Endocrinology Book

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Oral HypoglycemicAka: Oral Medications for Type 2 Diabetes

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  1. Agents: Most effective
    1. Obese patients
      1. Thiazolidinediones (e.g. Rosiglitazone)
      2. Metformin (Glucophage)
    2. Lean patients
      1. Sulfonylurea or other secretagogue
  2. Agents: Available
    1. General
      1. Lifestyle changes can lower A1C by 1-2%
      2. Efficacy Example: Weight loss, diet and Exercise
        1. Pre-intervention: HBA1C is 10%
        2. Post-intervention: HBA1C might drop to 8-9%
      3. Insulin is very cost effective (consider early)
        1. Lowers HBA1C an unlimited amount
        2. Can be used with Insulin Resistance agents
          1. Thiazolidinediones (e.g. Rosiglitazone)
          2. Metformin (Glucophage)
        3. Cost (monthly)
          1. Basal Insulins: NPH ($25) or Lantus ($80)
          2. Bolus Insulins: Regular ($35) or Lispro ($85)
    2. Insulin Secretagogues (early Type II Diabetes)
      1. Older agents (rarely used in United States)
        1. Chromium Picolinate
        2. First Generation Sulfonylurea (e.g. Tolbutamide)
      2. Newer Agents
        1. Second Generation Sulfonylurea (e.g. Glipizide)
          1. Cost: $11 per month
          2. Lowers HBA1C by 1.5%
        2. Meglitinides (e.g. Nateglinide, Repaglinide)
          1. Lowers HBA1C by 1.5%
    3. Insulin Resistance Agents
      1. Biguanides (e.g. Glucophage)
        1. Decreases hepatic glucose release
        2. Lowers HBA1C by 1.5%
        3. Cost: $45 per month
      2. Thiazolidinediones (e.g. Rosiglitazone)
        1. Increases muscle and fat Insulin sensitivity
        2. May also independently reduce cardiovascular risk
        3. Lowers HBA1C by up to 1.4%
        4. Cost: $180 per month
      3. Alpha-glucosidase inhibitors (e.g. Acarbose)
        1. Decreases gastrointestinal carbohydrate absorption
        2. Lowers HBA1C by 0.5 to 1%
    4. Combination agents
      1. Glucophage and Insulin secretogogue (e.g. Glucovance)
      2. Thiazolidinediones with Insulin secretogogue
      3. Basal Insulin (e.g. Lantus) with Glucophage
        1. Cost: $125/month
        2. Contrast Glucophage + Glitizone + Glipizide: $300
      4. Insulin with Glucophage and Glitazone
  3. Protocol: Sample Template for Prescribing Combination Oral Agents
    1. General
      1. Use a combination of agents (consider from onset)
      2. Treat Insulin Resistance and Insulin shortage
    2. Example of oral hypoglycemic regimen for obese patient
      1. Initial Management: Decrease hepatic glucose release
        1. Glucophage (Metformin)
      2. Next Management: Insulin Secretion
        1. Recent onset Type II Diabetes: Sulfonylurea
        2. Prolonged Type II Diabetes: Consider Insulin
      3. Next Management: Insulin Resistance
        1. Thiazolidinediones (e.g. Rosiglitazone) or
        2. Alpha-glucosidase inhibitor: (e.g. Acarbose)
    3. Example of oral hypoglycemic regimen for lean patient
      1. Initial Management: Insulin Secretion
        1. Recent onset Type II Diabetes: Sulfonylurea
        2. Prolonged Type II Diabetes: Consider Insulin
      2. Next Management
        1. Alpha-glucosidase inhibitor: (e.g. Acarbose)
    4. Examples based on timing of hyperglycemia
      1. Pre-meal fasting hyperglycemia
        1. Sulfonylurea (most effect is on pre-meal glucose)
        2. Insulin Resistance agents
          1. Glucophage (Metformin)
          2. Thiazolidinediones (e.g. Rosiglitazone)
      2. Postprandial hyperglycemia (Insulin deficiency)
        1. Meglitinides (e.g. Repaglinide)
        2. Alpha-glucosidase inhibitors
  4. Adverse Effects: Oral Agents
    1. Hypoglycemia
      1. Associated with Diabetics on ACE Inhibitors
      2. Higher risk with Captopril than Enalapril
      3. Higher risk for Sulfonylureas
      4. May account for 14% DM admissions for Hypoglycemia
    2. Weight gain
      1. Sulfonylureas
    3. Gastrointestinal side effects
      1. Biguanides (Glucophage)
      2. Alpha-glucosidase inhibitors (Acarbose, Miglitol)
    4. Lactic Acidosis
      1. Biguanides (Glucophage)
    5. Liver toxicity
      1. Thiazolidinediones (e.g. Actos or Avandia)
    6. Edema (avoid in Congestive Heart Failure)
      1. Thiazolidinediones (e.g. Actos or Avandia)
  5. References
    1. Luna (2001) Am Fam Physician 63(9):1747
    2. Yki-Jarvinen (2001) 24:758

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