treatment of diabetes mellitus department of internal medicine №2 as.-prof. martynyuk l.p
TRANSCRIPT
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Treatment of diabetes mellitus
Department of Internal Medicine №2
as.-prof. Martynyuk L.P.
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Plan of lecture
• The main principles of DM therapy• Methods of treatment DM• The main principles of diet• Oral hypoglycemic agents.
– 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
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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.
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Level of compensation Indexes
good sufficient insufficient Fasting glycaemia (mmol/l)
4,4 - 6,7 < 7,8 > 7,8
2 hours after meals
4,4 – 8,0 < 10,0 > 10,0
Glucosurea (%) 0 0,5 > 0,5 Hb Alc (%) < 6,5 6,5 – 8 > 8 Cholesterol (mmol/l)
< 5,0 5,0 – 6,5 > 6,5
Triglycerides (mmol/l)
< 1,7 1,7 – 2,2 > 2,2
HDL (mmol/l) > 1,1 0,9 – 1,1 < 0,9 Body mass index (kg/m2)
males < 25 females < 24
< 27 < 26
> 27 > 26
Blood pressure < 135/85 < 160/95 > 160/95
Criteria of DM compensation
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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
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The main principles of diet
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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.
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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).
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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.
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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.
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2 nd generation drugs (mg) Glibenclamid (Maninil, Euglucan, Daonil, Glinil, Gilamat, Gliben, Glucoven)
1; 1,75; 3,5; 5
1-2 12-24
Glibornurid (Glutrid) 25 25-75 8-12 Gliquidon (Glurenorm, Beglicor)
30 30-120
8-12 Without hepato- and nephrotoxic effects, metabo-lism through the intestinum
Gliclazid (Diamicron, Diabeton, Predian, Glizid) Diabeton MR
80 30
80-320 30-120
8-12 24
Normalizes micro- circulation, blood aggregation
Glipizid (Minidiab, Glucontrol, Antidiab)
5 20 8-12
3 rd generation drugs (mg) Glimepirid (Amaryl) 1-4 4 24
Commonly used sulphonylureas
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Commonly used biguanides
Name of drug Dose in 1 tabl.
Daily dose
Duration of
action (hours)
Metformin (Dianormet, Siofor, Metfogamma, Metfordar) Glucophage Forte
0,25; 0,5 0,5; 0,85
0,5-1,5 0,5-2,0
8-10 12-14
Buformin (Adebit) Buformin Retard
0,05 0,17
0,1-0,2 0,17-0,34
8-10 12-14
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Alpha-glucosidase inhibitors
Name of drug Dose in 1 tabl.
Daily dose
Duration of action (hours)
Acarbosa (Glucobay, Glucor, Prandase, Precose)
0,05; 0,1 0,15-0,6 2,7-9,6
Miglitol 0,025; 0,05; 0,1
0,05-0,3 2-4
Guar Gum (Guarem)
5,0 (gra-nules)
15-30 -
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Non-sulfanylureas insulin stimulators
Name of drug Dose in 1 tabl.
Daily dose
Duration of action (hours)
Repaglinid (Novonorm, Roglid) (meglitinide analogs)
0,001; 0,002; 0,003; 0,004
0,004-0,009
3 - 4
Nateglinid (Starlix) (D-Phenilalanine-derivative)
0,06; 0,12; 0,18
0,18-0,54
1,5 - 3
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Commonly used thiozolidinediones
Name of drug Dose in 1 tabl.
Daily dose
Duration of action (hours)
Rosiglitazone (Avandia, Rosinorm)
0,002; 0,004; 0,008
0,004-0,008
Pioglitazone (Actos, Pionorm)
0,015; 0,03; 0,045
0,015-0,03
Up to 24 hours
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From the history of insulin
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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.
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Insulin preparations of ultrashort action
(human analog, recombinant)
Insulin action
beginning maximum duration
NovoRapid Novo-Nordisk
2-10 min 40 - 50 min 3 - 5 hHumalogLilly
Epaidra
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Insulin preparations of short action
Insulin actionbeginning maximum duration
Monodar Indar
30 min 1 - 3 h 5 - 8 h
Humodar R (полусинт.) Indar
Humodar RR(рекомб) Indar
Humodar R100 Indar
Humodar R100R Indar
Farmasulin HN Farmak
Actrapid (МС, НМ) Novo-Nordisk
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Insulin preparations of intermediate action
Insulin actionbeginning maximum duration
Monodar B Indar
1 – 1,5 h 6 - 8 h 12 – 18 h
Humodar B Indar
Farmasulin Н NР Farmak
Protaphan (МС, НМ)
Novo-Nordisk
Insuman basal Aventis
Humulin NPH Lilly
Monotard НМ Novo-Nordisk
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Insulin preparations of long action
Insulin actionbeginning maximum duration
Farmasulin НL Farmak
3 – 4 h 10 -12 h 24 – 30 h
Ultralente Humulin Lilly
Ultratard НМ
МC Suinsulin Ultralong Indar
Glargine (Lantus)Aventis
-(human analog, recombinant)
24 hDetemir
Levemir
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Insumani comb 25/75
Aventis 30 min 1,5-2 h 12-18 h
Mixtard 30 НМ
Novo-Nordisc
30 min 2-8 h 24 h
Monodar К15 Indar 30-40 min
1,5-3 h 12-18 h
Monodar К30 Indar 30-40 min
1-3 h 12-16 h
Monodar К50 Indar 30 min 1-3 h 6-10 h Humodar К 15
Indar 30-45 min
1,5-3 h 12-18 h
Humodar К25 Indar 30-45 min
1,5-3 h 12-18 h
Humodar К50 Indar 30 min 1-3 h 6-10 h
Insulin preparationscombined
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Secretion of insulin in health people
Con
cen
trat
ion
of
insu
lin
3 Breakfast 2, Meal secretion 3 Lunch Dinner 1,5 1 0,5 7.00 12.00 19.00 24.00 7.00 0
Basal secretion
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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.
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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.
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Plant’s therapy (phytotherapy)
• hypoglycemic action;
• treatment of chronic diabetics complications;
• influence on the immune reactivity.
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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;
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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.
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Self - control
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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 Graw-Hill Book, 1985. - P. 261 – 262, 270 – 273.