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MELLITUS
Worldwide prevalence of
diabetes in 2030 (projected)
Number of persons
< 5000
500074,000
75,000349,000
350,0001,499,000
1,500,0004,999,000
> 5,000,000
No data available
Total cases > 370 million adults
World Health Organization, 2003
www.who.int/diabetes/facts/world_figures/en/ (accessed September 2004).
Countries with the highest numbers of
estimated cases of diabetes for 2030
Egypt
Philippines
Japan
Bangladesh
Brazil
Pakistan
Indonesia
USA
China
India
0 20 40 60 80 100
FPG
< 100 mg/dl (5.6 mmol/l) normal fasting glucose
100125 mg/dl (5.66.9 mmol/l) impaired fasting glucose
126 mg/dl (7.0 mmol/l) diabetes
or
OGTT 2-h post-load glucose
< 140 mg/dl (7.8 mmol/l) normal glucose tolerance
140199 mg/dl (7.811.1 mmol/l) impaired glucose tolerance
200 mg/dl (11.1 mmol/l) diabetes
Idiopathic diabetes.
no known etiologies
Other specific types of diabetes
A. Genetic defects of -cell function
Chromosome 12, HNF-1 (MODY3); Chromosome 7,
glucokinase (MODY2); Chromosome 20, HNF-4 (MODY1);
Chromosome 13, insulin promoter factor-1 (IPF-1;
MODY4); Chromosome 17, HNF-1 (MODY5);
Chromosome 2, NeuroD1 (MODY6); Mitochondrial DNA
B. Genetic defects in insulin action
Type A insulin resistance; Leprechaunism; Rabson-
Mendenhall syndrome; Lipoatrophic diabetes.
C. Diseases of the exocrine pancreas
Pancreatitis; Trauma/pancreatectomy; Neoplasia; Cystic
fibrosis; Hemochromatosis; Fibrocalculous pancreatopathy.
D. Endocrinopathies
Acromegaly; Cushings syndrome; Glucagonoma;
Pheochromocytoma; Hyperthyroidism; Somatostatinoma;
Aldosteronoma.
Other specific types of diabetes
E. Drug- or chemical-induced
Vacor; Pentamidine; Nicotinic acid; Glucocorticoids; Thyroid
hormone; Diazoxide; adrenergic agonists; Thiazides; Dilantin;
Interferon.
F. Infections
Congenital rubella; Cytomegalovirus.
G. Uncommon forms of immune-mediated diabetes
Stiff-man syndrome; Antiinsulin receptor antibodies.
H. Other genetic syndromes sometimes associated with
diabetes
Downs syndrome; Klinefelters syndrome; Turners
syndrome; Wolframs syndrome; Friedreichs ataxia;
Huntingtons chorea; Laurence-Moon-Biedl syndrome;
Myotonic dystrophy; Porphyria; Prader-Willi syndrome
Gestational diabetes mellitus (GDM)
Any degree of glucose intolerance with onset during
pregnancy
Return to normal glucose regulation after delivery is
common
Increased perinatal morbidity and mortality if untreated
Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications. Department of Noncommunicable
Disease Surveillance, World Health Organization, Geneva 1999.
What is insulin resistance?
Definition of Insulin Resistance :
Impaired response to the physiological effects of
insulin, including those on glucose, lipid, protein
metabolism and vascular endothelial function
Receptor:
Quantity / function
Post-receptor (mostly):
Translocation of GLUT
Synthesis of GLUT
ADA. Consensus Development on Insulin Resistance. 1997
Insulin resistance and -cell dysfunction
are fundamental to type 2 diabetes
Normal IGT Type 2 diabetes
Insulin Hyperinsulinaemia,
secretion then -cell failure
Post- Abnormal
prandial glucose tolerance
glucose
Fasting Hyperglycaemia
glucose
Adapted from Type 2 Diabetes BASICS. International Diabetes Center, Minneapolis, 2000.
Insulin Resistance and -Cell Dysfunction
Produce Hyperglycemia in Type 2 Diabetes
-Cell Dysfunction Insulin Resistance
Increased
Pancreas Lipolysis
Elevated
Liver Plasma FFA
Reduced
Plasma Insulin
Decreased Glucose Transport
& Activity (expression) of GLUT4
Hyperglycemia
MUSCLE
Lipolysis LIVER
Hyperglycemia
Genetic Rare
abnormalities disorders
INSULIN
RESISTANCE
Type 2
diabetes PCOS
Hypertension Atherosclerosis
Dyslipidemia
Reaven GM. Physiol Rev. 1995;75:473-486
Clauser, et al. Horm Res. 1992;38:5-12.
-cell dysfunction
Reduced ability of -cells to secrete
insulin
Impaired ability of -cells to compensate
for insulin resistance
Genetic
and environmental
pathophysiology
Amyloid
deposition
Management of
Diabetes Mellitus
General Therapeutic Objectives
Interventional of pharmacology
Oral treatment
Insulin
Basic education
1. Survival skills
How to make prescribe medication
Timing, action of medication, technique for
administration (insulin)
How to test blood glucose
Warning sign of hypo/hyperglycemia
Basic nutrition guidelines
Food types, timing of meal, balancing content and
quantity
2. Lifestyle management issues
Lifestyle ManagementDiet &
Exercise
Diet -- Three important components
Enough nutrition to meet energy demands
Food intake distributed throughout the day
Feeding pattern and amounts should be consistent
Exercise
Helps decrease blood glucose levels
Have physician approve exercise program
Adjust meals & medications accordingly
3-4 times per week usually recommended (30
minute)
Nutritional Recomendation
Energy needs
Basal energy requirements (BER) : 25-30 kcal/kg of
desirable body weight
Desirable body weight/Ideal body weight (IBW) :
Formula Brocca modified: 90%x {Body Length (cm)-
100}x1kg
Additional energy required for activity level
Sedentary 10% of BER
Moderate 20% of BER
Strenuous 50% of BER
Liver Muscle
Metformin Rosiglitazone
Rosiglitazone Hepatic Pioglitazone Glucos
Pioglitazone glucose Metformin e uptake
output
Oral Drug Therapy for Type 2 DM
Sulfonylureas
Repaglinide
Nateglinide
} Insulin secretagogues
Biguanides
Thiazolidinediones }
Insulin sensitizers
Acarbose
}
Inhibitors of CHO
absorption
Sulfonylureas : Mechanism action
Pancreatic effect
Specific receptor on the surface of pancreatic
beta cell bind the suflfonilurea receptors (SUR)
There is a family of SUR, Sur 1/Kir6.2 is found
in B cellsand the brain.
SUR 2A/Kir6.2 is found in cardiac and skeletal
muscle
Extrapancreatic effect
Studied in vitro and vitro
In human studies; enhances insulin-stimulated
perpheral glucose utilization in both adipose
tissue and skeletal muscle.
Sulfonylureas: Mechanism of Action
Sulfonylureas
GLUT2 Na+
K+ -
Na+ KIR K+
K+
Vm
K+
Ca2+ -
Pancreatic Ca2+
Voltage-gated
cell Ca2+ channel
Ca2+
Insulin granules
First Generation Sulfonylureas
Name Daily Max daily Doses/day
dose dose
range (mg/day)
Tolbutamide* 500-3000 3000 2-3
Chlorpropamide 100-500 500 1
Tolazamide * 100-1000 1000 1-2
Acetohexamide* 250-1500 1500 1-2
*not available
Second Generation Sulfonylureas
Name Daily Max daily Doses/day
dose dose
range (mg/day)
(mg/day)
Glibenclamide 1.25-2.50 20 1-2
Glipizide 2.5-40 40 1-2
Glipizide XL 5-20 20 1
Gliclazide 40-320 320 1-2
Glimepiride 4-8 8 1
Sulfonylureas: Metabolism & Excretion
Metabolized in the liver
Hepatic dysfunction will alter pharmacokinetics
Excretion
Second generation: significant fecal excretion
Glybenclamide -50%
Glimeperide - 40%
Clinical Uses of Sulfonylureas
Do not increase NH
ROSIGLITAZONE O
insulin secretion
Increase insulin
sensitivity in liver N O
S O
Translocation
Insulin
receptor
X
X Synthesis GLUT 4
PPARg +RXR mRNA
PPRE transcription
promoter Coding reg
Muscle
Cells
Modified from Howard L. Foyt et al. Thiazolidinediones. Diabetes Mellitus: a Fundamental and Clinical Text, 2nd Ed.
TZD reduce insulin resistance
Insulin Glucose
Insulin
receptor
Synthesis GLUT 4
PPARg + RXR mRNA
PPRE transcription
promoter Coding reg
Muscle
Cells
Modified from Howard L. Foyt et al. Thiazolidinediones. Diabetes Mellitus: a Fundamental and Clinical Text, 2nd Ed.
Thiazolidinediones: Rosiglitazone
Bioavailability of oral dose is 99%
Metabolites have no significant activity
Excreted in urine and feces
Half-life: plasma half-life is 3 to 4 hours
Extensively (99.8%) bound to albumin
Potency: 4 to 8 mg/day
As single dose or divided into 2 doses
No evidence of drug-induced hepatotoxicity
Should not be used in patients who experienced
jaundice
Thiazolidinediones: Pioglitazone
Some metabolites pharmacologically active
Excreted primarily in the feces
Half-life: plasma half-life is 3 to 7 hours
16 to 24 hours for metabolites
Extensively (>99%) bound to albumin
Potency: 15 to 45 mg/day
Given as a single dose
No evidence of drug-induced hepatotoxicity
Should not be used in patients who experienced
jaundice
a glucosidase inhibitors (Acarbose)
Mechanism of action: competitive and reversible
inhibitors of a glucosidase in the small intestine
Delay carbohydrate digestion and absorption
Smaller rise in postprandial glucose
Clinical use
For mild to moderate fasting hyperglycemia with significant
postprandial hyperglycemia
Taken with the first bite of a meal
Adverse effects:
Gastrointestinal
disturbances; Flatulence, nausea, diarrhea
Use gradual dose titration
Clinical Uses of Insulin
Type 1 diabetes mellitus
Type 2 diabetes mellitus uncontrolled on maximal
combination therapy with oral agents
Gestational diabetes
Hyperglycemic emergencies
Total pancreatectomy patients
Acute or chronic hyperglycemia provoked by:
Infection or trauma
Steroid therapy
Endocrinopathies such as hyperthyroidism
Other types of secondary diabetes
Insulin Preparations
Short-acting regular
Plasma [Insulin]
Intermediate- NPH
acting
lente
Long-acting ultralente
regular
lente
4 8 12 4 8 12 4 8 12
am pm am
Insulin treatment regimens
Intensive insulin treatment
Frequent monitoring of blood glucose
3 or more daily injections of insulin
Some regular alone, some combined regular and
intermediate- or long-acting
Adjusted to needs of individual patient
4 8 12 4 8 12 4 8 12
regular am pm am
lente
4 8 12 4 8 12 4 8 12
am pm am
lispro
glargine
4 8 12 4 8 12 4 8 12
am pm am
Insulin treatment regimens
Continuous subcutaneous insulin infusion
Insulin pump with lispro or regular insulin
Programmed basal delivery
allows control of dawn phenomenon
Patient-triggered bolus before meals
Continuous
infusion
regular or
4 8 12 4 8 12 4 8 12
lispro am pm am
Other Factors Affecting Insulin
Pharmacokinetics
Method of injection
Standard- subcutaneous
Intradermal- poor absorption
Intramuscular - accelerated absorption
Rate of blood flow through injection site
Site of injection
absorption from abdomen or buttock faster than
from thigh or deltoid
Ambient temperature
Exercise
Adverse Effects of Insulin Therapy
Hypoglycemia
Especially dangerous in Type 1 diabetics
Glucose or glucagon treatment
Allergy and resistance to insulin
Local cutaneous reactions or systemic
Switch to less antigenic form or desensitization
Lipohypertrophy
Due to lipogenic effect of insulin when small area used for frequent
injections
Absorption from such sites is unpredictable
Lipoatrophy
Due to impurities: switch to highly purified insulin
Lipogenic effect of insulin can repair lesion
Insulin edema- transient, rare
Treatment of Type 2 Diabetes
Diet and exercise
Monotherapy with oral agent
postprandial hyperglycemia: acarbose, repaglinide
normal weight: sulfonylurea
obese: biguanide, TZD
Combination therapy with oral agents: additive
acarbose with biguanide, sulfonylurea, or TZD
sulfonylurea with biguanide or TZD
biguanide with TZD
Insulin +/- oral agent
oral agent with bedtime insulin
oral agent with lispro
TERIMA KASIH