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Clinical Practice Guidelines:Management of
Type 2 Diabetes Mellitus
(4thEdition 2!!"
Topic 6:
#ral $nti Diabetic $gents
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2
Patients achie%ing target &b$'c
Diabcare Asia IHM,
MOHAudit
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M#& $udit 2!!):
Medications prescribed
Medication n %
T*C only
+iguanides,ulphonylureas
$carbose
Metiglinides
Glitazones (TZD)-nsulin
)!
2./"2.)!/
2!'
''
2040/
'14
67.871.5
)1/
!1
0.6'1
IMH, MOH 2005
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4
Targets for Control
LeelsGlycaemic Control
3asting 414 01' mmol5l
6on7fasting 414 81! mmol5l
&b$'c
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)
Diabetes Education
D$T$&:
linical 'alation
'D*T$&
&ein+o,ce on t-e
ipo,tance o+ continos
edcation
&eie/ +o, Medication
'D*T$&
Docto, ,se *ssistant Medical $++ice,
ealt- 'dcation $++ice, Dietitian and ot-e,s
$34'T'To ,eass,e and alleiate anietTo nde,stand t-e disease its ana9eent
and coplicationTo p,oote copliance and sel+ca,e
'D*T$ ;L*
*ssess el+ca,e?>3GM?+oot ca,e>top so
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0
Dia9nosis o+ Tpe 2 Dia=etes*ll patients adised L@'>TAL' Modi+ication
@;G =*1cat Dia9nosis and @ollo/ p
=*1c
B6.5% $&
@;G B6 ol?L
LIFESTYLE
APPROACH*
Follow-up with HbA1c
after
3 months.
If HbA1c6.5%,continuewith ifest!le Approach.
If HbA1c
"6.5% on follow-
up, consi#er OAD
MONOTHERAPY.
=*1c
6.5 B8.0%
$&
@;G 6 B10 ol?LOAD MONOTHERAPY
$etformin
&'
A(I ) *++- Inhibitor )
(lini#es ) ) /0*s.&ptimise #ose of &A* aent
in the subse2uent 3-6
months.
Follow-up with HbA1c
after 3-6
months.
If HbA1c
6.5%, continue
therap!.
If HbA1c"6.5%, consi#erCOMBINATION OAD
THERAPY.
=*1c
C10.0% $&
@;G C1 ol?LCOMBINATION
THERAPY + BASAL /
PREMIXED INSULIN
THERAPY.
&'
INTENSIVE INSULINTHERAPY, contin!
M!t"o#$in.
=*1c
8.010.0% $&
@;G 101 ol?L
COMBINATION THERAPY***
$etformin with other &A*
aents A(I ) *++-
Inhibitor ) (lini#es ) Incretin
$imetic ) ) /0*s4 or withinsulin.
&ptimise #ose of &A* aents
in the subse2uent 3-6
months.
Follow-up with HbA1c
after 3-6
months.
If HbA1c
6.5%, continue
therap!.If HbA1c
"6.5%, consi#er
a##ition of INSULIN
THERAPY.
T,eatent *l9o,it- +o, t-e Mana9eent o+ T2DM
Footnote:
If symptomatic (weight loss, polyuria, etc) at any HbA1cand FPG level, consider insulin therapy
! "onsider metformin#AGI#other insulin sensitiser in appropriate patients!! $etformin is preferred %st line agent, and &' should preferably not be used as %stline
!!! Although oral agents can be used, initiation and intensification of insulin therapy is preferred based oneffectiveness and epense
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/
Proacti%e management of glycaemia:
Early combination approach
OAD + basal insulin
OAD + multiple dailyinsulin injections
Diet
OAD monotherapy
OAD combinations
OADs up-titration
Duration o diabetes
!
"
#
$HbA%c
&'(
%0
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8
#ral $gent Monotherapy:
>ecommendations
'1 -f glycaemic targets are not achie%ed (&b$'cB01)9.3PG B0 mmol5*
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"
Combination #ral $gents:
>ecommendations
'1 6e
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'!
Combination #ral $gents F
-nsulin: >ecommendations'1 6e
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''
#ral $nti7Diabetic (#$D $gents
There are currently fi%e classes of #$Dagents:
'1 $lpha7glucosidase inhibitor ($G-s
21 +iguanides
1 Dipeptidyl peptidase74 (DPP74 -nhibitors
41 -nsulin ,ecretagogues ,ulphonylureas
6on7,s or Meglitinides
)1 Thia@olidinediones (TDs
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'2
$lpha7glucosidase inhibitor ($G-s
$G-s e1g1 acarbose. act at the gut epithelium. toreduce the rate of digestion of polysaccharides inthe pro;imal small intestine by inhibiting 7glucosidase en@ymes1 They should be ta=en
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'
$lpha7glucosidase inhibitor ($G-s(cont1
-f hypoglycaemia occurs
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'4
+iguanides (Metformin
Metformin does not stimulate insulin secretion. andlo
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')
+iguanides (Metformin
Generally
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'0
+iguanides (Metformin
@o,lation Mini Dose Mai Dose
Metformin)!! mg tablet
-nitial dose )!! mg #Dsual dose )!! mg TD,
Ma;imum dose'.!!! mg +D
Metformin >etard8)! mg tablet
-nitial dose 8)! mg #Dsual dose 8)! mg +D
Ma;imum dose'./!! mg #M 58)! mg #6
Metformine;tended release)!! mg tablet
-nitial dose )!! mg #D Ma;imum dose2.!!! mg #D
Glibenclamideand metforminfi;ed dosecombination
-nitial dose one '12)mg 52)!mg tablet #D or +D
Ma;imum dose t
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'/
-ncretins
The incretin effect is mar=edly decreased in T2DM.resulting in delayed and reduced insulin release as
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'8
DPP74 -nhibitor (,itagliptin
-t lo
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'"
DPP74 -nhibitor (,itagliptin (cont1
@o,lation Mini dose Mai dose
,itagliptin'!! 5 )! 5 2) mg tablet
'!! mg #D '!! mg #D
,itagliptin and metformin fi;eddose combination)! mg 5 )!! mg tablet)! mg 5 8)! mg tablet)! mg 5 '.!!! mg tablet
)! mg 5 )!! mg+D )! mg 5 '.!!!mg +D
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2!
-nsulin ,ecretagogues (,s
,s lo
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2'
-nsulin ,ecretagogues (,s (cont1
,s should be ta=en ! minutes before meals.e;cept Glimepiride and Glicla@ide M>
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22
-nsulin ,ecretagogues (,s (cont1
@o,lation Mini dose Mai dose
Glibenclamide) mg tablet
21) mg #M '! mg +D
Glicla@ide 8! mg tabletGlicla@ide M> ! mg tablet
4! mg #M! mg #M
'0! mg +D'2! mg #M
Glipi@ide) mg tablet
21) mg #M '! mg +D
Glimepiride2 mg 5 mg tablet
' mg #M 0 mg #M
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2
-nsulin ,ecretagogues
6on7,s or Meglitinides
These are short acting insulin secretagogues
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24
-nsulin ,ecretagogues
6on7,s or Meglitinides (cont1
-t is associated
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2)
Thia@olidinediones (TDs
TDs are pero;isome proliferator7acti%ated receptor7gamma (PP$>7N agonists and act primarily byincreasing insulin sensiti%ity of muscle. adipose tissueand li%er to endogenous and e;ogenous insulin (insulin
sensitisers Ohen used as monotherapy. TDs ha%e demonstrated a
!1)7'149 decrease in &b$'c
-mpro%ement in glycaemic control may only be seenafter si;
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20
Thia@olidinediones (TDs (cont1
>ecent long term studies ha%e found that both TDsha%e been associated
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2/
G*P7' $nalogue (E;enatide
-t is gi%en parenterally. Iust before brea=fast and
dinner
-t reduces &b$'cby !1)7'1!9. sustained efficacy
o%er 2 years -t can be added to metformin and5or , if
glycaemic targets are not achie%ed
Progressi%e
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28
G*P7' $nalogue (E;enatide (cont1
The main ad%erse effects are gastrointestinalsymptom. notably nausea this can beminimised by starting at a lo< dose
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2"
Proacti%e management of glycaemia: early
combination approach
OAD + basal insulin
OAD + multiple dailyinsulin injections
Diet
OAD monotherapy
OAD combinations
OADs up-titration
Duration o diabetes
!
"
#
$HbA%c&
'(
%0
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!
General Guidelines for se of #$D
$gents -n elderly non7obese patients. short acting insulin
secretagogues can be started. but long acting ,s are to bea%oided1 >enal function should be monitored
Compliance may be impro%ed
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'
Treatment strategy
Choice of monotherapy durability of drug. fit thephenotype
More aggressi%e strategy combination therapy for
those ational use of drugs
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2
,ummary
Current glycaemic management of diabetes isinadeHuate Too fe< patients are achie%ing targets for &b$'c
6e< approaches are needed to impro%e outcomes
6eed to inter%ene early F more aggressi%ely1 Treat to goal. treat to phenotype. indi%idualised1
Early combination therapy but =eep regimens simple 1Early insulin initiation start simply
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Thank you