Links

DUK (http://www.diabetes.org.uk/APCProgrammeAPC8 v g*) | ADA

NICE Guidelines

A1c vs Glu; CVD; Metabolic syndrome

A1c MBG* CVD Prev: MS=3:
5% 5 BP<130/80 BP≥130/85
6% 7 TC<4 TG≥1.7
7% 9 LDL-C<2 HDL≥1.3f|1.0m
8% 11 HbA1c<6.5% IFG≥6.1
9% 13
Waist>102m|88f
* MBG=mean(3pre+3post) = 1.91 x HbA(1c) - 4.36 [~ 2*A1c-5 for A1c=5:10]
5%=5.2, 6%=7.1, 7%=9.0, 8%=10.9, 9%=12.8, 10%=14.7
approx: 5%=5; 6%=7; 7%=9; 7.5%=10; 8%=11; 9%=13; 10%=15
or: MBG=5+2*(A1c-5)

Oral treatment

Class A1c dcr Drug & Dose Brand Comments
cf. Lifestyle 1-2% +:++; -:fails<1yr

Biguanide 1-2%

+: wt neutral;
-: GI, lact acid

Metformin 500-3000
[±MR: 500-2000od]
Glucophage®
Sulphonylureas 1-2% +:inexp;
-:wt gain, hypos
Gliclazide 40-160[od-bd]
[±MR: 30-120od]
Diamicron®
Glimepiride 1-4[-6] Amaryl®
Glipizide 2.5-15od [-10bd] Glibenese® Minodiab®

Thiazolidinediones
=Glitazones
=PPARgamma-Ag

0.5-1.4% +:improved lipid profile[Pio], ?dcrd MI risk[Pio];-:fluid retention, 2fold risk HF, ?icrd MI risk [Rosi]; wt icr, LFTs, macul oed, atherogenic lipid profile; expensive Lipscombe'07(JAMA) Rosiglitazone 4-8 Avandia®
Pioglitazone 15-45 Actos®
cf. Insulin 1.5-3.5% +:no dose limit, inexp, lipids;
-:sc, monitoring,
hypos


Secretagogues
=Glinides
1-1.5% +: short duration;
-:tds, expensive
Repaglinide
[0.5-]1-4[od-qds]
Prandin®
Nateglinide 60-180tds Starlix®
α-Glucosidase-
Inhibitors
0.5-0.8% +:wt neutral;
-:GI, tds, expensive
Acarbose 50-200[od-tds] Glucobay®
DPP4-Inhibitors
=Gliptins
0.5-0.8% +: wt neutral;
-: expensive
Sitagliptin 100od
Vildagliptin 50bd
Januvia®
SPC
Galvus®
SPC
Incretin Mimetics 0.5-1.0 +:wt dcr;
-:sc, GI,
expensive,
pancreatitis
Exenatide 5-10µSC bd

Byetta®
SPC

Amylin Analog 0.5-1.0% +:wt dcr;
-:sc, tds, GI,
expensive
Pramlintide Symlin®[US]

Src: Nathan'06/13 (Diabetes Care) Management of hyperglycemia in T2DM ...: pdf

Insulin types and pharmakokinetics

Insulin onset peak duration
analog <30' <2-4h <8h
human 30-60' 2-4h -8h
human(inh) <30-60' 2-4h -8h
intermediate 1-2h 4-12h 16-35h

Insulin available in the UK



Insulin Brand Pen
short-
acting
analog lispro Humalog®(L) Autopen®; HumaPen®; Humalog®-Pen
aspart NovoRapid®(NN) NovoPen®; FlexPen®
glulisine Apidra®(SA) OptiPen® Pro 1; Autopen®24; OptiClik®; Apidra® OptiSet®
human soluble Humulin S®(L) Autopen®; HumaPen®
soluble Actrapid®(NN) [10ml vial]
soluble Insuman® Rapid(AP) OptiPen® Pro 1; Insuman® Rapid OptiSet®
long-
acting
analog glargine Lantus®(AP) OptiPen® Pro 1; Autopen®24; OptiClik®; Lantus® OptiSet®
detemir Levemir®(NN) NovoPen®; FlexPen®
human isophane Insulatard®(NN) Novopen®; Insulatard InnoLet®
isophane Humulin I®(L) Autopen® HumaPen® Humulin I-Pen®
isophane Insuman® Basal(AP) OptiPen® Pro 1; Insuman® Basal OptiSet®
bi-
phasic
analog aspart+~prot. NovoMix®30(NN) NovoPen®; FlexPen®
lispro+~prot. Humalog®Mix25[/50](L) Autopen®; HumaPen®
human soluble+isoph. Mixtard®30(NN) Novopen®; Mixtard 30 InnoLet®

Legend: L=Lilly; NN=Novo Nordisk; SA=Sanofi-Aventis; AP=Aventis Pharma

Resources [top]

Insulin wallchart: http://www.diabetes.org.uk/Documents/Magazines/Insulinwallchart.pdf

Carbohydrate counting [top]

Inpatient Management [top]

Ketones [top]

  • nml<0.6mmol/L
  • 0.6-1.5mmol/L (& Glu>16.7): may need assistance
  • >1.5mmol/L (& Glu>16.7): risk of DKA
  • [Src: Optium Xceed leaflet]

"Alphabet Strategy" [pdf:JBS2'05]

  • Advice—edu., self Mngmnt, Tx concordance, smoking cess., diet, phys. activity, wt reduction, preconception, DVLA, MedicAlert
  • BP<130/80mmHg [diuretic,ACEI/ARB,CCB]
  • Chol=min(<4.0|-25%) & LDL-C=min(<2.0|-30%)
  • Diabetes: HbA1c%<= 6.5%: Metformin for T2DM esp if hi wt
  • Eyes: yearly digital photography
  • Feet: yearlyexamination
  • "Guardian" drug: Aspirin75 mg if { establ'datherosclerotic dis. | htn | age≥50yrs | DM>10yrs }

Driving

GI dysfunction

  • for diarrhoea (due to changes in alpha-adrenergic receptors): Clonidine 100mcg od [-300mcg od]
  • if impaired sphincter function: refer GI Physiology Dept, Hope Hospital