Oral Hypoglycemic Drugs (OHD)

Group Sub-group Generic name Brand-name (mg/tab) Daily dosage D.O.A

Freq/

dailyp.o

Insulin secretagogue

Sulphonylurea (SU)

Chlorpropramide Diabenese 100250

100 - 500 24 - 26 1

15-30 mins a.c

Glibenclamide Daonil 255

2,5 - 1,5 12 - 24 1 - 2

EugliconGlipizide Minidiab 5-10 5 - 20 10 - 16 1 - 2

Glucotrol-XL 1Gliklazide Diamicron 80 80 - 240 10 - 20 1 - 2

Diamicron-MRGlikuidone Glurenorm 30 30 - 120 – –Glimepiride Amaryl 1

234

0,5 - 6 24 1

d.c / p.c

Glinid Repaglinide NovoNorm 0,512

– – 3

d.c / p.c

Nateglinide Starlix 120 – – 3Insulin sensitizer

Tiazolidindion Rosiglitazon* 4 24 24 independ to meal

scheduleProglitazon Actos 1530

24 24

a-Glucosidase Inhibitor

Acarbose Glucobay 50100

100 - 300 – 3 w/ 1st

(suapan)

Biguanid Metformin Glucophage 500850

250 - 3000 6 - 8 1 - 3a.c / d.c /

p.cCombination Biguanid + SU Metformin +Glibenclamide

Glucovance

Notes : Start OHD on small dosage and increase base on BG level response into pre-maximum dosage* not sold in Indonesia yet

Drug mechanism, Primary side-effect and A1c (Hb-glycocylate) decrease-effect

Group Primary mechanism Primary side-effect A1c ↓ %Insulin secretagogue

Sulphonylurea (SU) Increase insulin secretion BW ↑↑ , hypoglicemic 1,5 – 2,5 %

Glinid Increase insulin secretion BW ↑↑ , hypoglicemic 1,5 – 2,5 %Biguanid / Metformin Depress hepatic gulocose production Diarrhea, Dyspepsia,

Lactate-acidosis 1,5 – 2,5 %

Tiazolidindion Increase sensitivity to insulin Oedema 1,3 %Insulin sensitizer

a-Glucosidase Inhibitor Inhibit glucose absorption Flatulence, soft-fecal 0,5 – 1,0 %

Insulin Insulin Depress hepatic glucose production,glucose-using stimulation Hypoglicemic, BB ↑↑ Normal potency

Type and D.O.A of Insulin drugs

O.O.A* P.O.A* Effective Duration* Maximum Duration*Human-Insulin

Regular 0,5 – 1,0 2 – 3 3 – 6 4 – 6NPH 2 – 4 1 – 10 10 – 16 14 – 18Lente 3 – 4 4 – 12 12 – 18 16 – 20

Analogue-InsulinLispro** 0,25 1 – 2 3 – 4Aspart** 0,25 1 – 2 3 – 4Glargine 4 – 5 no peak 24 24

Notes : * in hour** not sold in Indonesia yet

Insulin drugs sold in Indonesia

Type of Insulin Brand-name Pharmaceutical Peak effect* D.O.A*Fast-acting Novo-Rapid** Novo (U-40 and U-100) 2 – 4 6 – 8

Humalog Eli Lily (U-100)

Short-acting Actrpid Novo (U-40 and U-100)Humulin-R Eli Lily (U-100)

Intermediate-acting Insulatard Human Novo (U-40 and U-100) 4 – 12 8 – 24Monotard Human Novo (U-40 and U-100)Humulin-N Eli Lily (U-100)

Mixed-type Mixtar 30/70 Novo (U-40 and U-100) 1 – 8 14 – 15Humulin 30/70 Eli Lily (U-100)

Long-acting Lantus** Aventis no peak 24

Notes : * in hour

Penyuluhan DM menyeluruhSuggestion of Dietary & Physical exercise

Combination*** 3 OHD :B + PGa* + T

Combination*** of 2 OHD :between B / PGa* / T

1 OHD :B / PGa* / T****

Re-emphasize Dietary & Physical exercise

Combine*** 4 OHD :B + PGa* + T + Insulin secretagogues

Insulin

TA#TNA

Evaluate 2 – 4 wks(based on clinical condition)

TA#TNA

Evaluate 2 – 4 wks(based on clinical condition)

TA#STT Evaluate 2 – 4 wks

TKOI ** InsulinTNA

TA#

TNA Evaluate 2 – 4 wks

TKOI ** InsulinTNA

TA#TNA

Evaluate 2 – 4 wks

TKOI** InsulinTNA

TA#

TNA Evaluate 2 – 4 wks

Penyuluhan DM menyeluruhSuggestion of Dietary & Physical exercise

Combination*** 3 OHD :Insulin secretagogues + PGa* + B / T

Combination*** of 2 OHD :Insulin secretagogues + PGa* / B / T

Re-emphasize Dietary & Physical exercise+ Insulin secretagogues (IS)

Combine*** 4 OHD :Insulin secretagogues + PGa* + B + T

Insulin

TA#TNA Evaluate 2 – 4 wks

(based on clinical condition)

TA#TNA

Evaluate 2 – 4 wks(based on clinical condition)

TKOI ** InsulinTNA

TA#

TNA Evaluate 2 – 4 wks

TKOI ** InsulinTNA

TA#

TNA Evaluate 2 – 4 wks

TKOI ** InsulinTNA

TA#

TNA Evaluate 2 – 4 wks

Treatment Management Algorthm for NIDDM

OVERWEIGHT TYPE

TA : Target is achievedTNA : Target is not achieved# : Target achieved when match the DM control criteria* : PGa is given only in normal fast BG level** : OICT = OHD and Insulin Combination Therapy (OHD at noon and Insulin at night)*** : OHD combination theoritically can be given up to 4 type of OHD but so far there’s only EBM (Evidence Base Medicine) for up to 2 type of DHO

combination**** : In present day, Tiazolidindion is not given as a single medication in Indonesia

LOW-WEIGHT TYPE

TA : Target is achievedTNA : Target is not achieved# : Target achieved when match the DM control criteria* : PGa is given only in normal fast BG level** : OICT = OHD and Insulin Combination Therapy (OHD at noon and Insulin at night)*** : OHD combination theoritically can be given up to 4 type of OHD but so far there’s only EBM (Evidence Base Medicine) for up to 2 type of DHO

combination**** : In present day, Tiazolidindion is not given as a single medication in Indonesia

OHD#

OHD + 5 IU of Intermediate-acting Insulinbefore night sleep

If Insulin dosage > 30 IU/day,stop OHD

Mixed-type Insulin(premixed)

Morning2/3 of TID

Night1/3 of TID

of Dietary & Physical exercise

TNA

If necessary, obtain dosage of 2-4 IU after day 3-4OHD can be stopped when the patient is already comfortable with Insulin therapy

TD sistolik > 140 mmHgTD diastolik > 90 mmHg

Add another OHD(one of it is diuretics)

Microalbuminuria (+)or

Clinical aluminuria / nephropathy

ACE Inhibitor / AIIRACalcium antagonist –

non dihydropyridin group

Replace with another1st line OHDIncrase dosage Add another

1st line OHD

1 – 2 Months TNA

TD sistolik 130 – 140 mmHgTD diastolik 89 – 90 mmHg

Lifestyle modification

3 Months TNA

Lifestyle modification

Selectiveb-Inhibitor Diuretics ACE Inhibitor a-Inhibitor AIIRA

Oral and Insulin Combination Therapy (OICT)

TNA : Target is not achieved# : Oral Hypoglycemic DrugsTID : Total Insulin Dosage

DM CONTROL CRITERIAS

Good Intermediate BadFast Blood Glucose (mg/dL) 80–109 110–125 ≥ 126Post-prandial Blood Glucose (mg/dL) 80–144 145–179 ≥ 180A1c (%) < 6,5 6,5–8 > 8Total Cholesterol (mg/dL) < 200 200–239 ≥ 240LDL Cholesterol (mg/dL) < 100 100–129 ≥ 130HDL Cholesterol (mg/dL) > 45 – ≥Triglyceride (mg/dL) <150 150–199 ≥ 200BMI (kg/m2) 18,5–23 23–25 >25Blood Pressure ≤ 130/80 130–140 / 80–90 > 140/90

Albuminuria Classification

Urinalysis 24 H( mg.24H )

Urinalysis spesific( 𝜇/min )

Urinalysis at time( 𝜇/mg creatine )

Normal < 30 < 20 < 30Microalbuminuria 30–299 20–199 30–299Macroalbuminuria ≥ 300 ≥ 200 ≥ 300

Hypertensive Treatment On Diabetes