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7/27/2019 Intervention of t2dm
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INTERVENTION IN T2DM
KLINIK DIABETES TERPADU
RS ISLAM KLATEN
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Principals Intervention in T2DM
EducationMedical nutrition therapyPhysical activityPharmacologic intervention
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Hyperglycemia in T2DM
Defect of insulin secretion
Hepatic glucoseproduction
Carbohydrateabsorption
Glucose uptakeby muscle & adiposetissue
HYPERGLYCEMIA
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Intervention
Defect of insulin secretion
Hepatic glucoseproduction
Glucose uptakeby muscle and adiposetissue
CarbohydrateabsorptionHYPERGLYCEMIA
InsulinInsulin secretagogue
Alpha-glucosidase
inhibitorThiazolidinedioneMetforminInsulin
InsulinMetformin
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Insulin Secretagogue
Sulfonylureas:Use as adjunct to diet and exercise. Stimulate insulin
secretion by blocking K + channel of the beta cell.
Potential adverse effect: hypoglycemia,hypersensitivity, weight gain.EBM: decrease A1c by 1 to 2% (level 1A), causeweight gain of a proximately 2 to 3 kg (level 1A),major hypoglycemia 1 to 2% of patients receivingsulfonylureas.
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Insulin Secretagogue
Meglitinde analogues (repaglinide, nateglinide):stimulate release of insulin in response to a glucoseload (meal). One meal one dose, fast on fast off.Contraindications: diabetic ketoacidosis, T1DM,hypersensitivity.Adverse effects: hypoglycemia, hypersensitivity,weight gain.EBM: decrease A1c by 1 to 2% (level 1A), notsignificantly different from that seen withsulfonylureas (level 1A), hypoglycemia is similar withsulfonylueas (level 1A).
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Biguanid
Metformin: has insulin sensitizing properties.Decreases hepatic glucose production by improvinginsulin action at the liver.Contraindications: prone to metabolic acidosistates orhypoxic statesAdverse effect: lactic acidosis, anorexia, nausea,diarrheaEBM: it is associated with a 1 to 2% decrease in A1c(level 1A), similar to that of sulfonylureas (level 1A)
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Alpha-Glucosidase Inhibitor
Acarbose (Glucobay): inhibiting -glucosidase enzymesthere by slowing digestion of ingested carbohydrates,delaying glucose absorption.Contraindications: major gastrointestinal disorders.Adverse effects: flatulence, abdominal bloating.EBM: decreases A1c by 0.7 to 1.8% (level 1A)
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Thiazolinediones (insulin sensitizer)
Pioglitazone, Rosiglitazone: It enhances tissuesensitivity to insulin in muscle through activation ofintracellular receptors.Contraindications: hypersensitivity, active liverdisease, congestive heart failure.Adverse effects: weight gain, idiosyncratichepatocellular injury or necrosis.EBM: reduce A1c by 0.9 to 1.5% (level 1A)
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Oral Hypoglycemic AgentsClass Trade
names (mg)Daily dose
(mg)Initial
dose (mg)Duration ofaction (h)
Freq.
SulfonylureasChlorpropamide
Tolbutamide
Glibenclamide
Glipizide
Glicazide
Gliquidone
Diabenese100 & 200Rastinon500Renabetik2.5-5GlucotrolXL 5-10
DiamicronGlucodex80Glurenorm30
100-500
500-2000
2.5-20
5-20
80-240
30-120
50
-
2.5
5
40
15
24-36
6-12
12-24
10-16
10-20
10-20
1
2-3
1-2
1-2
1-2
1-3
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Oral Hypoglycemic AgentsClass Trade
names (mg)Daily dose
(mg)Initial
dose (mg)Duration ofaction (h)
Freq.
SulfonylureasGlimepirideRepaglinideNateglinide
BiguanideMetformin
Acarbose
TZDPioglitazone
Rosiglitazone
Amaryl 1-4NovonormStarlix
Diabex,glumin,glucophageGlucobay50-100
Actos
Avandia
0.5-16360
250-3000
75-300
15-45
2-8
250
50
10-20
12-42-4
1-3
3
1
1 or 2
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InsulinType Initiation (h) Peak (h) Duration (h)
Short acting:Regular insulinActrapidHumulin RIntermediate:InsulatardHumulin NLong acting:LantusMixed: mixtard,humulin 30/70Rapid acting: lispro,aspart, gluilysine
0.5-1
1-2
2
0.5-1