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INTERVENTION IN T2DM

KLINIK DIABETES TERPADU

RS ISLAM KLATEN

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Principals Intervention in T2DM

EducationMedical nutrition therapyPhysical activityPharmacologic intervention

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Hyperglycemia in T2DM

Defect of insulin secretion

Hepatic glucoseproduction

Carbohydrateabsorption

Glucose uptakeby muscle & adiposetissue

HYPERGLYCEMIA

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Intervention

Defect of insulin secretion

Hepatic glucoseproduction

Glucose uptakeby muscle and adiposetissue

CarbohydrateabsorptionHYPERGLYCEMIA

InsulinInsulin secretagogue

Alpha-glucosidase

inhibitorThiazolidinedioneMetforminInsulin

InsulinMetformin

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Insulin Secretagogue

Sulfonylureas:Use as adjunct to diet and exercise. Stimulate insulin

secretion by blocking K + channel of the beta cell.

Potential adverse effect: hypoglycemia,hypersensitivity, weight gain.EBM: decrease A1c by 1 to 2% (level 1A), causeweight gain of a proximately 2 to 3 kg (level 1A),major hypoglycemia 1 to 2% of patients receivingsulfonylureas.

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Insulin Secretagogue

Meglitinde analogues (repaglinide, nateglinide):stimulate release of insulin in response to a glucoseload (meal). One meal one dose, fast on fast off.Contraindications: diabetic ketoacidosis, T1DM,hypersensitivity.Adverse effects: hypoglycemia, hypersensitivity,weight gain.EBM: decrease A1c by 1 to 2% (level 1A), notsignificantly different from that seen withsulfonylureas (level 1A), hypoglycemia is similar withsulfonylueas (level 1A).

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Biguanid

Metformin: has insulin sensitizing properties.Decreases hepatic glucose production by improvinginsulin action at the liver.Contraindications: prone to metabolic acidosistates orhypoxic statesAdverse effect: lactic acidosis, anorexia, nausea,diarrheaEBM: it is associated with a 1 to 2% decrease in A1c(level 1A), similar to that of sulfonylureas (level 1A)

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Alpha-Glucosidase Inhibitor

Acarbose (Glucobay): inhibiting -glucosidase enzymesthere by slowing digestion of ingested carbohydrates,delaying glucose absorption.Contraindications: major gastrointestinal disorders.Adverse effects: flatulence, abdominal bloating.EBM: decreases A1c by 0.7 to 1.8% (level 1A)

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Thiazolinediones (insulin sensitizer)

Pioglitazone, Rosiglitazone: It enhances tissuesensitivity to insulin in muscle through activation ofintracellular receptors.Contraindications: hypersensitivity, active liverdisease, congestive heart failure.Adverse effects: weight gain, idiosyncratichepatocellular injury or necrosis.EBM: reduce A1c by 0.9 to 1.5% (level 1A)

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Oral Hypoglycemic AgentsClass Trade

names (mg)Daily dose

(mg)Initial

dose (mg)Duration ofaction (h)

Freq.

SulfonylureasChlorpropamide

Tolbutamide

Glibenclamide

Glipizide

Glicazide

Gliquidone

Diabenese100 & 200Rastinon500Renabetik2.5-5GlucotrolXL 5-10

DiamicronGlucodex80Glurenorm30

100-500

500-2000

2.5-20

5-20

80-240

30-120

50

-

2.5

5

40

15

24-36

6-12

12-24

10-16

10-20

10-20

1

2-3

1-2

1-2

1-2

1-3

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Oral Hypoglycemic AgentsClass Trade

names (mg)Daily dose

(mg)Initial

dose (mg)Duration ofaction (h)

Freq.

SulfonylureasGlimepirideRepaglinideNateglinide

BiguanideMetformin

Acarbose

TZDPioglitazone

Rosiglitazone

Amaryl 1-4NovonormStarlix

Diabex,glumin,glucophageGlucobay50-100

Actos

Avandia

0.5-16360

250-3000

75-300

15-45

2-8

250

50

10-20

12-42-4

1-3

3

1

1 or 2

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InsulinType Initiation (h) Peak (h) Duration (h)

Short acting:Regular insulinActrapidHumulin RIntermediate:InsulatardHumulin NLong acting:LantusMixed: mixtard,humulin 30/70Rapid acting: lispro,aspart, gluilysine

0.5-1

1-2

2

0.5-1