Institute for Studies on Diabetes Foundation, Inc.

Pharmacologic Management of Type 2 Diabetes (2011)

#94 New (571 Old) Apitong St., Marikina Heights, Marikina CityTelephone No.: 941-9856Telefax No.: 941-9856 E-mail: isdfi 1989@yahoo.com.ph

Diabetes

81

Institute for Studies on Diabetes Foundation, Inc.#94 New (571 Old) Apitong St., Marikina Heights, Marikina City

Telephone No.: 941-9856Telefax No.: 941-9856

E-mail: isdfi1989@yahoo.com.ph

Executive Officers

Founder/Chairman & President EmeritusPresident

Corporate SecretaryTreasurer

Chairman of the BoardExecutive Director

Ricardo E. Fernando, MD, FPCP, FPSEMLeorino M. Sobrepeña, MD, MS, FPCPRodolfo C. Rabanal, MD, MS, FPCPRima T. Tan, MD, MS, FPCPAraceli A. Panelo, MD, MS, FPCPElizabeth Ann F. Catindig, MD, MS

Ricardo E. Fernando, MD, FPCP, FPSEMAraceli A. Panelo, MD, MS, FPCPLeorino M. Sobrepeña, MD, FPCP, MSRodolfo C. Rabanal, MD, FPCP, MSRima T. Tan, MD, FPCP, MSAtty. Crispino ReyesJose Cavada (Servier)Edwin Liwanag, MD, MS, FPAMSPeter Sy-GaisanoEvelyn Fernando, MDNomer Garcia (Unilab - LRI)Beaver Tamesis, MD (MSD)Romeo Divinagracia, MD, FPCP, FPCCAgnes T. Cruz, MD, MS, FPCPGemiliano DL. Aligui, MD, MPH, PhDWilson T. Young

Ricardo E. Fernando, MD, FPCP, FPSEMAraceli A. Panelo, MD, MS, FPCPLeorino M. Sobrepeña, MD, MS, FPCPRodolfo C. Rabanal, MD, MS, FPCPRima T. Tan, MD, MS, FPCPRichard Elwyn V. Fernando, MD, MSAgnes T. Cruz, MD, MS, FPCPGrace K. De Los Santos, MD, MS, FPCPMarcelo A. Lim, MD, MSEdwin E. Liwanag, MD, MS, FPAMSElizabeth Ann F. Catindig, MD, MSNines P. Bautista, MD, MS, FPCPOlive DG. Quizon, MD, MPH, DPAFP, DPBCNLuinio S. Tongson, MD, FPCS, MSPHErnesto L. Ang, MD, MS, FPCPMaria Luisa H. Licaros, MDLeilani A. Baldeviso, MD, FPCPJeimeen J. Agra, MD, MSFrancis I. Pasaporte, MD, MSRowena P. Rivera, MD, FPCPRonaldo M. Toledo, MDIrene Susana Grace K. Tang, MD, MS

Faculty Members

The Board of Trustees

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HISTORICAL BACKGROUND

In the early 70s, Dr. Ricardo E. Fernando, fired up by the zeal of a church minister that he did not become, embarked on another ministry; to spread the gospel of diabetes. He believed then as he still does today, that educating the medical practitioner would improve the lot of the ultimate benefactor, the Filipino diabetics whose lives will not only be prolonged but be made as compli-cation-free as possible.

He started giving out one-time lectures/seminars on a regular basis. Changes in the course content and teach-ing strategies were meticulously adopted, making each course an improvement of the previous ones. All sessions were always well-attended.

1980 saw the birth of the very popular Diabetes Mellitus Postgraduate Course (also known as Fernando lectures). Unlike the previous ones, participants were limited to senior residents or graduates of Internal Medicine. Each course lasted for three months with the students meeting every Saturday. A Certificate of Proficiency was granted the attendee at the end of the course depending on his performance.

Graduate of these courses formed the Diabetes Forum, a quarterly update on selected topics in Diabetes.

The overwhelming response to these programs inspired Dr. Fernando to dream more and more. In 1987, he thought of putting up an institute for diabetes. While there were several offers for the venue, he chose to link-up with UERMMMC, the school where he taught diabetes for twenty years. The then UE President Isidro Cariño gave the project full support. It was not difficult to get the cooperation of Dean Joven Cuanang, who worked for the immediate approval of the project with the Department of Education, Culture & Sports (DECS) sometime August 1988. Hence, the birth of the UE Institute for Studies on Diabetes, the first for the Philippines and the only one of its kind in Asia in 1989.

THRUST OF THE INSTITUTE

• A two-year masteral program in diabetes approved by the DECS and duly recognized by CHED conferring a Master of Science Degree on qualified internists.

• A one-year course entitled Diploma in Diabetes Studies for non-internals.

• Scholarships and hospital fellowships to deserving doctors and diabetes teaching nurses.

• Courses in diabetes for nurses and nutritionists in coop-eration with Association of Diabetes Nurse Educators of the Phils. (ADNEP) and Nutritionists and Dieticians Association of the Phils. (NDAP).

• Courses in ambulatory diabetology for general practi-tioners.

• Resource speakers in diabetes for other medical center, societies, organizations, commercial firms, and the lay

• Technical support to the DOH in the formulation of programs for Diabetes Prevention and Control

Our Mission

Enable healthcare professionals to deliver excellent and humane diabetes care.

Our Vision

Everyone receives excellent and humane diabetes care.

Our Values

A.Family

We are one in our aspiration to make a dent on dia-betes. Our members and healthcare partners are family whom we value and respect. We care deeply for their well-being and growth. We deal in candor and openness. Our patients and their loved ones are family as well. They are our work's meaning.

B.Service

Service to Life is our ministry and driving force• for furthering the knowledge and skills that help make

life much better.• for diabetes sufferers and protect high-risk individuals

from the disease.We are committed to render service anytime, anywhere, and in any condition, so that no one shall be deprived of excellent and humane diabetes care.

C. Integrity

Ministering to life is an honorable mission for which our probity, zeal, and fairness, besides our expertise, keep us trustworthy. We practice Medicine in faithful adherence to the Hippocratic Oath, the physician's highest and noblest standard of ethics for centuries. D. Excellence

Life being our work's meaning, we strive to give our best at our best. We search continuously, trying to quench our insatiable thirst for knowledge. Our excellent and generous mentors, whom we owe much gratitude, challenge us ceaselessly with "What else?" and inspire us to renew constantly.

E. LoveofWork

We love seeing happiness in the eyes of the diabetes patients we treat. We find fulfillment in enabling people to help us seek solutions to diabetes. We love working together in an atmosphere of trust, loyal friendship and fun. In all humility we celebrate with quiet and dedicated work our privileged role of enhancing, extending and saving God's greatest gift: Human life.

A Call to Arms

There has been an increasing global prevalence of diabetes in the past two decades, especially in develop-ing countries like the Philippines. Much of the efforts to date are focused on management of overt diabetes and prevention of its complications. Hardly is prevention of diabetes properly emphasized when this has more far-reaching implications than treatment.

Past studies have shown that the type 2 diabetes can be prevented - the Malmo study, the Da Qing study, the Finnish study, the Diabetes Prevention Program, the TRIPOD, the STOP-NIDDM study. All have shown the

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positive effects of drugs and lifestyle changes with the latter proving definitely superior. Maybe a mixture of the two will prove more beneficial?

We live in a perverse society which eats all it can, drinks all it can, has become more sedentary and obese smokes and drinks wantonly, is subject to more and varying stresses in life. These studies are telling us that reversing our current lifestyle trends can save us from the burden of diabetes. Unfortunately lifestyle changes are perhaps the most difficult for all. For how do you change the lifestyle of people who have gradually moved into this compromised condition over the past hundred years?

The studies were aimed at high-risk subjects. That is Primary Prevention. The call of the hour is for primordial prevention on the entirety of our society. And if a reason-able Choice is to be made; it should be children 0-10 years old. In making decisions, one cannot demand for evidence base. The proof of the value of today's efforts will be seen in the next two generations when hopefully the prevalence of diabetes (and all other diseases of lifestyle) will subside to an acceptable low.

The one way doctors in the Philippines can help save the country is by beginning with themselves, their children and their families. Save your family, your clan, and your community. Children are most amenable to change. They are the potential diabetics of tomorrow. But children can not save themselves unless the parents - the elders - become role models. Each patient seen in a doctor's clinic is representative of a family. If you have 30 diabetic patients, that means 30 families - 200 people. Treat the patient but consider diabetes a family affair. Parents, brothers, sisters, children and grandchildren should not escape the warning that when there is diabetes in the fam-ily, everyone should be seriously involved in persistent preventive measures. Relatives have been seen falling prey to the disease one after the other with no one lifting a finger, as if any effort will prove futile. It is time for the community to wake up to the massive dangers diabetes threatens to throw into our future.

Communities should avail of parent-teachers' asso-ciations. Include the yayas. Involve social, civic, religious groups. The campaign that is more likely to succeed is the one that will take on the urgency and dedication of a truly missionary project. For it is the future not only of your families but the country as a whole that is at stake!

Ricardo E. Fernando, MD, FPCP, FPSEMInstitute for Studies on Diabetes Foundation, Inc.

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Algorithm for the Pharmacologic Approach to Type 2 DM

Treatment StrategiesBased on the Severity of Hyperglycemia

• One may opt to use combination therapy at the start

Legend:FPG - Fasting Plasma GlucosePPBG - Postprandial Blood Glucose AGI - α-glucosidase inhibitorsTZD - Thiazolidinediones † Average of all Fasting Plasma Glucose

FIGURE 1a HbA1c >9% Early Insulin Therapy

1

Type 2 DM

2

N

5

Y

3

Y

N

Upper limit or Overweight,

Obese?

4

Any one of the ff:- TZD- Metformin- AGI- Incretins (DPP4 Inhibitors,

GLP1 Analogues, or GLP1 Mimetics)

- Combination any two or three of the above

6

Lean or

Underweight

7

Any one of the ff:- AGI- TZD- Metformin- Small doses of sulfonylureas - Meglitinides - Incretins (DPP4 Inhibitors or GLP

Analogues) - Combi: AGI, TZD, Metformin, Sulfonylureas, Glinide + Metformin, or TZD, Metformin + TZD + DPP4 Inhibitor Y

9

Any of the ff:- Metformin- TZD - Incretins (DPP4

Inhibitors or GLP analogues)

- Combination Tx

11

Uncontrolled

12

Combi Metformin and TZD or Metformin/TZD with Sulfonylureas or Metformin/TZD with Glinides or AGI Metformin or TZD + Incretins (DPP4 Inhibitors or GLP Analogues)

Moderate:Blood glucose†

FBG >126 - 200 mg/dL

8

Upper limit or

Overweight?

N10

Leanor

Underweight

13

SulfonylureasGlinides DPP4 in

Combination Tx

14

Uncontrolled

15

- If on Mono Sulfonylureas, combine with Metformin,

TZD, AGI - If on Mono Glinides combine with Metformin or TZD- DPP4 Inhibitors + Metformin or TZD- If on combi, increase Sulfonylureas or

Glinide first

Mild?Blood glucose†

FBG <126 mg/dLPPBG - restored to

basal

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Treatment Strategies

FIGURE 1b

* One may also opt to give insulin alone from the start.

** Maintain dose of oral anti-diabetes agents; then add injection of NPH, or pre-mixed insulin, or basal insulin.

† Average of all Fasting Plasma Glucose

5

Severe:Blood glucose†

>250 mg/dL

7

Y

N

Overweight?

9

Underweight*

8

- Met + Sulfonylureas or Meglitinides- TZD + Sulfonylureas or Meglitinides- AGI + Sulfonylureas- Triple OADS- Incretins (DPP4 Inhibitors or GLP1

Analogues + Metformin,or TZD,or Insulin

- Any of above + insulin- Metformin or TZD or AGI + Insulin

11

- Sulfonylureas + Metformin- Sulfonylureas + TZD- Sulfonylureas + AGI- Meglitinides + Metformin- Meglitinides + TZD- DPP4 + Metformin, or TZD, or insulin- Triple OADs Any of above + Insulin

10

Uncontrolled

12

Any of the above + 1 or more injections of Insulin.

Beyond this, refer to Diabetes Center or Insulin right away.

Type 2 DM

2

Y

N

3

Refer to Diabetes Center or

Diabetologist

1

4

Insulin therapy

13

Uncontrolled

- Sulfonylureas or Meglitinides + BT insulin- Sulfonylureas or Meglitinides + Metformin + BT insulin- Sulfonylureas or Meglitinides + TZD + BT insulin- May even use triple OHA’s + insulin- Insulin aloneBeyond this, refer to Diabetes Center or Specialist

6

Insulin therapyHbA1c = 9%

Very severe?Blood glucose†

FBS >250 mg/dL; PPBs not restored

to basal

HbA1C <9%

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Pharmacologic Management of Type 2 Diabetes (2011-2012)

Araceli A. Panelo, M.D., M.S., F.P.C.P.Institute for Studies on Diabetes Foundation Inc.

Factors Responsible for Maintenance of Normal Glucose Tolerance

Pathophysiology of Type 2 Diabetes: the Quintes-sential Quintet*

*Adapted from Defronzo RA. Impaired glucose tolerance: do pharmacological therapies correct the underlying metabolic disturbance? British Journal of Diabetes & Vascular Disease 2003 3: S24 (note: HGP - hepatic glucose production)

Two Major Defects in T2DM

• Decreased insulin secretion

- Increases hepatic glucose production

- Causes plasma glucagon levels to rise

- Increases muscle proteolysis

- Increases adipose tissue lipolysis

- Decreases glucose uptake in muscle, adipose

tissue, and liver.

• These effects result in fasting and postprandial hyper-

glycemia and elevated plasma free fatty acids and

triglycerides.

Insulin Resistance: Consequences

• Postprandial hyperglycemia

- Decreased peripheral glucose uptake

- Increased hepatic glucose output

• Cardiovascular risk factor

Natural History of Type 2 Diabetes

Factors to Consider in the Choice of Antidiabetic Agents

• Weight• Severity of hyperglycemia• Timing of blood glucose lowering effect• Site of action• Age• ± Renal Disease• ± Liver Disease

Table 1. Factor of Weight Upper limit N Wt Lower limit of N Wt OW, Obese Underweight Dual Impairment Dual Impairment Insulin Resistance Insulin Deficiency Insulin Deficiency Insulin Resistance

Insulin Sensitizers Insulin Secretagogue Insulin Secretagogue Insulin Sensitizers Insulin Insulin

Table 2. Subclassification of Hyperglycemia

(Modified from Skyler's)

Category FPG* PPBG (3-4 hrs after a meal) Mild <126 Restored to basal Moderate 126 - 200 Restored to basal Severe >200 Restored to basal Very severe >250 - 300 Not Restored to basal

* in stable diet and activity program • This is applicable to known or previously diag-

nosed diabetics. Thisisadynamicsubclassification.

Timing of Blood Glucose Lowering Effect

I. Blood sugar lowering greater during fasting than post prandial

• Metformin • Sulfonylureas (also considered to have an equal

effect in lowering fasting and post prandial glucose) • Insulin II. Blood sugar Lowering Greater During Post Prandial

than fasting • α−glucosidase

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- Saxagliptin 2.5 mg - Sitagliptin 50 mg - Vildagliptin - dose to be determined if ECC <60

± Liver Disease • (±) Liver Disease - InsulinOther Indications for Insulin • Pregnancy • Surgery • Allergy to OAD’s • Diabetic ketoacidosis (DKA), hyperglycemic hyper-

osmolar nonketotic syndrome (HNKC) • Non-response to OAD’s

Strategy of Early Combination Therapy with Oral Agents1 a. To maximize efficacy (medium dose yields 80% of

the maximal effect) b. To minimize the side effects (e.g., weight gain, gas-

trointestinal discomfort, hypoglycemia) c. Ability to address both defects d. Address both FPG and PPB e. Preserve ß−cell function f. Ability to address the other RF's other than hyper-

glycemia

Escalation therapy in Type 2 Diabetes Mellitus Don't wait for failure, stay on target2

Guideline for Use of Insulin Secretagogoue:See Table 3

Guideline for Use of Biguanides: See Table 4

Guideline for Use of α-glucosidase inhibitors:See Table 5

Guideline for Use of Thiazolidinediones: See Table 6

Guideline for Use of DPP4 Inhibitors: See Table 7

Insulin/Oral Combination Therapy for Type 2 Diabetes Patients

• Eventually, oral combination therapies fail to ade-quately control blood glucose

• Full-dose insulin has disadvantages, including frequent hypoglycemia, weight gain and multiple daily injections

• Insulin/oral agent combination offers improved glyce-mic control, less weight gain and reduced insulin dose

• Most efficacious are the insulin/insulin sensitizer com-

Action Generic Preparation Daily Dose Sulfonylureas: - Short Tolbutamide 500 mg tablet 1/2 - 6 tabs - Intermediate Glibenclamide 2.5/5.0 mg tab 1/2 - 3 tabs Gliclazide 30 mg tablet 1 - 4 pre-breakfast 80 mg tablet 1/2 - 4 tabs Glipizide 2.5, 5, 10 mg tab OD 1/2 - 6 tabs Glimepiride 1, 2, 3, 5 mg tablet OD 1 - 4 mg - Long-acting Chlorpropamide 250 mg tablet 1/2 - 2 tabs

Meglitinides: Repaglinide 0.5, 1 & 2 mg tablet 0.5 mg tab TID to 2 mg tab TID

Table 3. Guideline for Use of Insulin Secretagogoue

• DPP4 inhibitors • GLP1 mimetics/analogues • Insulin sensitizers (glitazones) • Rapid insulinotrophics (repaglinide, nateglinide) • Monomeric insulin

Therapy for Type 2 Diabetes:

Site of Action

Pancreasßcells αcells • Impaired insulin secretion = • DPP4 inhibitors Insulin deficiency • GLP-1 analogues/ • Sulfonylurea increased GLP-1 mimetics • Repaglinide increased • Nateglinide • Exogenous insulin Rx • DPP4 Inhibitors • GLP-1 analogues/ GLP-1 mimeticsGut • Carbohydrate metabolism - delays conversion of

complex carbohydrates to glucose • Decreased acarbose • Decreased miglitol • Decreased vogliboseLiver • Increased hepatic glucose production • Increased metforminMusclesandfats • Decreased glucose uptake = Insulin resistance • Increased rosiglitazone • Increased pioglitazoneAge • Elderly - AGI - Glitazones - Insulin sensitizers - Mild and short acting sulfonylureas - Meglitinides± Renal Disease • Renal Disease - AGI - Glitazones - Insulin secretagogues - Mild and short acting sulfonylureas - Meglitinides - DPP4 inhibitors

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binations - insulin + metformin - insulin + thiazolidinediones• But insulin + sulfonylurea is another possibility• DPP4 inhibitors + Met or TZD or SU have been shown

to be effective in lowering FPG, PPG, and HbA1c

• Insulin + DPP4 inhibitors have also been shown to be effective in lowering FPG, PPG, and HbA1c

Oral Agents + Insulin in Type 2 Diabetes

• Simplifies insulin regimen• Improves glycemic control• Better patient acceptance• Compliance• Convenience• Lower doses of exogenous insulin• Less weight gain

Oral Agents + Insulin in Type 2 DiabetesSynergistic or Complementary Effects

• Sulfonylureas - Increase hepatic levels of endogenous insulin and

meet meal-related insulin requirements• Metformin - Improves insulin sensitivity at the liver and reduces

hepatic glucose production• Glitazones - Improve insulin action in peripheral tissues and en-

hance glucose uptake• α-Glucosidase Inhibitors - Decrease postprandial glucose absorption• DPP 4 Inhibitors - Suppresses glucagon and increases

insulin levels based the ambient glucose levels

Contraindications for Use of Oral Hyperglycemic Agents: See Table 8

The Complications of Type 2 Diabetes Mellitus

Macrovascular (Atherosclerosis)

Heart Myocardial infarction Brain Cerebrovascular accident (CVA) Limb Peripheral Arterial Occlusive Disease (PAOD)

Microvascular Brain Small vessel disease Eyes Retinopathy Kidney Nephropathy Nerves Neuropathy - Peripheral - Autonomic Skin Dermopathy

ReferencesAmerican Diabetes Association: Medical Management of Type 1 Diabetes.

Alexandria, VA, American Diabetes Association, 200 American Diabetes Association: Medical Management of Type 2 Diabetes.

Alexandria, VA, American Diabetes Association, 2008 American Diabetes Association: Standards of Medical Care in Diabetes–

2011. Alexandria, VA, American Diabetes Association, 2011 Defronzo RA. Impaired glucose tolerance: do pharmacological therapies

correct the underlying metabolic disturbance? British Journal of Diabetes & Vascular Disease 2003 3: S24

Genuth S, Alberti KG, Bennett P, Buse J, Defronzo R, Kahn R, Kitzmiller J, Knowler WC, Lebovitz H, Lernmark A, Nathan D, Palmer J, Rizza R, Saudek C, Shaw J, Steffes M, Stern M, Tuomilehto J, Zimmet P, Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160–3167

Table 4. Guideline for Use of Biguanides

Generic Preparation - Taken Daily dose with or after meals Metformin 500 & 850 mg tab 500 mg 1/2-4 tabs 850 mg 1/2-2 tabs

Table 5. Guideline for Use of α-Glucosidase Inhibitors

Generic Preparation Daily dose Taken pre-meals Acarbose 100 & 500 mg tab 1 tab after 1 tbsp of food (BLS)

Voglibose 0.2 & 0.3 µg tab 1 tab after 1 tbsp of food (BLS)

Table 6. Guideline for Use of Thiazolidinediones

Generic Preparation Daily dose Pioglitazone 15 to 30 mg tab 15 mg tab OD to BID 30 mg tab OD

Generic Name Contraindications

Sulfonylureas Known allergy to sulfonylureas Pregnancy Liver and renal insufficiency Type 1 Repaglinide/ Known allergies Nateglinide Pregnancy Type 1 Metformin Clinical states involving tissue

hypoxia (shock), acute blood loss, MI, heart failure, pulmonary embolism, arterial circulatory dis-orders, consumptive diseases, severe generalized infections, fasting states (less than 1,000 kcal/day)

α-Glucosidase Known history of allergy inhibitor GI disturbances like diarrheaPioglitazoneKnown or suspected liver disease Elevated liver enzyme DPP4Inhibitors Allergy to this class of OAD's Pregnancy

Table 8.

Table 7. Guideline for Use of DPP-4 Inhibitors

Generic Preparation (mg) Daily dose Sitagliptin 50, 100 100 mg OD

Saxagliptin 2.5, 5 5 mg OD

Vildagliptin 50, 100 50 mg BID

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ANTI-DIABETIC DRUGS

InsulinsShort-actingInsulins Actrapid HM Apidra Solostar Humalog Humulin R (Regular) Insuget-R Lupinsulin R NovoRapid FlexPen Wosulin-RIntermediate-actingInsulins Humalog Mix 25 Humulin 70/30 Humulin N (NPH) Insuget-N/Insuget 70/30 Insulatard HM/Insulatard HM Flexpen Lupinsulin 30:70 Lupinsulin N Mixtard 30 HM/ Mixtard 30 HM Flexpen NovoMix 30 FlexPen Wosulin-30/70 Wosulin-NLong-actingInsulins Lantus/Lantus Solostar Levemir FlexPen

Oral Hypoglycemics

Alpha Glucosidase InhibitorsAcarbose Glucobay 50/Glucobay 100 GluconaseVoglibose Basen

BiguanidesMetforminHCl Actosmet* Ansures ER Asamet XR Azulix 1 MF* Diafat Dimet-500 Euglo Plus* Fornidd Fornidd XR Galvusmet* Glucophage/Glucophage Forte Glucophage XR Glucovance* Gludin Glumet/Glumet-XR Humamet Janumet* Lupimet* Metta SR Neoform 500 Nidcor Nilgar M-15/Nilgar M-30* Panfor SR-500/Panfor SR-1000 Perglim M-1/Perglim M-2* Pharex Metformin Pioplus* Prialta-Met* Ritemed Metformin HCl Solosamet* Solosamet SR* Winthrop Metformin HCl

ZolidPlus*

Dipeptidyl Peptidase 4 (DPP-4) Inhibitor

Saxagliptin OnglyzaSitagliptinphosphate Janumet* JanuviaVidagliptin Galvus Galvusmet*

MeglitinidesNateglinide StarlixRepaglinide Novonorm

SulfonylureasFirst GenerationChlorpropamideSecond GenerationGlibenclamide Daonil Euglo Plus* Euglodin Euglucon Glucovance* Melix Orabetic Winthrop Glibenclamide Gliclazide Azukon MR Clibite Diamicron/Diamicron MR/ Diamicron MR 60 Dianorm Gliget MR Glubitor/Glubitor-OD Gluconil Glimepiride Acotril Aforglim 1/ 2/ 3/ 4 Amara-4 Asaglim Arya Azulix Azulix 1 MF* Diaberid Diaglim Euglim Geopride Getryl Glimarex Glimauno - 2/Glimauno - 3/ Glimauno - 4 Glimed Glimeryl Glipiren Lupimet* Mira Neoglim Norizec Perglim 2 Perglim M-1/Perglim M-2* RiteMED Glimepiride Solosa Solosamet* Solosamet SR* Sulfast 1/2/3/4

Winthrop Glimepiride Zoliget*Glipizide Glimax Minidiab/Minidiab OD

ThiazolidinedionesPioglitazone Actazone Actos Actosmet* Diabetone Glitaz Glitter 15/30 Glucozone Nilgar M-15/Nilgar M-30* Pharex Pioglitazone Pioplus* Piouno - 15/Piouno - 30/Piouno - 45 Piozar Piozone Prialta Prialta-Met* Zeal Zolid ZolidPlus* Zoliget* Zypi

Note: Other Preparations of Interest to the Practitioner (diabetes-related)

Ampalayaleaves Amargozin Jimm's Herbal Capsule*Banabapowderedleaves DiabanChromiumpicolinateExenatide ByettaFoodformula Diabetasol Nutrition Powder for Diabetics Diabetasol Zero Calorie Sweetener Glucerna Glucerna SR

Index of Products Mentioned in the Guideline

This index is not part of the guideline. It lists the products and/or their therapeutic classes as mentioned in the guideline. For the doctor's convenience, brands available in the PPD references are listed under each of the classes. For drug information, refer PPD, PPD Pocket Version, PPD Text, PPD Tabs, and www.TheFilipinoDoctor.com.

ERRATUM

In the previous edition (14th/2012 ed.) of the CPM, a one-page ad on Diabetasol appeared on page 62, opposite the title page of Food & Nutrition Research Institute's guideline, Nutrition Handbook for Persons with Diabetes. The material inadvertently used for the advertisement was an old version and the information contained within was either incorrect or not updated. Kalbe International holds office at 137 Zest Air Bldg., Yakal St., San Antonio Village, Makati City. The proper advertisement, as approved and authorized by Kalbe International, appears opposite this page of this current edition of the CPM.