Diabetes Mellitus and Insuline analogs

1605 Abubakkar Raheel
1553 Nazia Hassan
1652 Abrar Afridi
1638 Kehkashan Alam
Diabetes Mellitus
4th
Clinico-Pharmacological Conference
Frontier Medical College
3rd
year MBBS

4th
Learning Objectives
Diabetes MellitusDiabetes Mellitus
 Define the term Diabetes mellitus.
 Discuss brief History of Diabetes
 Identify the incidence and prevalence of diabetes mellitus.
 Discuss the Etiology of diabetes
 Discuss the Biostatical analysis of Diabetes
 Differentiate between Type 1 Diabetes and Type 2 Diabetes
 Know the drugs used for its treatment

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 Discuss the mechanism of action of Proto-Type Drugs
 Understand the Adverse Affects of mentioned Drugs
 Learn the Treatment and Management of Diabetes
 Discuss a Clinical Scenario
 Brief Question/Answer Session
Learning Objectives

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• In Simple terms, Diabetes Mellitus is a disease marked by
high levels of sugar in the blood. Mellitus is Latin for “sweet
as honey”.
• According to our Textbook Lippincott’s Pharmacology,
“Diabetes is not a single disease rather it is a
heterogeneous group of Syndromes characterized by
elevation of blood glucose caused by a relative or absolute
deficiency of Insulin.”
Definition

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History

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• There are currently over 2 million people diagnosed with
diabetes in the UK and there are up to another 1 million
people with diabetes who have the condition and don’t know
it!
• The global incidence of diabetes is rising and the number of
people affected is projected to exceed 300 million by the
year 2025.
(www.diabetes.org.uk)
Incidence of Diabetes

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• Estimated 245 million people globally
• 20% of adult population
• 5% of all deaths each year
• 80% of people with diabetes live in low and middle income
countries
Incidence of Diabetes

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Biostatical Analysis

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• A parent, brother, or sister with diabetes
• Obesity
• Age greater than 45 years
• Some ethnic groups
• Gestational diabetes or delivering a baby weighing more
than 9 pounds
• High blood pressure
• High blood cholesterol level
• Not getting enough exercise
Risk Factor which predispose to
Diabetes

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Normal Metabolism of Glucose

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Type 1 Diabetes

Type 1 Diabetes
• Insulin not produced due to non
fuctional beta-cell  Hence no
maintainance of basal secretion level of
Insuline and no response to variations
in circulating fuels.
• No insulin to ‘unlock’ the receptors 
• Glucose cannot enter the cell 
• Glucose re-enters the blood stream 
• Extent of glycemic control  related to
metabolic complications
4th

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Blood Sugar &
Spine connection
• Journal of Vertebral
Subluxation
research
• Vagus, T-8, T-9
• Disturbed Nerve
supply
• Loss of pancreatic
function & insuline
production

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Symptoms of type 1 Diabetes
• Polyuria
• Polydipsia
• Weight loss in spite of polyphagia
• Fatigue
• Nausea
• Vomiting
• Coma
• Patients with type 1 diabetes usually develop symptoms
over a short period of time, and the condition is often
diagnosed in an emergency setting.

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Morbidity/Complications
Complications of diabetes can be divided into three
categories
•Metabolic complications of low blood glucose levels
(hypoglycaemia) and of high blood glucose levels
(hyperglycaemia) e.g. Diabetic coma.
•Damage to small blood vessels (microvascular) leading in
turn to damage of:
retina (retinopathy)
kidney (nephropathy)
nerves (neuropathy)

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Morbidity/Complications
• Damage to the larger arteries (macrovascular) leading to
damage of:
brain (leading to stroke)
heart (leading to coronary heart disease)
legs and feet (leading to peripheral vascular disease)

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• Associated with aging, obesity, Peripheral Insuline
resistance rather than by auto-immune processes or
viruses.
• Metabolic alterations are less (Non-ketotic)
• Occurs mostly in people over 40
• Type 2 diabetes is the most common of the two main
types and accounts for between 85 - 95% of all people
with diabetes.

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Pancreas retain some beta-cell function
but variable insuline production is
insufficient and there is a decrease in the
number of receptors (insulin resistance)
Lack of sensitivity of target organs to
either endogenous or exogenous insuline

Glucose does not enter the cell
effectively Glucose re-enters the blood
stream 
Blood glucose levels rise.

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• Slower onset
• Polydipsia
• Polyuria
• Polyphagia
• Fatigue
• Blurred vision
• Slow-healing infections
• Impotence in men
Symptoms of Type 2 Diabetes

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• Hyperglycemia
• Diabetic Ketoacidosis / DKA
• Microvascular complications
• Macrovascular complications
Complications of Diabetes

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• Polyuria
• Polydipsia
• Fatigue
• Nausea and vomiting
• Muscular stiffness or aching
• Mental stupor/ decreased consciousness may progress to
coma
• Rapid breathing
• Fruity breath (pear drops / nail varnish smell)
• Headache
• Low blood pressure
• Decreased appetite
• Abdominal pain
Symptoms of DKA

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Microvascular Complications

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Macrovascular Complications

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Treatment: Dugs Classification

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Insuline and its
Preparations
By
Nazia Hassan

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Insuline is a polypeptide hormone, consisting of two
peptide chains that are connected by disulphide bonds. It is
synthesized as a precursor insuline (pro-insuline) that
undergoes proteolytic cleavages to form insuline and C-peptide,
both of which are secreted by the Beta-Cells of the pancreas.
Insuline

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Insuline is secreted from pancreatic B-Cell at a low basal rate and at a
much higher stimulated rate in response to a variety of stimuli, especially
glucose.
Other stimulants include
•Sugars (Mannose)
•Certain Amino acids (Leucine, Arganine)
•Hormones (Glucagon like polypeptide)
•Glucose dependent insulinotropic polypeptide
•Glucagon
•Cholecystokinin
•Vagal activity
Secretion

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Insuline and Glucagon

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• Insulin is stored in beta cells of pancreas in the form of
granules as crystals.
• Each crystal consist of 6 molecules of insulin binding with 2
atoms of Zn.
• Human pancreas can store 8gm of inuslin.
Storage

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Because insuline is a polypeptide, it is degraded in the
gastrointestinal tract if taken orally. Therefore it is generally
administered by subcutaneous injection. During
Hyperglycemic emergency, it is injected Intravenously.
Administration

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• Liver and kidney remove insulin from circulation
• Liver clears 60% while kidney removes about 40% of the
insulin
• This ratio is inverted for exogenous subcutaneous insulin
• Half life of insulin is 3-5min in the blood
Degradation

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• Insulin is measured in units u/ml
• 1mg is equal to 28u
• Basal insulin value is 5-15microU/ml
• Peak concentration can rise to 60-90microU/ml during
meals
Circulating insuline

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The symptoms of hypoglycemia are the most serious and
common adverse reactions to an excessive dose of Insuline.
Other adverse affects include
•Weight gain
•Lipodystrophy
•Allergic reactions
•local Injection site reactions
Adverse reactions to Insuline

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• S.t therapy involves twice injections daily
• Int.t therapy involves three or more times injection daily
• Frequency of hypogylcemic episodes, coma and seizures
are higher in Int.t than st.t therapy due to insulin
excessiveness
• Patient with Int.t therapy has significant reduction in
nephropathy, neuropathy and retinopathy
Standard and Intensive Therapy

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Insuline Preparations

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Treatment: Drugs Classification
Insuline Preparations (Combinations)

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• This group includes lispro, aspart and glulisine
• They have rapid onset of action and short acting duration
• Peak levels can be seen within 30-90min after injection
• Short acting insulin includes regular insulin
Rapid acting Insuline

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• It includes Neutral protamine hagedron or Isophane
• They act intermediately because of delayed absorption due
to formation of less soluble complexes
• Can be used in all type of diabetes except ketoacidoses and
emergency diabetes
Intermediate acting Insuline

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• This group include glargine and detemir
• Its has slower onset of action and no peak level
• These can be used in combination with rapid acting insulins
Long acting Insuline

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Plasma Insuline Levels/Hours

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Synthetic Amylin Analogs
&
Insulin Secretagogues
By
Kehkashan ALam

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• Pramlintide is indicated as an adjunct to mealtime insulin
therapy in patients with Type 1 & Type 2 Diabetes by acting
as amylinomimetic.
• Pramlintide delays gastric emtying & delays postprandial
Glucagon secretion.
Synthetic Amylin Analogs:
Pramlintides

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Pharmacokinetics

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• Inhibits Glucagon release from pancrease
• Delays Gastric Emptying
• Also causes Anorexia by acting on CNS
Mechanism of action

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• Along with insulin in Type 1 & Type 2 Diabetes Mellitus to
control Blood Glucose level after meal
• May help in weight loss
Clinical Uses

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• Hypoglycemia
• Nausea
• Vomiting
• Anorexia
Adverse Effects

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• Gastroparesis( delayed stomach emtying)
• Cresol Hypersensitivity
• History of Hypoglycemic unawareness
Contraindications

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1) Sulfonylureas 2) Glinides
1st
Generation Repaglinide
• Tolbutamide Nateglinide
• Tolazamide
• Acetohexamide
• Chlorpropamide
2nd
Generation
• Glibenclamide
• Glyburide
• Glipizide
• Glimepiride
Insulin Secretagogues

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• Given Orally before meals
• Bind to serum proteins
• Metabolized by liver
• Excreted by liver or kidney
• Duration of Action ranges from 12-24 hours
Sulfonylureas: Pharmacokinetics

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Tolbutamide 4-5 hours
Chlorpropamide 32 hours
Tolzamide 7 hours
Glipizide 2-4 hours
Glimepiride 5 hours
Note: Chlorpropamide in contraindicated in elder patients
because it may prolong Hypoglycemia.
Half Life

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Mechanism of action
• Blockage of ATP sensitive Potassium channels
• Depolarization
• Calcium ion Influx
• Stimulation of Insulin Release from Beta cells of Pancreas
• Resulting in decrease Glucose level in body

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•Hyperinsulinemia
•Prolonged Hypoglycemia
•Increase in Body Weight
•Nausea, Vomiting, Diarrhea
•Allergic Reactions like Skin Rashes
•Rarely Bone Marrow depression can occur
Adverse affects

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• Severe Hepatic & Renal Failure
• Pregnancy
• Lactation
• Porphyria
• Ketoacidosis
Contraindications

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• Orally administered
• Well absorbed after being taken 1-30 minutes before meal
• Metabolized to inactive products by cytochrome p450 3A4 in
the liver
• Excreted through bile
• Repaglinide should be used courtiously in individuals with
renal and hepatic impairment
Glinides: Pharmacokinetics

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• Bind to sulphonylurea receptor of ATP sensitive potassium
channels
• Initiate the release of insulin
• Lowers the blood glucose level
Mechanism of action

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• Hypoglycemia in patients who are also taking lipid lowering
drugs like Gemfibrozil
• Weight gain
Adverse affects

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Insulin Sensitizers: Oral AgentsInsulin Sensitizers: Oral Agents

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Biguanides

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Mechanism of action

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• Used in insulin resistant patient.
i-e, insulin resistance syndrome
• It does not increase weight, useful in obese diabetic
patient.
• Can be given as monotherapy OR with combination
of insulin secretogogues drugs.
Clinical Uses

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Adverse affects
• Lactic acidosis
• Reduce B12 absorption
• GIT disturbance
• anoxia
• nausia
• vomitting
• Diarrhea

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Contraindications
• Renal disease
• Alcohalism
• Hepatic disease
• Acute M.I

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• These are also insulin sensitizers.
• Also known as glitazones.
• Rosiglitazone & pioglitazone are currently available
agents.
• Does not promote insulin release from pancrease.
Thiazolidinediones

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• Tissues to be targeted are adipocytes, liver & skeletal
muscles.
• It binds with peroxisome proliferator activated
receptor gamma, a nuclear hormone receptor.
• These receptors regulate metabolism of glucose,
production of free fatty acids.
• Ultimately increasing sensitivity of insulin.
M.O.A

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• Both pioglitazone and rosiglitazone are well
absorbed orally.
• Bound extensively to plasma protein.
• Metabolized by cytochrome p450 enzymes in liver.
• Excreted through urine.
Pharmacokinetics

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• Hepatotoxicity
• Weight gain
• Osteopenia
• M.I
• Anemia
• Headache
Adverse Effects

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• This group includes acarbose and Miglitol
• They don’t have any effect on insulin production
Alpha glucosidase inhibitors

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• Inhibits glucosidases located on the intestinal brush
boarder
• So oligosaccharrides cant be converted to glucose
• In addition these also inhibit pancreatic amylase
• Postprandial hyperglycemia does not occure
M.O.A

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• These agents are intermediatly absorbed
• They don’t have any systemic affects
• Excrected by kidneys in unchanged form
Pharmacokinetics

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• Diarrhea
• Abdominal cramp
• Inflammatory bowl syndrome
• Colonic ulceration
Adverse affects

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What is an Incretin affect?
Oral glucose results in a higher secretion of insulin than occurs
when equal load of glucose is given IV. This effect is referred to
as Incretin effect. And is markedly reduced in diabetes type 2.
Incretin Mimetics

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Incretin hormone

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Classification

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LIRAGLUTIDE EXENATIDE
ADMINISTRATION S/C S/C
HALF LIFE LONG SHORT
INJECTION ONCE DAILY TWICE DAILY
EXCRETION - RENAL
AVOIDANCE - RENAL IMPAIRED
ADVERSE AFFECTS N.V.D.C,
PANCREATITIS, ABD
PAIN
N.V.D.C,
PANCREATITIS, ABD
PAIN
Liraglutide vs Exenatide

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• Act as GLP-1 Receptor Agonists
• Improve Glucose Dependent Insuline Secretion
• Slow gastric Emptying time
• Decrease Food Intake
• Decrease post-prandial Glucagon secretion
• Promote Beta-Cell proliferation
Mechanism of action

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Oral Agents: DPP-IV
Inhibitors

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GLP-1
Dipeptidyl
Peptidase- IV
Inhibitors
inactivates
inhibit
enzyme
Glucagon like
peptide-1
Mechanism of Action
Oral Agents: DPP-IV Inhibitors

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A 54-year-old woman is diagnosed with type 2 diabetes mellitus after a routine
follow-up for impaired fasting glucose showed that her hemoglobin A1C is now 7.6%.
She has attempted to lose weight and to exercise with no improvement in her
hemoglobin A1C, and drug therapy is now recommended. She has
mild systemic hypertension that is well controlled and no other medical conditions.
Which of the following is the most appropriate first-line therapy?
A. Acarbose
B. Exenatide
C. Glyburide
D. Metformin
E. Sitagliptin
Short Clinical Scenario

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Thank you for your patience


Diabetes Mellitus and Insuline analogs

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