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Diabetes mellitus

Diabetes mellitus is a group of metabolic disease, occurs

when the level of glucose in the blood becomes higher than
normal.
Types of Diabetes

There are two main types of diabetes ±

1 Type 1 diabetes (IDDM) &

2 Type 2 diabetes (NIDDM)

Type 2 Diabetes (NIDDM)

Type 2 diabetes develops in the middle age and is also

known as adult onset diabetes. Generally, type 2
diabetes patients are overweight and have insulin
resistance instead of lack of insulin. Typically, this type
of diabetes is hereditary in nature and the insulin cells in
the patients are either normal or high, however, the cells
are slow in eliciting a response. Due to the slow
response, these patients have higher blood glucose
levels.
Type 2 Diabetes risk factors includes

mge of 45 years or older

Obesity
Family history of diabetes
Diabetes during pregnancy
Impaired Glucose Tolerance ( IGT )
Physical inactivity
_ymptoms of Type 2 Diabetes

The symptoms of type 2 Diabetes vary from person to

person but may include:
Increased thirst
Increased hunger (especially after eating)
Dry mouth
Nausea and occasionally vomiting
Frequent urination
Fatigue (weak, tired feeling)
Blurred vision
Numbness or tingling of the hands or feet
Frequent infections of the skin, urinary tract or vagina
Drugs used to treat NIDDM Patients

Medications that increase the insulin output by the

pancreas ±

_ulfonylureas

_ulfonylureas primarily lower blood glucose levels by

increasing the release of insulin from the pancreas.
1st Generation-
( arbutamide
( mcetohexamide
( hlorpropamide
( Tolbutamide
( Tolazamide
2nd Generation-
( Glipizide
( Gliclazide
( Glibenclamide
( Gliquidone
( Glyclopyramide
3rd Generation-
( Glimepiride
'hat Do They Do?
'hen the body does not have enough insulin, or does
not use the insulin it has effectively, blood sugar levels
increase. _ulfonylureas stimulate beta cells in the
pancreas to produce more insulin and also help the body
use insulin, lowering blood sugar levels by up to 20%.
'ho _hould Not Use _ulfonylureas
_ulfonylureas? ?
Patients with type 1 diabetes or with allergies to
sulfonamides (sulfa drugs) should not use sulfonylureas.
In addition, sulfonylureas may have to be discontinued in
patients who are exposed to high levels of physical
stress (infection, injury or surgery, for example), and may
have to be stopped temporarily for patients who are not
eating regularly. Glyburide should not be taken
simultaneously with Tracleer (bosentan), which is used
in the treatment of pulmonary artery hypertension.
_ide Effects

(
ypoglycemia
( 'eight gain
( Drug interaction (mainly 1st Generation)
( mllergic reaction
( Pruritus
( ash
ãrands in ãangladesh

ãrand Name Generic Name Dose Company Name

omprid Tablet Gliclazide 80 mg & 30 mg _quare

1 mg , 2 mg, 3 mg _quare
_ecrin 1 Tablet Glimepiride
& 4 mg
DImON Glimepiride Eskayef
onsucon Gliclazide 80 mg Incepta

osucon 1 & 2 Glimepiride 1 mg & 2 mg Incepta

Glims Glimepiride ! Mg & 2 mg Opsonin

Glizid Gliclazide 80 mg Opsonin

 Meglitinides

Meglitinides also work on the pancreas to promote

insulin secretion. Unlike sulfonylureas that bind to
receptors on the insulin producing cells, meglitinides
work through a separate potassium based channel on
the cell surface. Unlike the sulfonylureas which last
longer in the body, repaglinide (Prandin) and nateglinide
(_tarlix) are very short acting, with peak effects within
one hour. For this reason, they are given up to three
times a day just before meals. _ince these drugs also
increase circulating insulin levels, they may cause
hypoglycemia, but the literature suggests this is less
frequent than the hypoglycemia seen with sulfonylureas.
ow It 'orks?
Meglitinides prevent a rise in blood sugar levels by
increasing the amount of insulin produced by the
pancreas, similar to the way sulfonylurea medications
work.
_ide Effects
( ow blood sugar
( Upper respiratory infections, nasal and sinus
inflammation, and bronchitis
( oint pain
( Nausea
( 'eight gain
'hile repaglinide may cause low blood sugar and weight
gain, these side effects are milder than in those people
who take glyburide
Drug--Drug Interactions
Drug
mzole antifungals and erythromycin may interfere with the
metabolism of repaglinide, resulting in hypoglycemia. ifampin
may decrease the effectiveness of repaglinide, resulting in
hyperglycemia. alcium channel blockers, corticosteroids,
estrogens, isoniazid, nicotinic acid, oral contraceptives,
phenothiazines, phenytoin, sympathomimetics, thiazide diuretics,
and thyroid supplements may cause hyperglycemia in
combination with other antidiabetic agents, so blood glucose
levels should be closely monitored when one of these drugs is
added or discontinued. Monoamine oxidase inhibitors, non
selective beta blockers, N_mID's, probenecid, salicylates, and
sulfonamides may cause hypoglycemia in combination with other
antidiabetic agents, so blood glucose levels should be closely
monitored when one of these drugs is added or discontinued.
Drug--Food Interactions
Drug
_hould be taken 130 minutes prior to meals
ãrands in ãangladesh

ãrand Name Generic Dose Company

Name Name
epanid epaglinide 0.5 mg, 1 mg Opsonin
& 2 mg
Nomopil epaglinide 0.5 mg, 1 mg Incepta
& 2 mg
Medications that decrease the amount of glucose
produced by the liver-

ãiguanides

Biguanides are another type of diabetes medicine.

Biguanides that helps lower blood glucose by making sure
your liver does not make too much glucose. Biguanides also
lowers the amount of insulin in the body.
Metformin

Phenformin
ow It 'orks?
The action of biguanides in treating type 2 diabetes is not
completely understood. They lower blood sugar by:
( Decreasing the amount of sugar produced by the liver. This
is the primary action of these medicines.
( Increasing the amount of sugar absorbed by muscle cells
and decreasing the body's insulin resistance.
( Metformin does not cause the pancreas to produce more
insulin. mnd when taken alone, it should not cause low blood
sugar (hypoglycemia) or weight gain. _ome people taking
metformin may lose weight.
( Metformin may lower the amount of fat (triglycerides) in the
bloodstream, which may reduce the risk of heart disease. It
also has been shown to reduce certain abnormal clotting
factors and markers of inflammation that can lead to
hardening of the arteries.
_ide Effects

The most common side effects of metformin are

( Temporary nausea.
( oss of appetite.
( Diarrhea.
( Increased abdominal gas.
( m metallic taste
ãrands in ãangladesh
ãrand Name Generic Name Dose Company
Name
omet X 1 Gm _quare
Metformin
l 1000 mg
Tablet

omet 1 Gm Tablet Metformin
l 1 gm _quare

omet 500 Tablet Metformin
l 500 mg _quare

omet 750 Tablet Metformin
l 750 mg _quare

_quare
omet 850 Tablet Metformin
l 850 mg

_quare
omet X 500 Tablet Metformin
l 500 mg

Metformin Eskayef
GLUNOR
hydrochloride
Metformin Eskayef
GLUNOR XR
hydrochloride
Metformin 500 mg & 850 mg Incepta
Mefoglip 500 & 850

ydrochloride
 Medications that increase the sensitivity of cells to
insulin

Thiazolidinediones

Thiazolidinediones are oral medications that help lower

blood sugar in type 2 diabetes. In addition to a healthy diet
and exercise, they are another way to control blood sugar
levels.
 osiglitazone

Pioglitazone
'hat Thiazolidinediones Do?

Thiazolidinediones help to lower insulin resistance in cells,

improving the way that the body responds to insulin.
Thiazolidinediones are typically taken by mouth once or
twice daily. They may be used alone, with other pills or with
insulin.
'ho _hould Not Use Thiazolidinediones?
Thiazolidinediones?

People with type 1 diabetes (requiring regular insulin

injections), heart failure or liver disease should not use
thiazolidinediones. hildren and pregnant or nursing women
should also avoid using these medications. People with eye
or bone problems should talk with their health care providers
before taking thiazolidinediones.
_ide Effects

_ome reported side effects of thiazolidinediones include:

( Upper respiratory infections and sinusitis
(
eadaches.
( Mild anemia
( etention of fluid in the body. This may lead to heart
failure
( 'eight gain
( Muscle pain
( 'omen who take rosiglitazone (mvandia) or pioglitazone
(mctos) may increase their risk for upper arm or foot
fractures, according to a warning from the U._. Food and
Drug mdministration
ãrands in ãangladesh
ãrand Name Generic Name Dose Company Name

_quare
_ensulin osiglitazone 2 mg & 4 mg

_quare
Tos Pioglitazone 15 mg & 30 mg

Piol Pioglitazone 15 mg & 30 mg Opsonin

Piodar 15 & 30 Pioglitazone 15 mg & 30 mg Incepta

Medications that decrease the absorption of
carbohydrates from the intestine

Alpha glucosidase inhibitor

m class of oral medications for type 2 diabetes that decrease

the absorption of carbohydrates from the intestine, resulting
in a slower and lower rise in blood glucose throughout the
day, especially right after meals.
ow It 'orks?
mcarbose and miglitol help keep blood sugar levels within a
safe range by slowing the rate at which the intestines absorb
sugar (glucose) from food. These medications do not cause
the pancreas to produce more insulin. They will not cause
low blood sugar (hypoglycemia) unless they are used in
combination with other oral medications for diabetes or with
insulin.

Contraindications
( Diabetic Ketoacidosis (DKm)
( Intestinal disorder
± Inflammatory Bowel Disease
± olonic Ulceration
( Partial Intestinal Obstruction
_ide Effects

( Poorly tolerated
( Gastrointestinal side effects (unabsorbed carbohydrate)
± mbdominal Pain
± Diarrhea
± Flatulence
(
ypoglycemia
± If used with other Oral
ypoglycemic agent or Insulin
± Use oral glucose (not sucrose) to treat
ypoglycemia
Dosages

mcarbose (Precose)
± _tart dose: 25 mg PO tid at start of meal
± Maintenance: 50100 mg PO tid
Miglitol (Glyset)
± _tart dose: 25 mg PO tid at start of meal
± Maintenance: 50100 mg PO tid
 New medications that affect glycemic control

_ymlin (pramlintide)
Pramlintide (_ymlin) is the first in a new class of injectable, anti
hyperglycemic medications for use in patients with type 2 or type 1
diabetes treated with insulin. Pramlintide, the active ingredient in _ymlin,
is a synthetic analog of human amylin, a naturally occurring
neuroendocrine hormone synthesized by pancreatic beta cells that helps
control glucose control after meals. mmylin, similar to insulin, is absent or
deficient in patients with diabetes. 'hen used with insulin, this
compound can improve glycemic control and has additional benefits that
cannot be realized with insulin alone.
mccording to published data, _ymlin reduces post meal blood sugar
peaks, reduces glucose fluctuations throughout the day, enhances
satiety (the sensation of fullness) leading to potential weight loss, and
lowers mealtime insulin requirements. _tudies have shown it improves
m1 beyond the effect of insulin alone.
_ymlin is taken just prior to meals, three times a day. It is given in
injection form and is used for:
( Type 2 diabetes, as an additional treatment in patients who
use mealtime insulin therapy and have failed to achieve
desired glucose control despite optimal insulin therapy, with
or without a concurrent sulfonylurea agent and/or metformin.
( Type 1 diabetes, as an additional treatment in patients who
use mealtime insulin therapy and who have failed to achieve
desired glucose control despite optimal insulin therapy.
( _ymlin is considered a therapy option in patients with
insulinusing type 2 or type 1 diabetes, that are unable to
achieve adequate glycemic control despite individualized
insulin management. Insulinusing patients with type 2
diabetes may also be taking a concurrent sulfonylurea agent
and/or metformin.
 ãyetta (exenatide)
Exenatide (Byetta) is a medication on the market that has it's origins in
an interesting placethe Gila monster's saliva. _cientists studying this
small lizard noted it could go a long time without eating. They found a
substance in it's saliva that slowed stomach emptying, thus making the
lizard feel fuller longer. This substance was similar in nature to a gut
hormone found in humans known as GP1. GP1 is broken down in
the body by an enzyme called DPPIV. _o, if you could make a
substance like GP1 that was not so easy to breakdown, this would
have potential benefit; thus, the studies began. Ultimately, after
modifying this hormone, exenatide (with the trade name Byetta) was
developed.
( Byetta is the first in a class of drugs for the treatment of type 2 diabetes
called incretin mimetics. Byetta has been shown to have many of the
same effects on sugar regulation as GP1, so it mimics the body's
natural physiology for selfregulating blood sugar. Namely, it slows the
release of glucose from the liver, slows stomach emptying thereby
regulating delivery of nutrients to the intestine for absorption, and works
centrally in the brain to regulate hunger.
Byetta is indicated as additional therapy to improve control
of blood sugars in patients with type 2 diabetes who are
taking metformin, a sulfonylurea, or a combination of
metformin and a sulfonylurea but who have not achieved
adequate sugar control. It enhances the way the insulin
producing beta cells in the pancreas work. Insulin secretion
increases only when blood sugars are high and decreases
as blood sugars approach normal. In addition to enhancing
the normal physiology of the beta cell, Byetta suppresses
glucose release from the liver, slows stomach emptying and
the absorption of nutrients including carbohydrate, and
reduces intake of food.
 mictoza (lyraglutide)

Victoza (lyraglutide) is an injectable prescription medicine

that improves blood sugar (glucose) in adults with type 2
diabetes when used with a diet and exercise program.
Victoza is not insulin. It is not known if Victoza is safe and
effective when used with insulin. Victoza is not for people
with type 1 diabetes or people with diabetic ketoacidosis.
Victoza is not recommended for use in children. Victoza, like
Byetta, belongs to a class of medicines known as glucagon
like peptide1 (GP1) receptor agonists, which help the
pancreas make more insulin after eating a meal.
 DPP-Im inhibitors

GP1 in the body is broken down by an enzyme called DPP

IV. ogically, you can either make a synthetic GP1 that is
not broken down by this enzyme (for example, Byetta) O
you could try to stop the enzyme that breaks down the GP
1 your body already makes.
ence, the new class of drugs
called DPP IV inhibitors. They do just that, that is, they
inhibit this enzyme from breaking down GP1. This allows
GP1 already in the blood to circulate longer. There are a
number of companies working on this class of drug.
 Combination medications
Glyburide/metformin (Glucovance), rosiglitazone/metformin
(mvandamet), glipizide/metformin (Metaglip), and
pioglitazone/metformin (mctoplus §
), and metformin/sitagliptin
(anumet) are are five relatively new combination pills that are on
the market to treat diabetes.
ãrand Name Generic Name Dose Company Name

Glimepiride + _quare
Glyros 1 mg + 4 mg
osiglitazone
Pioglitazone + _quare
ezulin 15mg+500mg
Metformin
l

osiglitazone + _quare
_ensimet 4mg+1000mg
Metformin
l

Pioglitazone + _quare
Tosirin 30mg+2mg
Glimepiride