Sulfonylurea + Biguanide

Thiazolidinedione + Biguanide

Sulfonylurea + Thiazolidinedione 

                Lispro insulin

                Aspart insulin

                Glulisine insulin      

        NPH   

        Lente insulins

What are examples of Long-Acting Insulins?

                Ultralente insulin

                Glargine insulin
       

                Detemir insulin

Exubera

(regular insulin) 

70/30

50/50 

-    Rapid-acting insulins can be taken just before meals.  
-    Clear solutions, neutral pH
-    Onset time: 5-15 minutes
-    Peak time: 1 hour
-    Duration: 3-5 hours
-    Improve patient convenience
-    Improve control

1. Improve patient convenience
2. Modify time action of human insulin toward a more physiologic profile
3. Reduce postprandial hyperglycemia
4. Minimize postprandial hypoglycemia
5. Reduce need for between-meal snacks
6. Adjust dosage size based on actual meal
7. Improve control

EXUBERA has an onset of action similar to rapid-acting insulin analogs and has a duration of glucose-lowering activity comparable to SC regular human insulin

In patients with type 1 diabetes, EXUBERA should be used in regimens that include a longer-acting insulin

In patients with type 2 diabetes, EXUBERA can be used as monotherapy or in combination with oral agents or longer-acting insulins

 EXUBERA is indicated for the treatment of adult patients with diabetes mellitus for the control of hyperglycemia
 

These include:

    EXUBERA is not recommended for use in patients with underlying lung disease, such as asthma or COPD

    Safety and effectiveness of EXUBERA in pediatric patients have not been established

    EXUBERA is Pregnancy Category C
    EXUBERA should be given to a pregnant woman only if clearly needed

• Designed to bind specifically to albumin
• Albumin binding protracts:

•  
  •     Absorption of insulin detemir from the subcutaneous depot
  •     Residency of insulin detemir in the circulation

• Albumin binding buffers variability of action of insulin detemir
• There are no safety concerns with albumin binding of insulin detemir or with changes to its insulin structure

• Inject air into both vials
• Draw up regular insulin first
• Draw up NPH insulin
• Avoid contamination of Regular (clear) insulin with NPH (cloudy) insulin
• Avoid air bubbles

• Convenience and mixing accuracy of a premixed insulin
• Unique rapid onset of action of insulin
• Injection closer to mealtime, anytime within 15 minutes before a meal
• More physiologic insulin profile

• Faster testing
• Less blood
• Less pain
• Alternate sites
• Noninvasive testing

• Insulin Administration
  • preferred injection site
  • Fast-acting insulin bolus within 15 minutes before meals
  • Regular insulin 30–45 minutes before meals
• When to self-monitor blood glucose
  • 4 times per day (pre-meals)
  • Occasionally 1–2 hours postmeal
  • Occasionally at 3:00 a.m.
• How to recognize and treat hypoglycemia and hyperglycemia

• Eliminated physical education classes
•  Served high-fat lunches and fast food
•  Provided soda and snack machines

INCREASE OBESITY 

Trigger the Liver to decrease glucose release

Trigger Fat/muscle to increasae insulin sensitivity

• Sulfonylureas increase endogenous insulin secretion
• Other Effects
  • Hypoglycemia
  • Weight gain
  • No specific effect on plasma lipids or blood pressure
  • Generally the least expensive class of medication
• Medications in this Class:
  • First generation sulfonylureas: chlorpropamide (Diabinese), tolazamide, acetohexamide (Dymelor), tolbutamide
  • Second generation sulfonylureas: glyburide (Micronase, Glynase, and DiaBeta), glimepiride (Amaryl), glipizide (Glucotrol, Glucotrol XL)

• Meglitinides stimulate insulin secretion (rapidly and for a short duration) in the presence of glucose.
• Other Effects
  • Hypoglycemia (although may be less than with sulfonylureas if patient has a variable eating schedule)
  • Weight gain
  • No significant effect on plasma lipid levels
  • Safe at higher levels of serum Cr than sulfonylureas
• Medications in this Class: repaglinide (Prandin), nateglinide (Starlix)

• Biguanides decrease hepatic glucose production and increase insulin-mediated peripheral glucose uptake.
• Other Effects
  • Diarrhea and abdominal discomfort
  • Lactic acidosis if improperly prescribed
  • Cause small decrease in LDL and triglycerides
  • No specific effect on blood pressure
  • No weight gain, with possible modest weight loss
• Contraindicated in patients with impaired renal function (Serum Cr > 1.4 mg/dL for women, or 1.5 mg/dL for men)
• Medications in this Class: metformin (Glucophage), metformin extended release (Glucophage XR)

• Thiazolidinediones decrease insulin resistance by making muscle and adipose cells more sensitive to insulin. They also suppress hepatic glucose production.
• Other Effects
  • Weight gain, edema
  • Hypoglycemia (if taken with insulin or agents that stimulate insulin release)
• Contraindicated in patients with abnormal liver function or CHF
• Improves HDL and triglycerides; LDL neutral
• Medications in this Class: pioglitazone (Actos), rosiglitazone (Avandia), [troglitazone (Rezulin) - taken off market due to liver toxicity]; FDA warning for early cardiac death

• Alpha-glucosidase inhibitors block the enzymes that digest starches in the small intestine
• Other Effects
  • Flatulence or abdominal discomfort
  • No specific effect on lipids or blood pressure
  • No weight gain
• Contraindicated in patients with inflammatory bowel disease or cirrhosis
• Medications in this Class: acarbose (Precose), miglitol (Glyset)

• Amylin is naturally made in the pancreas along with insulin
  •     Decreases glucagon release
  •     Decreases blood glucose rise after a meal
  •     Decreases hunger
•     Taken by injection before meals
•     May produce weight loss

• Type 2 diabetes,
  
  • as an adjunct treatment in patients who use mealtime insulin therapy and have failed to achieve desired glucose control despite optimal insulin therapy
  • with or without a concurrent sulfonylurea agent and/or metformin.
• Type 1 diabetes, 
  • as an adjunct treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy.

• Analog of Glucagon-Like Peptide 1 (GLP-1)
• Increases insulin secretion from pancreas
• Restores first phase insulin secretion
• Decreases glucagon release from pancreas
• Slows gastric emptying,  delays absorption
• Induces a feeling of fullness
• Produces weight loss
• Taken by injection before meals
• Broken down too quickly to have a therapeutic effect

what are some fears of diabetic patients?

1. Fear of injections

2. Fear of hypoglycemia

3. Fear of Weight Gain

4. some falsely believe that insulin leads to "worse diabetes"

5. The disease is an inconvenience

• Peptide hormone
• Made in the pancreas
• Secreted when blood glucose level becomes too low
• Used clinically to rescue patient with severe hypoglycemia