones (TZD)

  • Insulin Sensitizers, they improve insulin sensitivity over time and improve lipid profile
  • Causes fluid retention and weight gain, higher rate of bone fractures in women
  • Contraindicated in patients with diabetes, Co-Existing Heart Failure and active Liver disease

 

Step Three (further adjustments):

The combination of basal insulin with meal associated rapid acting insulin should be used in patients who are unable to achieve glycemic control on basal insulin with or without oral antiglycemic therapies

Intensified Insulin

  • The type of insulin used should reflect the patient glycemic profile (post prandial and fasting) as well as the individual lifestyle
  • Patients can continue to take insulin with metformin but stop taking secretagogues when rapid acting insulin to the regimen as they work the same
  • Basal Bolus insulin therapy provides the most physiological glycemic control and optimal flexibility for patients to adjust therapy to match lifestyle choices

Alternatively, premixed insulin (NPH plus regular human insulin) can be used in one or more daily doses, generally before supper, before breakfast and supper or prior to each meal

Summary:

  • The first choice drug is Metformin
  • When HbA1C concentrations are higher than the glyceamic goal, appropriate treatment variations must be speedily implemented
  • It is essential to combine two or more oral hypoglycemic drugs in patients who lack good control with monotherapy
  • It is essential to start either basal or multi-injection insulin therapy when blood glucose control is inadequate even with multi oral
  • Take into account possible poor adhesion to the prescribed treatment.

 




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