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ORAL AGENTS FOR DIABETIC
MANAGEMENT
Prepared by : Cik Hema Latha Sinniah
Pegawai Farmasi U41
Klinik Kesihatan Sungai Besar
DIABETES
 A chronic metabolic disorder characterised by
a high blood glucose concentration-
hyperglycaemia
 fasting plasma glucose > 7.0 mmol/l, or plasma
glucose> 11.1 mmol/l 2 hours after a meal
 caused by
 insulin deficiency
 insulin resistance
TARGETS FOR TYPE 2 DIABETES MELLITUS
Glycemic control Levels
Fasting 4.4-6.1 mmol/L
Non fasting 4.4-8.0 mmol/L
HbA1c < 6.5%
Lipids Levels
Triglycerides ≤ 1.7 mmol/L
HDL cholesterol ≥ 1.1 mmol/L
LDL cholesterol ≤2.6 mmol/L
Exercise 150 mins/week
Blood pressure Levels
Normal Renal Function ≤130/80 mmHg
Renal Impairment/Gross Proteinuria ≤125/75 mmHg
TYPES OF DIABETES
 Type 1 (Juvenile-Onset)
 Type 2 (Adult-Onset)
 Other types including:
- Gestational diabetes
- MODY (maturity onset diabetes of the young)
- LADA (latent auto-immune diabetes of adults)
- Others
CAUSE OF TYPE 1 DM
Auto-immune destruction of
insulin-producing β-cells in
the pancreas
CAUSE OF TYPE 2 DM
 Insulin resistance (genetics)
- aggravated by obesity
- aggravated by lack of exercise
 “Exhaustion” of insulin-producing β-cells
MAJOR METABOLIC DEFECTS
IN TYPE 2 DIABETES
 Peripheral insulin resistance in
muscle and fat
 Decreased pancreatic
insulin secretion
 Increased hepatic glucose
output
Haffner SM, et al. Diabetes Care, 1999
ORAL ANTIDIABETIC AGENTS:
 Agents that are given orally to reduce the
blood glucose levels in diabetic patients
 Five types of oral antidiabetic drugs are
currently in use:
• Biguanides :metformin
• Sulfonylureas: glimepiride, gliclazide,
glyburide, tolbutamide, glibenclamide,
glipizide
• Meglitinides : nateglinide, repaglinide
• Thiazolidinediones : pioglitazone,
rosiglitazone
 Alpha -glucosidase inhibitors: acarbose,
miglitol
 The oral antidiabetic drugs are of value only in the treatment
of patients with type 2 (NIDDM) diabetes mellitus whose
condition cannot be controlled by diet alone.
 These drugs may also be used with insulin in the management
of some patients with diabetes mellitus, Use of an oral
antidiabetic drug with insulin may decrease the insulin dosage
in some individuals.
METFORMIN (BIGUANIDES)
 does not stimulate insulin secretion
 increase glucose uptake and utilisation in skeletal
muscle (thereby reducing insulin resistance) and
reduce hepatic glucose production (gluconeogenesis).
 First line drug treatment in overweight/obese
patients.
 will lower HbA1c by about 1.5%.
 Usually not accompanied by hypoglycemia
 Contra indications
-Metformin should not be given to patients with
Renal failure
Hepatic disease
Hypoxic pulmonary disease
Heart failure or shock
GLIBENCLAMIDE AND GLICLAZIDE
(SULFONYLUREAS)
 Works by increasing insulin secretion.
 can lower plasma glucose by up to 25%
 lower HbA1c by about 1.5%.
 SUs should be taken 30 minutes before meals
 Combining two different sulfonylurea is not
recommended
 Long acting sulfonylurea (i.e Glibenclamide)
associated with greater risk of hypoglycemia.
ACARBOSE -ALPHA-GLUCOSIDASE INHIBITOR
(AGI)
 Act at the gut epithelium, to reduce the rate of
digestion of polysaccharides in small intestine.
 primarily lower postprandial glucose without causing
hypoglycemia
 Patients receiving insulin or SUs as well as acarbose
need to carry glucose to counteract possible
hypoglycemia.
 Need to be taken together with food.
BEFORE INITIATING INSULIN:
 Before considering to start patient on
insulin, there are a few points that needs to
be considered:
 Patient’s compliance towards current
medication
 Patient’s age
 Patient’s other comorbidities
 Patient’s diet control and lifestyle
 Patient’s agreement
PROACTIVE MANAGEMENT OF GLYCAEMIA:
EARLY COMBINATION APPROACH
OAD + basal insulin
OAD + multiple daily
insulin injections
Diet
OAD monotherapy
OAD combinations
OADs up-titration
Duration of diabetes
7
6
9
8
HbA1c(%)
10
TYPES OF INSULIN
 Short-acting
 Actrapid, Humulin R
 Intermediate-acting
 Insulatard, Humulin N
 Biphasic
 Mixtard, Humulin 30/70
 Long-acting
 Insulin Glargine, Monotard
PENGGUNAAN UBAT SECARA
BERKUALITI
UBAT YANG
BETUL
PENGGUNA
UBAT YG
BETUL
MASA
YANG
BETUL
CARA
PENGAMBILAN
YANG BETUL
DOS
YANG
BETUL
PENGGUNA UBAT YANG
BETUL
UBAT YANG BETUL
DOS YANG BETUL
CARA PENGAMBILAN YANG
BETUL
MASA YANG BETUL
B
B
B
B
B
PENGGUNA UBAT YANG
BETUL
UBAT YANG BETUL
DOS YANG BETUL
CARA PENGAMBILAN YANG
BETUL
MASA YANG BETUL
B
B
B
B
B
SAYA MENGIDAP
PENYAKIT
GASTRIK. INILAH
UBAT UNTUK
PENYAKIT SAYA
PENGGUNA UBAT YANG
BETUL
UBAT YANG BETUL
DOS YANG BETUL
CARA PENGAMBILAN YANG
BETUL
MASA YANG BETUL
B
B
B
B
B
PENGGUNA UBAT YANG
BETUL
UBAT YANG BETUL
DOS YANG BETUL
CARA PENGAMBILAN YANG
BETUL
MASA YANG BETUL
B
B
B
B
B
CARA PENGAMBILAN
BENTUK
DOSEJ
CARA PENGAMBILAN
MIXTURE/
SYRUP
MINUM SEPERTI DIARAHKAN
LOTION/ KRIM SAPU PADA TEMPAT YANG
MENGALAMI MASALAH SAJA
SEPERTI DIARAHKAN
SUPPOSITORI MASUKKAN KE DALAM DUBUR
SEPERTI DIARAHKAN
INHALER /
TURBOHALER
GUNAKAN MENGIKUT TEKNIK
YANG BETUL
TABLET/
KAPSUL
TELAN. JANGAN KUNYAH ATAU
HANCURKAN JIKA TIDAK
DIARAHKAN.
PENGGUNA UBAT YANG
BETUL
UBAT YANG BETUL
DOS YANG BETUL
CARA PENGAMBILAN YANG
BETUL
MASA YANG BETUL
B
B
B
B
B
SEKALI
SEHARI SETIAP 24JAM
WAKTU YANG SAMA
SETIAP HARI. MALAM @
SIANG
2 KALI
SEHARI SETIAP 12JAM CTH: 8 PAGI, 8 MALAM
3 KALI
SEHARI SETIAP 8JAM
CTH: 6 PAGI, 2 PETANG,
10 MALAM
4 KALI
SEHARI SETIAP 6JAM
CTH: 6 PAGI, 12 TGH, 6
PTG, 12 MLM
BILA
PERLU
DIAMBIL BILA DIPERLUKAN
SAJA
CTH: BILA SAKIT, BILA ADA
SERANGAN ASTHMA
MASA PENGAMBILAN/
PENGGUNAAN UBAT
THANK YOU FOR YOUR ATTENTION

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Oral agents for diabetic management

  • 1. ORAL AGENTS FOR DIABETIC MANAGEMENT Prepared by : Cik Hema Latha Sinniah Pegawai Farmasi U41 Klinik Kesihatan Sungai Besar
  • 2. DIABETES  A chronic metabolic disorder characterised by a high blood glucose concentration- hyperglycaemia  fasting plasma glucose > 7.0 mmol/l, or plasma glucose> 11.1 mmol/l 2 hours after a meal  caused by  insulin deficiency  insulin resistance
  • 3. TARGETS FOR TYPE 2 DIABETES MELLITUS Glycemic control Levels Fasting 4.4-6.1 mmol/L Non fasting 4.4-8.0 mmol/L HbA1c < 6.5% Lipids Levels Triglycerides ≤ 1.7 mmol/L HDL cholesterol ≥ 1.1 mmol/L LDL cholesterol ≤2.6 mmol/L Exercise 150 mins/week Blood pressure Levels Normal Renal Function ≤130/80 mmHg Renal Impairment/Gross Proteinuria ≤125/75 mmHg
  • 4. TYPES OF DIABETES  Type 1 (Juvenile-Onset)  Type 2 (Adult-Onset)  Other types including: - Gestational diabetes - MODY (maturity onset diabetes of the young) - LADA (latent auto-immune diabetes of adults) - Others
  • 5. CAUSE OF TYPE 1 DM Auto-immune destruction of insulin-producing β-cells in the pancreas
  • 6. CAUSE OF TYPE 2 DM  Insulin resistance (genetics) - aggravated by obesity - aggravated by lack of exercise  “Exhaustion” of insulin-producing β-cells
  • 7. MAJOR METABOLIC DEFECTS IN TYPE 2 DIABETES  Peripheral insulin resistance in muscle and fat  Decreased pancreatic insulin secretion  Increased hepatic glucose output Haffner SM, et al. Diabetes Care, 1999
  • 8. ORAL ANTIDIABETIC AGENTS:  Agents that are given orally to reduce the blood glucose levels in diabetic patients  Five types of oral antidiabetic drugs are currently in use: • Biguanides :metformin • Sulfonylureas: glimepiride, gliclazide, glyburide, tolbutamide, glibenclamide, glipizide • Meglitinides : nateglinide, repaglinide • Thiazolidinediones : pioglitazone, rosiglitazone  Alpha -glucosidase inhibitors: acarbose, miglitol
  • 9.  The oral antidiabetic drugs are of value only in the treatment of patients with type 2 (NIDDM) diabetes mellitus whose condition cannot be controlled by diet alone.  These drugs may also be used with insulin in the management of some patients with diabetes mellitus, Use of an oral antidiabetic drug with insulin may decrease the insulin dosage in some individuals.
  • 10. METFORMIN (BIGUANIDES)  does not stimulate insulin secretion  increase glucose uptake and utilisation in skeletal muscle (thereby reducing insulin resistance) and reduce hepatic glucose production (gluconeogenesis).  First line drug treatment in overweight/obese patients.  will lower HbA1c by about 1.5%.  Usually not accompanied by hypoglycemia
  • 11.  Contra indications -Metformin should not be given to patients with Renal failure Hepatic disease Hypoxic pulmonary disease Heart failure or shock
  • 12. GLIBENCLAMIDE AND GLICLAZIDE (SULFONYLUREAS)  Works by increasing insulin secretion.  can lower plasma glucose by up to 25%  lower HbA1c by about 1.5%.  SUs should be taken 30 minutes before meals  Combining two different sulfonylurea is not recommended  Long acting sulfonylurea (i.e Glibenclamide) associated with greater risk of hypoglycemia.
  • 13. ACARBOSE -ALPHA-GLUCOSIDASE INHIBITOR (AGI)  Act at the gut epithelium, to reduce the rate of digestion of polysaccharides in small intestine.  primarily lower postprandial glucose without causing hypoglycemia  Patients receiving insulin or SUs as well as acarbose need to carry glucose to counteract possible hypoglycemia.  Need to be taken together with food.
  • 14. BEFORE INITIATING INSULIN:  Before considering to start patient on insulin, there are a few points that needs to be considered:  Patient’s compliance towards current medication  Patient’s age  Patient’s other comorbidities  Patient’s diet control and lifestyle  Patient’s agreement
  • 15. PROACTIVE MANAGEMENT OF GLYCAEMIA: EARLY COMBINATION APPROACH OAD + basal insulin OAD + multiple daily insulin injections Diet OAD monotherapy OAD combinations OADs up-titration Duration of diabetes 7 6 9 8 HbA1c(%) 10
  • 16. TYPES OF INSULIN  Short-acting  Actrapid, Humulin R  Intermediate-acting  Insulatard, Humulin N  Biphasic  Mixtard, Humulin 30/70  Long-acting  Insulin Glargine, Monotard
  • 19. PENGGUNA UBAT YANG BETUL UBAT YANG BETUL DOS YANG BETUL CARA PENGAMBILAN YANG BETUL MASA YANG BETUL B B B B B
  • 20.
  • 21. PENGGUNA UBAT YANG BETUL UBAT YANG BETUL DOS YANG BETUL CARA PENGAMBILAN YANG BETUL MASA YANG BETUL B B B B B
  • 23. PENGGUNA UBAT YANG BETUL UBAT YANG BETUL DOS YANG BETUL CARA PENGAMBILAN YANG BETUL MASA YANG BETUL B B B B B
  • 24.
  • 25. PENGGUNA UBAT YANG BETUL UBAT YANG BETUL DOS YANG BETUL CARA PENGAMBILAN YANG BETUL MASA YANG BETUL B B B B B
  • 26. CARA PENGAMBILAN BENTUK DOSEJ CARA PENGAMBILAN MIXTURE/ SYRUP MINUM SEPERTI DIARAHKAN LOTION/ KRIM SAPU PADA TEMPAT YANG MENGALAMI MASALAH SAJA SEPERTI DIARAHKAN SUPPOSITORI MASUKKAN KE DALAM DUBUR SEPERTI DIARAHKAN INHALER / TURBOHALER GUNAKAN MENGIKUT TEKNIK YANG BETUL TABLET/ KAPSUL TELAN. JANGAN KUNYAH ATAU HANCURKAN JIKA TIDAK DIARAHKAN.
  • 27. PENGGUNA UBAT YANG BETUL UBAT YANG BETUL DOS YANG BETUL CARA PENGAMBILAN YANG BETUL MASA YANG BETUL B B B B B
  • 28. SEKALI SEHARI SETIAP 24JAM WAKTU YANG SAMA SETIAP HARI. MALAM @ SIANG 2 KALI SEHARI SETIAP 12JAM CTH: 8 PAGI, 8 MALAM 3 KALI SEHARI SETIAP 8JAM CTH: 6 PAGI, 2 PETANG, 10 MALAM 4 KALI SEHARI SETIAP 6JAM CTH: 6 PAGI, 12 TGH, 6 PTG, 12 MLM BILA PERLU DIAMBIL BILA DIPERLUKAN SAJA CTH: BILA SAKIT, BILA ADA SERANGAN ASTHMA MASA PENGAMBILAN/ PENGGUNAAN UBAT
  • 29. THANK YOU FOR YOUR ATTENTION