Download TREATMENT OF DIABETES MELLITUS

Treatment of diabetes
mellitus
Department of Internal Medicine №2
as.-prof. Martynyuk L.P.
Plan of
lecture
•
•
•
•
The main principles of DM therapy
Methods of treatment DM
The main principles of diet
Oral hypoglycemic agents.
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Sulfanilureas
biguanides
Alpha-glucosidase inhibitors
Non-sulfanylureas insulin stimulators
Thiozolidindiones
Combined preparates
• Insulin therapy
• Future directions in improving
glycemic control
• Exercise program
• Education of the patients
The main principles of DM therapy
•
•
•
•
Maintenance of metabolic status at
normal level or as close to normal as
possible (especially blood glucose and
lipid concentration). Achievement of DM
compensation.
Achievement and maintenance of normal
or reasonable body weight.
Maintenance (preservation) of working
capacity.
Prophylaxis of acute and chronic
complications.
Criteria of DM compensation
Indexes
Level of compensation
good
sufficient insufficient
Fasting
glycaemia
4,4 - 6,7
(mmol/l)
2 hours after
4,4 – 8,0
meals
Glucosurea (%)
0
Hb Alc (%)
< 6,5
Cholesterol
< 5,0
(mmol/l)
Triglycerides
< 1,7
(mmol/l)
HDL (mmol/l)
> 1,1
Body
mass males < 25
index (kg/m2)
females < 24
Blood pressure
< 135/85
< 7,8
> 7,8
< 10,0
> 10,0
0,5
6,5 – 8
> 0,5
>8
5,0 – 6,5
> 6,5
1,7 – 2,2
> 2,2
0,9 – 1,1
< 27
< 26
< 160/95
< 0,9
> 27
> 26
> 160/95
Methods of treatment DM
•
•
•
•
•
•
Diet.
Oral hypoglycemic agents or insulin
(indications for each vary with the type of
DM and severity of the disease).
Exercise program.
Phytotherapy (plant’s therapy).
Nontraditional methods of treatment.
Education
The main principles of diet
The main principles of diet.
Normal-calorie diet in patients with type I DM
(35-50 kcal/kg of ideal weight (weight =
height – 100)) and low-calorie diet in obese
persons (mostly in patients with type II DM
(20 – 25 kcal/kg of ideal weight)). We try to
decrease weight in obese patients on 1-2
kg/month by such diet.
•
The main principles of diet.
Regimen has to be consist of 4 – 5 – 6 small
feedings a day.
(The most frequent regimen consists of 4 feedings a
day, in which:
- breakfast comprises 30 % of total calories,
- dinner – 40 %,
- lunch – 10 %,
- supper – 20 %.
Sometimes patients need second breakfast (when they
have a tendency to develop hypoglycemia). In such
case it comprises15 % of the total calories and we
decrease the quantity of calories of the first
breakfast and dinner).
• Exclusion of high-calorie carbohydrates (sugar,
biscuits, white bread, alcohol).
The main principles of diet.
•
Increasing the quantity of high fiber-containing foods
(fruits (exclusion: banana, grapes), vegetables,
cereal grains, whole grain flours, bran. Patients need
40 g fibers per day
•
Limiting of meat fat, butter, margarine in diet,
decrease red and brown meats, increase poultry and
fish, encourage skim milk-based cheeses. Should be
used skim or low-fat milk, not more than 2 – 3 eggs
weekly.
•
Alcohol should be avoided as much as possible
because it constitutes a source of additional calories,
it may worsen hyperglycemia, and it may potentiate
the hypoglycemic effects of insulin and oral
hypoglycemic agents.
Oral hypoglycemic agents.
• Inadequate control of hyperglycemia by the diet
and exercises interventions suggests the need for a
good glucose-lowering agent.
• Oral hypoglycemic agents are useful only in the
chronic management of patients with type II
DM.
• The most commonly used are:
- the sulfanilureas,
- biguanides,
- alpha-glucosidase inhibitors,
- non-sulfanylureas insulin stimulators,
- repaglinides.
Commonly used sulphonylureas
2 nd generation drugs (mg)
Glibenclamid
(Maninil,
Euglucan, Daonil, Glinil,
Gilamat, Gliben, Glucoven)
Glibornurid (Glutrid)
Gliquidon
(Glurenorm,
Beglicor)
1;
1-2
1,75;
3,5; 5
25
25-75
30
30120
Gliclazid
(Diamicron, 80
Diabeton, Predian, Glizid)
30
Diabeton MR
Glipizid
(Minidiab, 5
Glucontrol, Antidiab)
3 rd generation drugs (mg)
Glimepirid (Amaryl)
1-4
1224
8-12
8-12
80320
30120
20
8-12
24
4
24
8-12
Without hepatoand nephrotoxic
effects, metabolism through the
intestinum
Normalizes
microcirculation, blood
aggregation
Commonly used biguanides
Name of drug
Metformin
(Dianormet,
Siofor,
Metfogamma,
Metfordar)
Glucophage Forte
Buformin (Adebit)
Buformin Retard
Dose in
1 tabl.
0,25;
0,5
0,5;
0,85
0,05
0,17
Daily
dose
0,5-1,5
0,5-2,0
0,1-0,2
0,170,34
Duration
of
action
(hours)
8-10
12-14
8-10
12-14
Alpha-glucosidase inhibitors
Name of drug
Duration of
Dose in
Daily
action
1 tabl.
dose
(hours)
0,05; 0,1 0,15-0,6 2,7-9,6
Acarbosa
(Glucobay, Glucor,
Prandase,
Precose)
Miglitol
0,025;
0,05;
0,1
Guar
(Guarem)
0,05-0,3 2-4
Gum 5,0 (gra- 15-30
nules)
-
Non-sulfanylureas insulin
stimulators
Duration
Dose in Daily
Name of drug
of action
1 tabl. dose
(hours)
Repaglinid
0,001;
0,004- 3 - 4
(Novonorm, Roglid)
0,002;
0,009
(meglitinide analogs)
0,003;
0,004
Nateglinid (Starlix)
0,06;
0,18- 1,5 - 3
(D-Phenilalanine-derivative) 0,12;
0,54
0,18
Commonly used
thiozolidinediones
Dose
Name of drug
in 1
tabl.
Rosiglitazone
0,002;
(Avandia,
0,004;
Rosinorm)
0,008
Pioglitazone (Actos, 0,015;
Pionorm)
0,03;
0,045
Daily
dose
Duration
of action
(hours)
0,0040,008
0,0150,03
Up to 24
hours
From the history of insulin
Indications for insulin therapy
1. All patients with type I DM.
2. Some patients with type II DM:
• uncontrolled diabetes by diet or oral
hypoglycemic agents;
• ketoacidosis, coma;
• acute and chronic liver and kidneys disease with
decreased function;
• pregnancy and lactation;
• II – IV stages of angiopathy;
• infection diseases;
• acute heart and cerebral diseases;
• surgery.
Insulin preparations of
ultrashort action
(human analog, recombinant)
Insulin
action
beginning
maximum
duration
2-10 min
40 - 50 min
3-5h
NovoRapid
Novo-Nordisk
Humalog
Lilly
Epaidra
Insulin preparations of
short action
Insulin
Monodar Indar
Humodar R (полусинт.) Indar
Humodar RR(рекомб) Indar
Humodar R100 Indar
Humodar R100R Indar
Farmasulin HN Farmak
Actrapid (МС, НМ)
Novo-Nordisk
action
beginning
maximum duration
30 min
1-3h
5-8h
Insulin preparations of
intermediate action
Insulin
action
beginning
Monodar B Indar
Humodar B Indar
Farmasulin Н NР Farmak 1 – 1,5 h
Protaphan (МС, НМ)
Novo-Nordisk
Insuman basal Aventis
Humulin NPH Lilly
Monotard НМ Novo-Nordisk
maximum duration
6-8h
12 – 18 h
Insulin preparations of
long action
Insulin
action
beginning
Farmasulin НL Farmak
Ultralente Humulin Lilly
Ultratard НМ
3–4h
МC Suinsulin Ultralong
maximum
duration
10 -12 h
24 – 30
h
Indar
Glargine (Lantus)Aventis
Detemir
Levemir
24 h
(human analog, recombinant)
Insulin preparations
combined
Insumani
comb 25/75
Mixtard
30
НМ
Monodar К15
Aventis
30 min
1,5-2 h
12-18 h
NovoNordisc
Indar
30 min
2-8 h
24 h
30-40
min
30-40
min
30 min
30-45
min
30-45
min
30 min
1,5-3 h
12-18 h
1-3 h
12-16 h
1-3 h
1,5-3 h
6-10 h
12-18 h
1,5-3 h
12-18 h
1-3 h
6-10 h
Monodar К30 Indar
Monodar К50 Indar
Humodar
К Indar
15
Humodar К25 Indar
Humodar К50 Indar
Secretion of insulin in health people
3
Breakfast
Concentration of insulin
2,
Meal secretion
3
Lunch
Dinner
1,5
1
0,5
7.00
12.00
0
Basal secretion
19.00
24.00
7.00
Exercise program
• Exercise is an excellent adjunct to diet
therapy, but it is very ineffective when
used as the sole weight-reducing modality.
• Exercises must be clearly planned and
depend on patient’s abilities and the
physical condition, exclusion of the
competition’s elements.
Exercise program
• Exercises may be valuable adjunct to the
management of the DM by:
• lowering blood glucose concentration;
• decreasing insulin requirements;
• potentiation the beneficial effects of diet and
other therapy.
• To prevent hypoglycemia, patients should
carefully monitor glucose level and taking of
insulin. Mostly they need to reduce the insulin
dosage by 20 – 25 % on the day that strenuous
exercises is planned.
Plant’s therapy (phytotherapy)
•
•
•
hypoglycemic action;
treatment of chronic diabetics
complications;
influence on the immune reactivity.
Patient’s education
•
•
•
•
the nature of DM and importance of
metabolic control;
the principles and importance of good
nutrition and reasonable exercise
program;
the principles of adequate foot, dental
and skin care;
treatment of DM during the periods of
illness;
Patient’s education
•
•
•
techniques of insulin administration and
measurement of urine and blood glucose
level (if taking insulin);
recognition of hypoglycemia, its causes
and methods of prevention;
the importance of general and specific
measures to minimize in the best
possible way diabetic complications and
maintain of good overall health.
Self - control
References
• The Merck Manual of Diagnosis and Therapy
(seventeenth Edition)/ Robert Berkow, Andrew J.
Fletcher and others. – published by Merck Research
Laboratories, 1992. – P. 169 - 177.
• Manual of Endocrinology and Metabolism (Second
Edition)/ Norman Lavin. – Little, Brown and Company.Boston-New York-Toronto-London, 1994. - P. 563 - 566.
• Endocrinology (A Logical Approach for Clinicians
(Second Edition)). William Jubiz.-New York: WC GrawHill Book, 1985. - P. 261 – 262, 270 – 273.