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LEARNING OBJECTIVES
At the end of the class the students should be able to mention various classes of antidiabetic drugs
Explain their mechanism of action Choose appropriate drug for management of Diabetes
OUTLINE
INTRODUCTION VARIOUS ANTIDIABETIC DRUGS INSULIN ORAL ANTIDIABETIC DRUGS
Mr.ramesh, 45 yr old accountant, has been newly diagnosed of DM type 2. he weighs 100 kilos and has increased increased LDL. Which group of antidiabetic drug would be appropriate in his case?
INTRODUCTION
Diabetes mellitus (DM) type 1 and type 2 Persistently elevated plama glucose leads to various micro and macrovascular complications
ANTIDIABETIC DRUGS
INSULIN AND ORAL ANTIDIABETIC DRUGS InsulinHuman and animal insulin and their analogues
INSULIN
SOURCES OF INSULIN
Bovine and pork insulin Human insulins-
Advantages of human insulin Diminished antibody production Less allergic reactions Less lipodystrophy
Insulin analogues-
ACTIONS OF INSULIN
Target cells-liver, skeletal muscles and adipose tissue Reduction in blood glucose Transit of amino acids and potassium into cells
PHARMACOKINETICS
Naturally insulin secreted- enters liver through portal vein and then to systemic circulation When administered (SC or IV) both liver and other organs receive the same concentration Route- Subcutaneous, Inhalational Intravenous
INSULIN DELIVERY SYSTEMS Syringes Insulin pens External infusion Implantable pumps
Insulin aspart
SHORT-ACTING Soluble insulin
INTERMEDIATE ACTING-
LONG ACTING-
Insulin regimens
FLEXIBLE Multiple injections of short-acting and single night time dose of long-acting insulin CONVENTIONAL Two injections a day of biphasic insulin(combination of short and long-acting insulins)
Adverse effects
Mainly because of overdose Hypoglycemia- coma and convulsions and even death Lipodystrophy- rare with purified insulin and patient education to rotate injection site
USES
Diabetes mellitus Hyperkalemia Testing of anterior pituitary function
Hypoglycemic drugs
SULFONYLUREAS (2nd generation)-
MOA Increase insulin secretion and decease glucagon secretion Inhibition of ATP-sensitive potassium channels- increased amount of insulin released
Increase only pulsatile secretion Increased insulin and somatostatin- decreased glucagon (normalize insulin glucagon ratio) Extra-pancreatic- insulin sensitization
ADVERSE EFFECTS- Hypoglycemia, skin rashes, nausea , vomiting , cholestasis and blood dyscrasias
DRUG INTERACTIONS Decrease effectiveness- thiazide diuretics, corticosteroids, estrogen Increase effectiveness- ACE inhibitors, sulfonamides, salicylates and NSAID s
INDICATIONS First line therapy in type 2 DM Used as monotherapy or in combination with metformin or thiazolidinediones
MEGLITINIDES
Repaglinide Nateglinide
MOA- similar to sulfonylureas PHARMACOKINETICSt1/2- 1-1.5, short and rapid acting
Orally well absorbed Taken before food Completely metabolized in liver in 4hrs.
ANTIHYPERGLYCEMIC DRUGS
BIGUANIDEmetformin MOA- Not completely known
AMPK activation
Suppresses hepatic glucose output Enhance insulin mediated glucose uptake Reduced intestinal glucose absorption
INDICATIONS
First-line therapy for type 2 DM Particularly appropriate- obese diabetics with insulin resistance and hyperlipidemia Single or in combination with sulfonylureas
THIAZOLIDINEDIONES
Rosiglitazone Pioglitazone
Suppression of hepatic gluconeognesis Insulin sensitizing action- stimulates GLUT-4 expression and translocation Activation of genes regulating FA metabolism and lipogenesis in adipose tissue Pioglitazone lowers serum TG s and raises HDL
ADVERSE REACTIONS Usually well tolerated Weight gain and edema Headache, myalgia, hepatic dysfunction
DRUG INTERACTION Failure of oral contraception due to pioglitazone therapy Ketoconazole inhibits pioglitazone metabolism
INDICATIONS Mainly used to supplement sulfonylureas or biguanides and in case of insulin resistance. Particularly in patients with insulin resistance
OTHERS
-Glucosidase inhibitors- Acarbose, Miglitol
Inhibits alpha glucosidase- prevents digestion of polysaccharides and sucrose. Postprandial glycaemia is reduced Taken at the beginning of meal
Mild hyperglycemic and used mainly as adjuvant in obese diabetics Flatulence , abdominal discomfort and loose stools
INCRETIN ANALOGUES- Exenatide GLP-1 enhances insulin release in response to raised plasma glucose concentration Adjunctive therapy in type 2 DM
DIPEPTIDYL PEPTIDASE (DPP) 4 INHIBITORS Sitagliptin and Vildagliptin DDP 4 breaksdown GLP-1 and its inhibition improves glucose control