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DIABETES
MOHAMMAD NASIM
MBBS,FRSH(UK)
FELLOWSHIP IN ENDOCRINOLOGY ,DIABETES
AND METABOLISM
POSTGRADUATE DIPLOMA IN FAMILY MEDICINE
S E N I O R G P C O N S U LTAN T / FAM I LY P H Y S I C I A N
BADRUDDIN MEDICAL GROUP
JEDDAH,KSA
CASE STUDY
A 45-year-old woman with type 2 diabetes arrives for a
follow-up visit . She has been compliant with metformin
1000 mg twice daily. She reports that her home blood
sugar readings have improved slightly but are still high.
She admits to a few dietary indiscretions, such as having
multiple servings of dessert when going out with friends.
For exercise, she has been walking 10 to 15 minutes a
day.
CASE STUDY
She denies polyuria, polydipsia, or blurry vision. The
review of systems is unremarkable.
MEDICAL HISTORY
Her medical history is significant for:
Type 2 diabetes, diagnosed 6 months ago when she
presented with polyuria, blurry vision, and a random
glucose level of 276 mg/dl. Her HbA1c at that time was
9.0%.
She was started on metformin 500 mg twice daily, and
within 3 months her HbA1c dropped to 8.3%. The
metformin was increased to 1000 mg twice daily at that
time. She has not had significant hypoglycemic
episodes.
TREATMENT HISTORY
Hypertension, treated with PERINDOPRIL 5mg daily.
Dyslipidemia, treated with atorvastatin 20 mg daily.
Esophageal reflux treated with omeprazole 20 mg daily.
EXAMINATION
Vital signs are :
Blood pressure 122/76 mm Hg, heart rate 82, respiratory
rate 16, temperature 98.0 F,
Height 55, weight 73 kg, and BMI 26.0. She has not
gained or lost significant weight since she started
treatment for diabetes.
EXAMINATION
On exam:
The lungs are clear to auscultation, the heart has a
regular rate and rhythm without murmurs, and the
abdomen is non tender.
Peripheral pulses are normal, and there is no lower
extremity edema. The foot exam shows normal
sensation to light touch and no skin or toenail lesions.
LAB FINDINGS
HbA1c level, determined last week, is 7.8%.
Patients blood glucose log shows morning fasting
glucose ranging from 120 mg/dl to 150 mg/dl, and
postprandial readings at 190 mg/dl to 220 mg/dl.
ASSESSMENT
The patients HbA1c has improved since starting metformin,
but is still not at target. Her fasting and postprandial glucose
levels are also too high. The underlying causes for
hyperglycemia in this patient include dietary factors,
inadequate exercise, and obesity. She has no signs or
symptoms of an acute illness that could cause
hyperglycemia.
The maximum recommended dose of metformin for adults is
2000 to 2500 mg daily, depending on the formulation. Her
current total daily dose is 2000 mg, and it is unlikely that her
glycemic control will improve significantly just by adding
another 500 mg of metformin.
DISCUSSION
DISCUSSION
A number of issues should be considered when choosing
between these medication classes, including:
Patient preference for route of administration and other
factors
Efficacy in reducing HbA1c
Potential to cause hypoglycemia
Potential to induce weight gain
Side effects
Cost
EFFICACY
means.
efficacy
10.0
9.5
9.0
8.5
Mean HbA1c
at final visit
P<0.0001
8.0
7.5
7.3%
7.0
6.5%
6.5
6.0
5.5
5.0
0
Follow-up (years)
4/5 < 7%
Satoh Trial
(B-cell Preservation)
Peace of mind
Safe
A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.
Diamicron MR
Glimepiride
Glibenclamide
A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.
HYPERGLYCEMIA
Diamicron MR
Glimepiride
Glibenclamide
A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.
NORMOGLYCEMIA
A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.
NORMOGLYCEMIA
Conclusions:
The incidence of Hypoglycaemia was lower with gliclazide relative
to the other sulphonylurea agents and similar to that observed with
sitagliptin.
Diamicron MR
Protection
Nephro protection
Diamicron MR guarantees
Thank you