Internal Diseases and Therapy · MU Sofia

74. Diabetes mellitus - treatment

Covers insulin therapy for type 1 diabetes, listing the five insulin preparations with a table of onset and duration, the usual starting regimen and titration, and first- and second-line basal-bolus and fixed-dose options. It then sets out a stepwise approach to type 2 diabetes using HbA1c thresholds, with a diagram of drug combinations, and notes on metformin and sulfonylureas including doses, side effects and mechanisms.

Inside: 2 sections · 1 labelled picture · 1 table · 15 flashcards · 5 min

Topic 75 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 1 section, about 363 words (5 min of reading), with 15 flashcards.

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  1. Diabetes mellitus - treatment with insulin and oral medications

Diabetes mellitus - treatment with insulin and oral medications

Management of T1DM

The management of type 1 diabetes is centered around education and insulin injections. There are five types of insulin preparation:

  • Rapid-acting insulin analogues (e.g. Insulin lispro)
  • Short acting soluble insulin (e.g. Actrapid)
  • Intermediate-acting insulin (e.g. insulatard)
  • Long acting insulin (e.g. Glargine)
  • Predetermined combinations of the above

Most common preparation is a mix of short and long acting (e.g. 70/30). Usually begin therapy with 10u before bed, then check glucose in the morning. Where glucose is high increase base dose, if low, decrease base dose. From here, if after 3 months HbA1c is high then add rapid insulin before each main meal.

So, first line looks something like this:

  • Basal-bolus insulin - start with the Glargine once daily AND regular insulin/lispro 2-3xday

Second line

  • Fixed-dose insulin - NPH/insulin regular (50/50,70/30) twice daily

In general, exact dosage should be based on patient's current glycemic control..

Management of T2DM

This isn’t that hard. In essence:

  • If HbA1c > 48 start metformin
  • If contraindicated offer dipeptidyl peptidase 4 inhibitor, sulfonylurea or pioglitazone
  • If HbA1c 58 mmol/mol add one additional drug (dipeptidyl peptidase 4 inhibitor, sulfonylurea, sodium glucose cotransporter2 inhibitor or pioglitazone)
  • If HbA1c rises above this go for triple therapy or consider insulin

Do not offer antiplatelet therapy (aspirin or clopidogrel) unless there is cardiovascular disease

  • MET = Metformin
  • SU = Sulfonylurea
  • SGLT = sodium-glucose cotransporter 2 inhibitors
  • DPP = Dipeptidyl peptidase -4 inhibitor
  • PIO = Piogilitazone

A quick word on some of the drugs here:

  • Metformin
  • 500mg/day is a good starting dose
  • Contraindicated in acute metabolic acidosis
  • Side effects include abdominal pain, decreased appetite, diarrhoea, GI disturbance, nausea and vomiting. Rarely hepatitis, lactic acidosis, skin reactions and vitamin B12 absorption decrease
  • Its mechanism is not fully understood, but it has an insulin sensitizing effect on the liver, muscles, endothelium and adipose tissues as well as increasing insulin secretion and suppressing hepatic glucose production.
  • Sulfonylurea
  • Examples include glibenclamide, gliclazide and glipizide
  • These have an increased risk of causing hypoglycemia and are associated with weight gain
  • Glipizide 2.5-5mg/day
  • Contraindications include ketoacidosis
  • Mechanism is to close K+ channels on the cell membrane of pancreatic cells, causing rise in Ca2+ influx, leading to increased secretion of insulin.

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