Pharmacology-2 Dietitian Program PDF

# Pharmacology-2 Dietitian Program ## Section 1: Diabetes Mellitus (DM) **Dr. Ahmed Hassan** **Under supervision of Prof Dr Manar A Nader** ## Overview - The pancreas produces the peptide hormones insulin, glucagon, and somatostatin. - The peptide hormones are secreted from cells in the isle...

# Pharmacology-2 Dietitian Program ## Section 1: Diabetes Mellitus (DM) **Dr. Ahmed Hassan** **Under supervision of Prof Dr Manar A Nader** ## Overview - The pancreas produces the peptide hormones insulin, glucagon, and somatostatin. - The peptide hormones are secreted from cells in the islets of Langerhans: - β cells produce insulin - α cells produce glucagon - δ cells produce somatostatin ## Islets of Langerhans - **Image description:** A diagram of the Islets of Langerhans, showing the different cell types and their respective secretions. - There are alpha cells labelled as "Alpha cell (secretes glucagon)" - There are beta cells labelled as "Beta cell (secretes insulin)" - There are delta cells labelled as "Delta cell (secretes somatostatin)" - There are also "F cells" labelled as "F cell (secretes pancreatic polypeptide)" - The diagram shows the exocrine part of the pancreas with cells labelled as "Exocrine pancreas (acinar cells and duct cells)." ## Classification of Diabetes Mellitus | Characteristic | Type 1 | Type 2 | |---|---|---| | Age of onset | Usually during childhood or puberty | Commonly over age 35 | | Nutritional status at time of onset | Commonly undernourished | Obesity usually present | | Prevalence | 5% to 10% of diagnosed diabetics | 90% to 95% of diagnosed diabetics | | Genetic predisposition | Moderate | Very strong | | Defect or deficiency | β cells are destroyed, eliminating the production of insulin | Inability of β cells to produce appropriate quantities of insulin; insulin resistance; other defects | ## Management of Type 1 Diabetes Mellitus - **Image description:** A man pricking his finger with a blood glucose monitor, with the words "Management of type 1 DM" below it. ## Insulin Preparations - **Image description:** A diagram showing different types of insulin preparations along with their respective brand names. | Type of Insulin | Brand Names | Duration of Action | |---|---|---| | Rapid acting | Lispro, Aspart, Glulisine | 3 hours | | Short acting | Regular (soluble) | 6 hours | | Intermediate acting | NPH (isophane) | 12 hours | | Long acting | Detemir, Glargine, Degludec | 24 hours | ## Rapid Acting Insulin - **Image description:** Pictures of three rapid-acting insulin pens, "Humalog KwikPen", "NovoRapid FlexPen", and "Apidra SoloStar" ## Intermediate Acting Insulin - **Image description:** Pictures of three intermediate-acting insulin vials, "Humulin N" (NPH) and two pictures of "Mixtard 30" (mixed 70/30). ## Long Acting Insulin - **Image description:** Pictures of three long-acting insulin pens, "Levemir FlexPen", "Lantus SoloStar", and "Insulin degludec Tresida FlexTouch". ## Insulin Preparations Summary Table | Type of Insulin | Preparation | Clear | Onset | Duration | Features | |---|---|---|---|---|---| | Rapid acting | Aspart, Lispro, Glulisine, Inhaled | Clear IV or SC | 15 min | 3 hr | 15 min prior meal; Bolus/post prandial insulin | | Short acting | Regular | Clear IV or SC | 30 min | 6 hr | 30 min prior meal; Bolus/post prandial insulin | | Intermediate acting | Neutral protamine hagedron | Cloudy SC| 1 hr | 12 hr | Basal insulin | | Long acting | Detemir, Glargine, Degludec | Clear SC | 2 hr | 24 hr | Basal insulin | ## General Roles for Management of Type 1 Diabetes Mellitus ### Total Daily Insulin (TDI) - The TDI requirement for individuals with T1DM is 0.3 to 0.6 unit/kg/day, divided into multiple doses delivered according to the regimen used (old or new strategy). - When insulin requirements exceed 100 units/day, efforts to shrink insulin resistance must be enforced, for example, exercise and restricting dietary carbohydrate intake. - It is preferred to start with the least dose 0.3 u/kg/day, then titrate the dose according to the patient situation. ### Old Strategy for Management - (Short + intermediate acting insulin) - Divided into 2 doses: 2/3 of the dose is taken 30 min before breakfast and 1/3 is taken 30 min before evening meal. - **Example:** A patient weighing 100 kg needs 30 U/day, divided as 20 U before breakfast and 10 U before dinner. - The dose is then adjusted according to the patient's requirement. ### Advantages and Disadvantages of the Old Strategy - **Advantages:** Daily insulin injection frequency is two or three times daily and less expensive than newer insulins. - **Disadvantages:** Does not mimic natural insulin secretion pattern, and is prone to hypoglycemic events. ### Recent Strategy for Management - (Long + rapid acting insulin; Basal/Bolus strategy, physiologic insulin therapy). - The preferred regimen simulates the physiological insulin release. - Use insulin analogs to better mimic natural insulin secretion patterns. - **Use long-acting basal insulin to prevent ketosis and control FPG.** - **Use bolus insulin to control postprandial hyperglycemia** - **Advantages:** More physiologic, less hypoglycemia, more flexible to patient mealtimes. - **Disadvantages:** Cost and increased frequency and number of daily injections (rapid-acting and basal insulin must be injected separately). ### Basal/Bolus Strategy - **Bolus taken with each meal**. - **Basal taken at rest** (no feed, during rest and sleep). - **Dose of insulin divided as 50% being delivered as basal insulin, and the remaining 50% as bolus insulin**. - **The basal insulin is taken before sleep**. - **The bolus insulin is divided equally on the 3 meals**. **Example:** A patient weighing 100 kg takes 0.3 U/kg so the total dose is 30 U. - 15 U is taken at bedtime of insulin detemir. - 15 U is taken as insulin lispro (5 U, 15 min before each meal). - The dose is then adjusted according to the patient's requirement. ## Insulin Dose Adjustment Roles ### Insulin Titration Algorithm | Pre-breakfast blood glucose (mg/dl) | Basal insulin dose (pre-bed dose) | Pre lunch/Pre dinner Pre bed blood glucose (mg/dl) | Bolus insulin dose increment (Pre lunch, Pre dinner, Pre bed blood glucose mg/dl) | |---|---|---|---| | More than 180 | 8 | More than 180 | 4 | | 160-180 | 6 | 160-180 | 3 | | 140-159 | 4 | 140-159 | 2 | | 120-139 | 2 | 120-139 | 1 | | 100-119 | 1 |100-119 | - | | 80-99 | - | 80-99 | -1 | | 60-79 | -2 | 60-79 | -2 | | Less than 60 | -4 | Less than 60 | -3 | ## Case Study: A1C of 8.6% - A woman with T2D has an A1C of 8.6%. She is receiving insulin glargine (60 units once daily at bedtime) and insulin aspart (8 units before breakfast, 7 units before lunch, and 12 units before dinner). She is consistent in her carbohydrate intake at each meal. Her morning fasting plasma glucose (FPG) and pre-meal blood glucose (BG) readings have consistently averaged 112 mg/dL. Her bedtime readings are averaging 185-200 mg/dL. What is the best insulin adjustment to improve her overall glycemic control? - **Answer:** B. Increase pre-dinner aspart to 16 units. ## Case Study: Diagnosis of T1D with Fasting Glucose 298 mg/dL - A patient weighing 65 kg with symptoms of hyperglycemia and a fasting glucose concentration of 298 mg/dL is given a diagnosis of type 1 diabetes (T1D). The patient's physician asks for a recommendation of an appropriate starting dose of basal insulin and estimates the total daily insulin (TDI) needs of 0.4 unit/kg/day. Which recommendation is the most appropriate? - **Answer:** A. 13 units of insulin detemir. ## Case Study: 21-year-old Patient with Elevated Glucose - A 21-year-old patient (weight 80 kg) is given a diagnosis of T1D after the discovery of elevated glucose concentrations (average 326 mg/dL) and has signs and symptoms of hyperglycemia. What is the most appropriate initial dose of rapid-acting insulin before breakfast for this patient? Assume a TDI regimen of 0.5 unit/kg/day. - **Answer:** B. 4 units.