Workshop 6 Pharmacology Of Diabetes PDF Aa 2024-25

WORKSHOP 6 PHARMACOLOGY OF DIABETES 3° Medicine Aa 2024-25 Professor: Vittoria Carrabs PhD  Diabetes 1 and 2 https://www.youtube.com/watch?v=bFnO8Uc9gjQ  What is diabetes?  Types of diabetes:  Diabetes tipo 1 Type 1 diabetes is due to an autoimmu...

WORKSHOP 6 PHARMACOLOGY OF DIABETES 3° Medicine Aa 2024-25 Professor: Vittoria Carrabs PhD  Diabetes 1 and 2 https://www.youtube.com/watch?v=bFnO8Uc9gjQ  What is diabetes?  Types of diabetes:  Diabetes tipo 1 Type 1 diabetes is due to an autoimmune reaction and the destruction of the islets of lagerans ( cells). This reaction prevents the body from producing insulin. People with type 1 diabetes have to take insulin every day to survive.  Type 2 diabetes  With type 2 diabetes, the body doesn't use insulin properly and can't keep blood sugar at normal levels.  Gestational diabetes DIABETES 1 ALL PATIENTS WITH TYPE 1 DIABETES REQUIRE INSULIN American Diabetes Association (ADA) recommends multiple daily insulin injections or continuous subcutaneous insulin infusion, and use of insulin analogs (to reduce hypoglycemia risk)  INSULINES These graph helps visualize the onset, peak, and duration of these insulins, guiding how they are used in managing diabetes, either alone or in combination to maintain stable blood sugar levels throughout the day.  INSULINES (types) 1.Aspart, Lispro, Glulisine (Rapid-acting Insulin): Rapid onset, peaking within 1-2 hours, and lasting about 4 hours. These are typically taken before meals to manage postprandial blood sugar spikes. 2.Regular Insulin (Short-acting): Onset within 30 minutes to 1 hour, peaking at 2-3 hours, and lasting for up to 6 hours. It is used to control blood sugar levels around meal times but requires administration 30- 60 minutes before eating. 3.NPH (Intermediate-acting Insulin): Onset occurs 2-4 hours after injection, peaks between 4-12 hours, and has a duration of around 12-18 hours. This type is used for longer coverage, often combined with rapid or regular insulin. 4.Detemir (Long-acting Insulin): A long-acting insulin that has a more gradual onset (around 2 hours), without a pronounced peak, and provides a more stable insulin level, lasting up to 24 hours. 5.Glargine (Ultra-long-acting Insulin): This insulin has a very steady effect, with no significant peak, lasting up to 24 hours or more, providing baseline insulin coverage for an entire day. MEDICATIONS (IN ADDITION TO INSULIN MAY INCLUDE) ADJUVANT GLUCOSE-LOWERING MEDICATIONS PRAMLINTIDE (SYNTHETIC ANALOG OF HUMAN AMYLIN. COSECRETED WITH INSULIN) Associated with improved glycemic control in adults with type 1 diabetes.  Slowing gastric emptying and promoting satiety. Prevents post- prandrial pikes.  Given subcutaneously immediately before each major meal MEDICATIONS (IN ADDITION TO INSULIN MAY INCLUDE) ADJUVANT GLUCOSE-LOWERING MEDICATIONS Addition of METFORMIN might reduce insulin dose in patients with diabetes mellitus type 1, but effect on glycemic control unclear. MEDICATIONS (IN ADDITION TO INSULIN MAY INCLUDE) LIPID-LOWERING DRUG THERAPY is effective for primary and secondary prevention of major coronary events in patients with diabetes. STATINS are more frequently recommended for diabetic patients over 40 due to their higher cardiovascular risk, but they might also be used in younger patients (21-40 years). MEDICATIONS (IN ADDITION TO INSULIN MAY INCLUDE) – ANTIHYPERTENSIVE MEDICATIONS - Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin receptor blocker (ARB) MEDICATIONS (IN ADDITION TO INSULIN MAY INCLUDE) – ANTIPLATELET MEDICATIONS - consider Aspirin 75 mg/day as primary prevention strategy for patients with diabetes with at increased risk of atherosclerotic cardiovascular disease, such as most men or women ≥ 50 years old with ≥ 1 additional major risk factor MEDICATIONS (IN ADDITION TO INSULIN MAY INCLUDE) INSULIN PRAMLINTIDE METFORMIN LIPID LOWERING ANTIHYPERTENSIVE ANTIPLATELET DRUGS DRUGS DRUGS statins ACE inibitor angiotensine antagonist  DIABETES 1 PANCREAS OR ISLET TRANSPLANT May be considered in patients with unstable glucose control despite all traditional approaches to glycemic control  DIABETES 1.HYPOGLYCEMIA FOR TREATMENT OF HYPOGLYCEMIA – Give GLUCOSE – 15-20 g orally to conscious individual (any form of carbohydrate that contains glucose is acceptable alternative) , – 25 g IV if unconscious or unable to take glucose orally DIABETES 1.HYPOGLYCEMIA Prescribe GLUCAGON to all individuals at significant risk of severe hypoglycemia and instruct caregivers or family members on its use. DIABETES 2 DIABETES 2 LIFESTYLE INTERVENTIONS INCLUDE  DIETARY MANAGEMENT  Individualized medical nutrition therapy for all patients, preferably by a registered dietitian.  PHYSICAL ACTIVITY  For ≥ 150 minutes/week.  DIABETES SELF-MANAGEMENT EDUCATION (DSME).  DIABETES PSYCHOLOGICAL COUNSELING  LIPID-LOWERING DRUG THERAPY  WEIGHT LOSS  MEDICATIONS DIABETES 2 TREATMENT OVERVIEW  GLYCEMIC GOALS  HbA1c < 7% in most non pregnant adults  HbA1c < 6% during pregnancy  If higher than 10, start insulin.  LIPID GOALS  Low-density lipoprotein (LDL) cholesterol < 100 mg/dL (2.6 mmol/L)  consider LDL < 70 mg/dL (1.8 mmol/L) in patients with cardiovascular disease  BLOOD PRESSURE GOALS  Vary across guidelines but range from < 130/80 mm Hg to < 140/90 mm Hg DIABETES 2. MEDICATIONS METFORMIN Is first-line drug of choice for type 2 diabetes  Initially 500 mg twice daily or 850 mg once daily,  Increase by 500 mg/day weekly or 850 mg/day every other week,  Maximum dose 1 g twice daily or 850 mg 3 times daily NO HIPOGLUCEMIA Risk Action on Lipid Metabolism: Plasma [ ] Reduction: TG, LDL Cholesterol, Total Cholesterol ADD SECOND DRUG If glycemic goals not met on maximal tolerated dose of Metformin monotherapy , Add third drug if glycemic goals not met on 2-drug combination. OTHER ORAL ANTIDIABETIC AGENTS INJECTABLE ANTIDIABETIC AGENTS DIABETES 2. MEDICATIONS SECOND DRUG METFORMIN THIRD DRUG ORAL ANTIDIABETIC AGENTS INJECTABLE ANTIDIABETIC AGENTS DIABETES 2. MEDICATIONS SECOND DRUG METFORMIN THIRD DRUG ORAL ANTIDIABETIC AGENTS INJECTABLE ANTIDIABETIC AGENTS ANTIHYPERTENSIVE ANTIPLATELET DRUGS DRUGS DIABETES 2 ANTIHYPERTENSIVE MEDICATIONS  Angiotensin-converting enzyme (ACE) inhibitor or Angiotensin receptor blocker (ARB) ANTIPLATELET MEDICATIONS ASPIRIN 75-162 mg/day not same concentration as anti-inflammatory drug  Should be considered as PRIMARY PREVENTION STRATEGY for patients with diabetes at increased cardiovascular risk (such as most men > 50 years old and women > 60 years old with ≥ 1 additional major risk factor) but should not be recommended for patients with low cardiovascular risk.  Recommended as secondary prevention strategy for patients with diabetes and history of cardiovascular disease. CLOPIDOGREL 75 mg/day can be used for patients with aspirin allergy DIABETES 2. MEDICATIONS SECOND DRUG METFORMIN THIRD DRUG ORAL ANTIDIABETIC AGENTS INJECTABLE ANTIDIABETIC AGENTS ANTIHYPERTENSIVE ANTIPLATELET DRUGS DRUGS ACE y ARB ASPIRIN AND CLOPIDOGREL PREGNANT WOMEN INSULIN THERAPY AND METFORMIN are preferred medications in gestational diabetes Diabetes 2 oral treatment METFORMIN (BIGUANIDE): Slows down the release of glucose made by the liver, and also helps cells use glucose. May also lower blood fat and cholesterol. Will not cause hypoglycemia (low blood sugar) by itself. METFORMIN SECOND DRUG THIRD DRUG  THIAZOLIDINEDIONES (GLITAZONES):  Decrease insulin resistance at peripheral sites and in liver  Decrease hepatic glucose production  Increase glucose uptake – PIOGLITAZONE  SULFONYLUREAS Increases insulin secretion by pancreas and may increase tissue sensitivity to insulin GLIMEPIRIDE GLIPIZIDE GLYBURIDE ALPHA-GLUCOSIDASE INHIBITORS Slower and lower rise of blood glucose after meals during the day, altering its intestinal absorption. saccharide into monosaccharides break down glucose MIGLITOL ACARBOSE VOGLIBOSE SGLT-2 INHIBITOR DAPAGLIFLOZIN – Inhibitor of sodium-glucose cotransporter 2 (SGLT2) which increases glucose excretion  INCRETINS (GLP-1) and DIPEPTIDYL PEPTIDASE IV (DPP-4) INHIBITORS (GLIPTINS) GLP-1 MIMETICS (Incretins) GLP-1 is transcribed from the same gene that codes for glucagon and secreted by specialized intestinal cells in response to a food stimulus. EXENATIDE and LIRAGLUTIDE (injectables) DIEPTIDYL PEPTIDASE-4 (DPP4) INHIBITORS Inhibition of the enzyme that hydrolyzes incretin GLP-1 SITAGLIPTIN, VILDAGLIPTIN CLINICAL CASES  Indicate how to proceed step by step. Talk about life styles, goals and medications. If the goal is not achieved in three This patient has obesity class 1 (with a BMImonths choose of 33) and she the presents with typeideal 2 diabetes since her last A1C level is higher between 8 and 9.5% and her fasting level is higher than 200. glycemic therapy. Show different She presents an intermediate lipid profile for LDL and HDL therefore she is at risk of cardiovascular diseases. scenarios. Recommendation: She needs to change her alimentation, reduce the amount of fried food and promote a healthier diet. She also needs to exercise or practice sports regularly. Prescription: oral agent = Metformin Goal: After 3 months, the blood glucose level needs to be reduced. If no amelioration is seen, we need to combine metformin with a second drug, such as DPP-4 inhibitors, to increase the effect. If the blood glucose level is stabilized we can study the minimum dose of metformin required with the amelioration of the diet and the exercise to see if the medication is still necessary or if the life style improvement is enough. intermediate intermediate normal  intermediate > 9.5% high normal Indicate how to proceed step by step. Talk about life styles, goals good and medications. good If the goal is not achieved in three months choose the ideal glycemic therapy. Show different scenarios.  intermediate intrmediate intermediate fair high Indicate how to proceed step by step. Talk high about life styles, goals and medications. If the goal is not achieved in three months choose the ideal glycemic therapy. Show different scenarios.  Information to solve the cases A1c levels (or HbA1c levels) indicate the average blood glucose over the past 2-3 months and are critical for managing diabetes. Information to solve the cases Information to solve the cases Information to solve the cases Information to solve the cases Information to solve the cases Information to solve the cases  TOTAL CHOLESTEROL/ HDL =RATIO Information to solve the cases Information to solve the cases Information to solve the cases