CLINICAL PRACTICE

GUIDELINES FOR THE

DIAGNOSIS AND MANAGEMENT
OF DIABETES MELLITUS
OUTLINE

Definition of Diabetes Mellitus

Classification
Spectrum
Summary of the Clinical Practice Guidelines for each
Specialty:
Pediatrics (AAP)
Medicine (ADA and PSEM)
Obstetrics (POGS)
Pharmacology of Anti-Diabetic Drugs
DIABETES MELLITUS

Complex metabolic disorder characterized by

persistent hyperglycemia resulting from:
o Reduced insulin secretion
o Decreased glucose utilization
o Increased glucose production
CLASSIFICATION OF
DIABETES
TypeMELLITUS
1 Diabetes (insulin-dependent/
Juvenile DM)
o Complete or near-total insulin deficiency
o Caused by the autoimmune destruction of -
cells of the pancreatic islets
o May be idiopathic
Type 2 Diabetes (noninsulin-dependent
DM)
o Variable degrees of insulin resistance,
impaired insulin secretion, and increased
glucose production
Gestational Diabetes Mellitus (Type 4)
o DM that is diagnosed for the first time in
pregnancy
DIFFERENTIATION BETWEEN
TYPE 1 AND TYPE 2 DM
 DEFINITION OF DIABETES
MELLITUS
TEST WHO ADA Philippi AACE IDF
ne CPG
Fasting
Plasma 126 mg/dL (7.0 mmol/L)
Glucose
2-h
Plasma
Glucose 200 mg/dL (11.1 mmol/L)
after 75-g
OGTT
HbA1c 6.5%
Random
Plasma 200 mg/dL (11.1 mmol/L) + symptoms
PRE-DIABETES

Impaired Fasting Glucose

o FPG of 100125 mg/dL (5.66.9 mmol/L) ADA, AACE, Phil.
CPG

o FPG of 110125 mg/dL (6.16.9 mmol/L) WHO:

Impaired Glucose Tolerance
o 2h 75-g OGTT of 140199 mg/dL (7.811.0 mmol/L)
ADA, WHO, AACE, Phil. CPG

Increased HbA1c (ADA)

o HbA1c level of 5.7 6.4% ADA, WHO, Phil. CPG
o HbA1c level of 5.5 6.4% AACE
DIABETES MELLITUS IN
THE PEDIATRIC AGE
GROUP

SOURCES:
AMERICAN ACADEMY OF PEDIATRICS CPG ON DMT2
AMERICAN DIABETES ASSOCIATION CPG ON DM
UNITE PHILIPPINES CPG ON DM
SCREENING FOR DIABETES
MELLITUS
Screening for Type 1 diabetes among children
is NOT recommended because the disease
appears to be of low prevalence; screening
tests using serologic markers are not readily
available and do not appear to be cost-
effective; and there are as yet no clearly
effective preventive approaches.
SCREENING FOR DIABETES
MELLITUS
Screening for pre-diabetes and Type 2 DM is
recommended among asymptomatic children
commencing at age10 years or at onset of puberty ,
if puberty occurs at a younger age (ADA) with the
following risk factors: (Grade C, Level 4):
o Overweight (BMI > 85th percentile for age and sex,
weight-for-height > 85th percentile, or weight >
120% of ideal for height) OR
o Obese: BMI >95th centile or > +2SD
SCREENING FOR DIABETES
MELLITUS
Screening for pre-diabetes and Type 2 DM is recommended
among asymptomatic children commencing at age10 years
or at onset of puberty , if puberty occurs at a younger age
(ADA) with the following risk factors: (Grade C, Level 4):
o Plus any 2 of the following risk factors
Family history (especially parents and grandparents) of
Type 2 DM
Signs of insulin resistance (Acanthosis nigricans,
hypertension, dyslipidemia, PCOS, or small for gestational
age birth weight)
Maternal history of diabetes or GDM during the childs
gestation
SCREENING FOR DIABETES
MELLITUS
Should screening for Type 2 DM be done in
children?
o Screening for pre-diabetes and Type 2 DM is
recommended among asymptomatic children
commencing at age10 years or at onset of
puberty, if puberty occurs at a younger age (ADA)
with the following risk factors: (Grade C, Level 4):
SCREENING FOR DIABETES
MELLITUS
DIABETES MELLITUS IN
THE ADULT AND THE
ELDERLY

SOURCES:
AMERICAN DIABETES ASSOCIATION CPG ON DM, 2013
UNITE PHILIPPINES CPG ON DM
SCREENING

All individuals being seen at any physicians clinic or

by any healthcare provider should be evaluated
annually for risk factors for type 2 diabetes and pre-
diabetes. (Table 2) (Grade D, Level 5)
Obesity, pre-diabetes, components of the metabolic
syndrome, PCOS, previous GDM, family history and
schizophrenia are some of the risk factors for DM.
Universal screening using laboratory tests is not
recommended as it would identify very few
individuals who are at risk. (Grade D, Consensus)
SCREENING

Laboratory testing for diabetes and prediabetes is

recommended for individuals with any of the risk
factors for Type 2 diabetes mellitus. (Table 2)
(Level 3-4, Grade B)
SCREENING

Testing should ideally be carried out within the

health \care setting (clinics, hospitals, local
health centers) because of the need for follow-
up and discussion of abnormal results by
qualified health care professionals (nurse,
diabetes educator, physician). (Grade B, Level 3)
Testing at any setting should be supervised by a
qualified health care professional. (Grade D,
Level 5)
SCREENING

If initial test/s are negative for diabetes,

repeat testing should ideally be done
annually. (Grade D, Level 5)
DIAGNOSIS

The diagnosis of Diabetes Mellitus can be made

based on the following criteria*: (Grade B, Level
2)
o Plasma glucose > 126 mg/dL (7.0 mmol/L) after an
overnight fast
o Two-hour plasma glucose > 200 mg/dl (11.1 mmol/l)
during an Oral Glucose Tolerance Test
o A random plasma glucose > 200 mg/dl (11.1 mmol/l) in
a patient with classic symptoms of hyperglycemia
(weight loss, polyuria, polyphagia, polydipsia) or with
signs and symptoms of hyperglycaemic crisis.
DIAGNOSIS

*Among ASYMPTOMATIC individuals with

positive results, any of the three tests should
be REPEATED within two weeks for
confirmation. (Grade C, Level 4)
DIAGNOSIS

A 75-gram OGTT is preferred as the first test

in the following individuals who have: (Grade
B, Level 3)
A previous FBS showing Impaired Fasting Glucose
(100 to 125 mg/dL or 5.6 to 6.9 mmol/L)
Previous diagnosis of Cardiovascular Disease
(Coronary Artery Disease, Stroke, Peripheral
Arteriovascular Disease) or who are at high risk for
cardiovascular disease.
A diagnosis of Metabolic Syndrome
DIAGNOSIS

At the present time, we cannot recommend the

routine use of the following tests for the diagnosis of
diabetes: (Grade C, Level 3)
o HBA1c (because of poor access and lack of standardiazation)
o Capillary Blood Glucose
o Fructosamine

However, if a result is available upon consultation due to prior testing, it

should be interpreted with caution and should be confirmed by any of the
3 tests that are considered standard: fasting plasma glucose, oral glucose
tolerance test or random plasma glucose. (Grade B, Level 2)
DIAGNOSIS

We do not recommend the following tests for

the diagnosis of diabetes (Grade B, Level 3):
o Urine glucose
o Plasma Insulin
MANAGEMENT AND
MONITORING
Initial evaluation - comprehensive medical
history and PE
o Coronary heart disease risk assessment
o Foot evaluation: assess risk for foot ulcer (identify
high-risk feet)
o Eye exam: fundoscopy on diagnosis
o Dental history or oral health history
MANAGEMENT AND
MONITORING
Minimal initial tests to be requested
Fasting blood glucose, complete lipid profile
HbA1c
Liver function tests
Urinalysis; spot urine albumin-to-creatinine ratio
Serum creatinine and calculated GFR

Optional tests
ECG and TET
TSH in type 1 diabetes, dyslipidemia or women over age 50 y
 GLUCOSE CONTROL
IDF AACE ADA
HBA1c 6.5% 6.5% < 7%
Preprandial < 110 < 110 70-130
plasma glucose mg/dL mg/dL mg/dL
Peak NA < 140 < 180
postprandial mg/dL mg/dL
glucose
Bedtime plasma NA NA 110-150
glucose mg/dL
*Goals should be individualized
*Certain populations require special
considerations
*Less intensive glycemic goals may be
MANAGEMENT AND
MONITORING

Glycemic targets should

be achieved within 6
months of diagnosis or
first prescription.
MANAGEMENT

The major components of the treatment of

diabetes are: Diet and
A Exercise

Oral
B hypoglycaemic
therapy

C Insulin Therapy
MANAGEMENT

Diet is a basic part of management in every case.

Treatment cannot be effective unless adequate
attention is given to ensuring appropriate
nutrition.
Dietary treatment should aim at:
Ensuring weight control
Providing nutritional requirements
Allowing good glycaemic control with blood glucose
levels as close to normal as possible
Correcting any associated blood lipid abnormalities
Controlling of blood pressure
MANAGEMENT

Protein:
o Intake can range between 10-15% total energy
(0.8-1 g/kg of desirable body weight)
o Should be derived from both animal and vegetable
sources.
Recommended: One serving of protein from animal
sources every other day
MANAGEMENT

Carbohydrates:
Should be 50-60% of total caloric content of the
diet
Has the greatest effect on blood glucose
Enough Glucose available throughout the day (not
so much not little)
Consistent timing and composition of meals and
snacks from day to day
Evening snack helps prevent nocturnal
hypoglycemia
Whole grain
bread Cereals

Legumes
Fruits and Vegetables
MANAGEMENT AND
MONITORING
Initiate treatment with metformin for
monotherapy unless with contraindications or
intolerance of its ADEs
o Diarrhea
o Severe nausea
o Abdominal pain
MANAGEMENT AND
MONITORING
When optimization of therapy is needed,
choose the second drug according to the
following -
o Degree of HbA1c lowering
o Hypoglycemia risk
o Weight gain/loss
o Patient profile (dosing complexity, renal/hepatic
problems, other contraindications and age)
Sequence of Antihyperglycemic Therapy (ADA, 2012)
MANAGEMENT AND
MONITORING
Since HbA1c reduction is the overriding goal,
the precise combination used may not be as
important as the glucose level achieved.
There is no evidence that a specific
combination is any more effective in lowering
glucose levels or preventing complications
than another.
o SU + Pio = SU + Metformin
(Hanefield et al, 2004 & Nagasaka et al, 2004)

o SU + Met = SU + DPP-IV inhibitors (?)

MANAGEMENT AND
MONITORING
The goal BP for most persons with diabetes is
<140/90 mm Hg.
o Lifestyle therapy alone for 3 months if pre-
hypertensive (SBP 130-139 mm Hg or DBP 80-89
mm Hg)
o Pharmacologic + lifestyle therapy if SBP>140 mm
Hg or DBP >90 mm Hg, or pre-hypertensive
uncontrolled with lifestyle therapy alone
MANAGEMENT AND
MONITORING
ACE inhibitors & ARBs are generally
recommended as initial therapy. If one class
is not tolerated, the other should be
substituted.
Multiple drug therapy (>2 agents at
maximal doses) is generally required to
achieve BP targets. Thiazide-type diuretics,
calcium channel blockers and B-blockers may
be given as additional agents.
MANAGEMENT AND
MONITORING
Recommendations are consistent with
Philippine Practice Guidelines for the
Treatment of Dyslipidemia.
LDL is the primary target for dyslipidemia
management in persons with diabetes
MANAGEMENT AND
MONITORING
Statin therapy should be added to lifestyle therapy,
regardless of baseline levels for diabetics
o With overt CVD (A)
o Without CVD who are >40 y and have 1 more other CVD risk
factors (A)
For patients at lower risk (e.g. without overt CVD and
<40 y), statin therapy should be considered in addition
to lifestyle therapy if
LDL-C remains >100 mg/dL
Those with multiple risk factors (hypertension, familial
hypercholesterolemia, LVH, smoking, family history of premature CAD, male sex,
age >55 y, proteinuria, albuminuria, BMI>25)
MANAGEMENT AND
MONITORING

The 100-70 rule

Without overt CVD, goal is LDL-C <100 mg/dL
(2.6 mmol/L) [A]
With overt CVD, goal is LDL-C <70 mg/dl (1.8
mmol/L). Use of high dose statin is an option.
[B]
MANAGEMENT AND
MONITORING
Insufficient evidence to recommend aspirin
for primary prevention in lower risk
individuals
o Men < 50 y
o Women <60 y

Clinical judgment if with multiple risk factors

MANAGEMENT AND
MONITORING
Use aspirin therapy for secondary prevention
strategy in those with DM and a history of CVD
[A].
For patients with CVD and documented aspirin
allergy, clopidogrel (75 mg/day) should be used.

Combination therapy of ASA (75-162 mg/day)

and clopidogrel (75 mg/day) is reasonable up to
a year after an acute coronary syndrome [B].
 LIPID PROFILE, BLOOD
PRESSURE AND BMI TARGET
Parameter Ideal Acceptable Bad
TG <1.5 mmol/L <2.2mmol/L > 2.2
(150 mg/dl) mmol/L
TC < 4.5mmol/L >4.5 mmol/L > 6.0
(200 mg/dl) mmol/L
LDL < 2.5 mmol/L (100 < 4.4mmol/L > 4.4
mg/dl) mmol/L
HDL > 1.1 mmol/L 0.9- < 0.9
(40 mg/dl in men; 50 1.1mmol/L mmol/L
mg/dl in women)
BP < 130/80mmHg >130/80- > 140/90
<140/90
BMI (Males) < 25 <27 27
BMI < 24 <26 26
MANAGEMENT AND
MONITORING
The following patients must be referred to
internists or diabetes specialists
(endocrinologists or diabetologists) -
o Type 1 diabetes
o Moderate to severe hyperglycemia
o Co-morbid conditions (infections, acute CV events
i.e. CHF or acute MI)
o Significant hepatic and renal impairment
o Women with diabetes who are pregnant
CLINICAL PRACTICE
GUIDELINES FOR THE
DIAGNOSIS AND MANAGEMENT
OF DIABETES MELLITUS
DIABETES MELLITUS IN
PREGNANCY

SOURCE:
PHILIPPINE OBSTETRICS AND GYNECOLOGY SOCIETY CPG ON DM
EPIDEMIOLOGY

7% of all pregnancies are complicated with

GDM worldwide
In PH, 1.9% of pregnant women admitted
have GDM
5.1% of Filipinas had DMT2 or GDM according
to POGS, Inc.
RISK FACTORS

Increase overall and abdominal obesity

Sedentary lifestyle and change in diet (caloric diet)
Cigarette smoking
Inadequate cell response as seen among Japanese
population
LBW and undernutrition in utero
Genes (SEA descent)
Chronic infections (HBV and PTB)
Exposure to environmental irritants
Moderate Fe++ overload i.e., hemoglobinopathies
ASSOCIATED DISEASES

Childhood autism
Fetal overnutrition (macrosomia) and insulin
resistance
COMPLICATIONS
COMPLICATIONS
SCREENING AND
DETECTION
Recommendations for Filipino Pregnant Women
DM recognized during pregnancy may be classified as either
GDM or overt DM based on plasma glucose levels (Level III,
Grade C)
Universal screening for GDM is recommended among Filipino
Gravidas (Level III, Grade B)
At 1st PNCU determine if gravida is high risk accdg to history
and risk factors (Level III, Grade B)
If low risk, with normal intial test (FBS, HBA1c or RBS),
screening should be done at 24-28 weeks AOG using 2 hr 75g
OGTT
SCREENING AND
DETECTION
Recommendations for Filipino Pregnant Women
If OGTT is normal at 24-28 weeks AOG, re-test at 32
wks AOG or earlier if there are sx of hyperglycemia (3
Ps, plus polyhydramnios, accelerated fetal growth)
OGTT should be performed in the morning after an
overnight fasting of 8-14 hours.
o Have an unrestricted diet 3 days or more prior to
testing, i.e., >/ 150 g of CHO per day
o Do not smoke and remain seated during the test
GDM WHO ADA POGS
FBS >125 mg/dL >92 mg/dL >92 mg/dL
(6.9 mmol/L) (5.1 (5.1
mmol/dL) mmol/dL)

Overt:
>/126
mg/dl (7
mmol/L)
1 hr >180 mg/dL
(10 mmol/dL)

2 hr >140 mg/dL >153 >140

(7.8 mmol/dL) mg/dL (8.5 mg/dL (7.8
mmol/dL) mmol/dL)

Overt: >/
200mg/dL
(11.1
mmol/L)
TREATMENT

DIET! Medical Nutrition therapy

o For normal-weight women (BMI: 20-25 kg/m2) 30
kcal/kg should be prescribed;
o For overweight and obese women (BMI > 24-34
kg/m2) calories should be restricted to 25 kcal/kg,
o For morbidly obese women (BMI > 34 kg/m2)
calories should be restricted to 20 kcal/kg or less
TREATMENT

Weight Management weight gain

recommendations for women with GDM who had
normal weight or were underweight prepregnancy
is the same as for those without GDM

Energy intake for overweight or obese women

with GDM may be modestly restricted as long as
weight gain is appropriate while minimizing risk
of ketosis.
TREATMENT

Lifestyle changes cessation of smoking

and counseling about alcohol consumption.
 The most important
thing in the reduction of
complications among
women with GDM is
glycemic control
GOALS OF MANAGEMENT

OUTPATIENT GLUCOSE TRAGETS FOR PREGNANT

WOMEN

For GDM treatment goals are:

- Pre-prandial glucose concentration of 95mg/dL (5.3
mmol/L)
- 1-hour postmeal glucose value of 140mg/dL (7.8
mmol/L)
- 2-hour post meal glucose value of 120mg/dL (6.7
mmol/L)
GOALS OF MANAGEMENT

For women with pre-existing DM type I or

II who become pregnant, goals are:
- Premeal, bedtime, and overnight glucose
values of 60-99mg/dL (3.3-5.4 mmol/L)
- Peak post prandial glucose value of 100-
129mg/dL (5.4- 7.1 mmol/L)
- HbA1c of 6%
TREATMENT

The optimal treatment for

women with GDM or type 2 DM
who are not able to maintain
normoglycemia with CHO
restricted diet INSULIN
TREATMENT

Dosages:
- 0.7-0.8 U/kg BW on 1st trimester
- 1.0 U/kg BW on 2nd trimester
- 1.2 U/kg BW on 3rd trimester

- 2/3 given before breakfast, 1/3 given before dinner (NPH insulin)
- Regular insulin and rapid acting insulin are best dosed with each
meal
TREATMENT

Oral Hypoglycemic Agents use?

o ACOG and the ADA do not currently recommend
oral hypoglycemic agents.
PHARMACOLOGY OF
ANTI-DIABETIC DRUGS
ORAL HYPOGLYCEMIC
AGENTS
 There are currently six classes of oral
anti-diabetic agents:
Biguanides
Insulin Secretagogues Sulphonylureas
Insulin Secretagogues Non-
sulphonylureas
-glucosidase inhibitors
Thiazolidinediones (TZDs)
DPP-IV Inhibitors
 Drug Class Agents Mechanism of Action
Alpha-glucosidase Acarbose Delay intestinal
inhibitors Voglibose carbohydrate absorption
Hepatic glucose
production
Biguanides Metformin
Liver and muscle
insulin sensitivity
Glimepiride
Insulin Glipizide
secretagogues Glyclazide insulin secretion
sulfonylureas Glibenclamide
(glyburide)
Insulin
Nateglinide,
secretagogues insulin secretion
Repaglinide
Meglitinides
Postrandial insulin
Sitagliptin
secretion,
DPP-IV Inhibitors Vildagliptin
glucagon secretion,
Saxagliptin
Delay gastric emptying
Pioglitazone Adipose and muscle
Thiazolidinediones
Rosiglitazone insulin sensitivity
BIGUANIDE: METFORMIN
Primary effects are to decrease hepatic
glucose production and increase insulin-
mediated peripheral glucose uptake
Efficacy:

HbA1c FPG
1-2% 40-70 mg/dl
11-22 mmol/mol 2.2-3.9 mmol/mol
 METFORMIN
SIDE EFFECTS CONTRAINDICATIO DRUG Preparation
NS
INTERACTION
Lactic acidosis Kidney failure Cimetidine Tablets: 500,
(rare; in patients Liver disease Furosemide 850, and 1000
with CHF) Lactic acidosis Nifedipine mg. Tablets
Diarrhea and (extended
abdominal release): 500,
discomfort 750, and 1000
Weight loss mg. Solution:
500 mg/5 ml
Usual dose:
o 500 mg BID to TID
Max dose:
o 850 mg TID to 3g/day
Max effective dose:
o 1000 mg BID
METFORMIN
BRAND STOC PRICE BRAND STOCK PRICE
NAME K NAME DOSE
DOSE Melta-SE 500 6.00
RiteMed 500 3.09 Neomet 500 6.00
Gludin 500 3.20 Panfor SR 500 6.50
Neoform 500 3.35 Ansures 500 7.00
Diamet 500 3.50 MR
500 Glumet 500 7.22
Pharex 500 3.75 Fornidd 500 7.40
Nidcor 500 4.32 Euform 850 8.90
Winthrop 500 4.50 Retard
Diafat 500 5.19 Humamet 500 9.40
Glucofor 500 5.60 Glucophag 500,
m e 750, 850
I-Max 500 5.60
SECRETAGOGUES
These medications try to
replace the natural
stimulus for beta cells to
secrete insulin.
SULFONYLUREAS
Efficacy:
HbA1c FPG
1-2% 40-70 mg/dl
11-22 mmol/mol 2.2-3.9 mmol/mol

Short-acting:
o Tolbutamide
Intermediate-acting:
o Tolazamide
o Glipizide
o Glyburide/ Glibenclamide
Long-acting:
o Chloropropamide
o Glimepiride
 SULFONYLUREAS
SIDE EFFECTS CONTRAINDICATION DRUG INTERACTION
S
Hypoglycemia IDDM (next slide)
Weight gain DKA
Diabetic Coma
Pregnancy, Lactation
Short-acting:
o Tolbutamide: not available
Intermediate-acting:
o Tolazamide: not available
o Glipizide: Minidiab 5,10mg OD max: 40mg/d
o Glyburide/ Glibenclamide: Daonil 5mg Maintenance: 5-10 mg/day
Long-acting:
o Chloropropamide: not available
o Glimepiride: Aforglim 2, 3 mg OD
o Glicazide: Diamicron 30, 80mg OD
MEGLITINIDES
Efficacy:
HbA1c FPG
0.5-1.5% 20-60 mg/dl
5.5-16.5 mmol/mol 1.1-3.3 mmol/mol

PPG
75-100 mg/dl
4.2-5.6 mmol/mol
 MEGLITINIDES
SIDE EFFECTS CONTRAINDICATION DRUG INTERACTION
S
Hypoglycemia (less) DKA NSAIDs
Weight gain T1DM Salicylates
Pregnancy and MAOIs
Lactation Nonselective -
blockers
Thiazides
Corticosteroids
Thyroid preparation
Sympathomimetics
Oral antidiabetic
agents
CYP2C9 inhibitors
MEGLITINIDES

BRAND GENERIC STOCK PRICE

NAME NAME DOSE
Novonorm Repaglinide 0.5 15.67
Starlix Nateglinide 120 31.27

Nateglinide: Starlix 120mg/tab TID

Repaglinide Novonorm 0.5,1.2mg- TID
ALPHA-GLUCOSIDASE
INHIBITORS
Efficacy:
HbA1c FPG
0.5-1% 10-20 mg/dl
5.5-11 mmol/mol 0.5-1.1 mmol/mol

PPG
40-50 mg/dl
2.2-2.8 mmol/mol
 ALPHA-GLUCOSIDASE
INHIBITORS
SIDE EFFECTS CONTRAINDICATION DRUG INTERACTION
S
Flatulence Chronic intestinal Cholestyramine,
Abdominal discomfort disorders associated w/ intestinal absorbents &
distinct disturbances of digestive enzymes
digestion & absorption, may attenuate its
conditions which may effect
deteriorate as a result
of increased intestinal
gas formation.
Patients w/ CrCl <25
mL/min/1.73 mL,
hepatic impairment.
Pregnancy & lactation.
Patients <18 yr.
ALPHA-GLUCOSIDASE
INHIBITORS
BRAND GENERIC STOCK PRICE
NAME NAME DOSE
Basen Voglibose 0.2 12.35
Glucoba Acarbose 50 12.96
y

Acarbose: 50, 100mg/tab, TID

Miglitol (glyset) NA
Voglibose (Basen)- 0.2-0.3 mg/ TID
THIAZOLIDINEDIONES
Increase the sensitivity of muscle and adipose cells to
insulin and suppressing hepatic glucose production
Inhibit hepatic gluconeogenesis
Stabilize beta cell dysfunction
Efficacy:

HbA1c FPG
0.5-1.5% 20-55 mg/dl
5.5-16.5 mmol/mol 1.1-3.1 mmol/mol
 THIAZOLIDINEDIONES
SIDE EFFECTS CONTRAINDICATION DRUG INTERACTION
S
Weight gain Patients with abnormal Other antidiabetic
Edema liver function agents
Risk of fractures CHF patients -blockers
Salicylic acid
preparation
MAOIs
Fibrate derivatives
Warfarin
Epinephrine
Adrenocortical &
thyroid hormone
CYP2C8 inducer eg
rifampicin & inhibitor
Pioglitazone - 15mg, 30mg/tab, OD
eg gemfibrozil
Rosiglitazone - not available inc risk for CVD
Troglitazone (Rezulin), which was withdrawn from the market
due to an increased incidence of drug-induced hepatitis.
THIAZOLIDINEDIONES
BRAND GENERIC STOCK PRICE
NAME NAME DOSE
Pioglon Pioglitazone 15 3.50
Insulact Pioglitazone 15 14.18
Prialta Pioglitazone 15 15.88
Glitaz Pioglitazone 15 15.92
Piozone Pioglitazone 15 16.98
Diabeton Pioglitazone 15 17.25
e
Zolid Pioglitazone 15 17.75
Ppar Pioglitazone 30 18.00
Piozar Pioglitazone 30 18.50
Actos Pioglitazone 15 67.58
DPP-4 INHIBITORS
Efficacy:
HbA1c FPG
0.5-1% 20 mg/dl
5.5-11 mmol/mol 1.1 mmol/mol

PPG
45-55 mg/dl
2.5-3.1 mmol/mol
 DPP-4 INHIBITORS
SIDE EFFECTS CONTRAINDICATION DRUG INTERACTION
S
Generally well Type 1 DM Digoxin
tolerated Diabetic ketoacidosis Cyclosporine
Low risk of
hypoglycemia
Not associated with
weight gain
Upper respiratory tract
infection has been
reported in clinical Sitagliptin (Januvia): 25, 50,100mg/film
studies
coated tab OD
Vildagliptin (Galvus): 50mg/tab OD-BID
Saxaglitpin (Onglyza): 2.5, 5mg OD
Linagliptin (Trajenta): 5mg OD
DPP-4 INHIBITORS
BRAND GENERIC STOCK PRICE
NAME NAME DOSE
Galvus Vildagliptin 50 27.15
Onglyza Saxagliptin 5 52.04
Trajenta Linagliptin 5 52.07
Januvia Sitagliptin 25, 50, 52.14
100
GLUCAGON-LIKE PEPTIDE 1
AGONIST
Aka incretin mimetics

is an insulinsecretagogue, with
glucoregulatory effects.

for patients whose diabetes was not well-

controlled on otheroral medications.
GLUCAGON-LIKE PEPTIDE 1
AGONISTS
Efficacy:
HbA1c FPG
1-2% 5.76-11.7 mg/dl
11-22 mmol/mol 0.32-0.65 mmol/mol

PPG
6.12-17.28 mg/dl
0.34-0.96 mmol/mol
 GLUCAGON-LIKE PEPTIDE 1
AGONISTS
SIDE EFFECTS CONTRAINDICATION DRUG INTERACTION
S
Moderate and Not for type 1 DM or May increase
transient nausea, diabetic ketoacidosis. hypoglycemia when
vomiting and diarrhea Do not use in end- used w/ a sulfonylurea.
Low risk of stage renal disease or OC, antibiotics,
hypoglycemia and no severe renal warfarin
evidence of increased impairment (<30
CV risk mL/min), severe GI
disease
Exenatide (Byetta): 250mcg/mL
5mcg/dose bid SC
Liraglutide (Victoza): 6mg/mL , 3mL 0.6ml
SC daily
COMBINATION THERAPY
BRAND NAME GENERIC NAME STOCK PRICE
DOSE
Azulix MF Glimepiride + Metformin 1+500 8.00
Euglo Plus Glibenclamide + 2.5+400 9.28
Metformin
Glimet Glimepiride + Metformin 2+500 14.00
Zolid Plus Pioglitazone + Meformin 15+500 16.98
Pioplus Pioglitazone + Meformin 15+500 16.98
Prialta-Met Pioglitazone + Meformin 15+500 17.57
Solozamet Glimepiride + Metformin 2 +500 21.93
Zoliget Pioglitazone + 30+2 24.55
Glimepiride
Galvusmet Metformin + Vildagliptin 500+50 28.18
Janumet Sitagliptin + Metformin 50+500 28.57
Velmetia Sitagliptin + Metformin 50+500 29.43
Actosmet Pioglitazone + 15+850 33.93
Metformin
INSULIN THERAPY
INSULIN THERAPY

Characteristics
Onset is the length of time before insulin reaches the
bloodstream and begins lowering blood glucose.

Peaktime is the time during which insulin is at

maximum strength in terms of lowering blood glucose.

Duration is how long insulin continues to lower blood

glucose.
INSULIN

Insulin Therapy Indications

o Short-Term Use:
Acute illness, surgery, stress and emergencies
Pregnancy
Breast-feeding
Insulin may be used as initial therapy in type 2
diabetes in marked hyperglycaemia
Severe metabolic decompensation (diabetic
ketoacidosis, hyperosmolar nonketotic coma,
lactic acidosis, severe hypertriglyceridaemia)
INSULIN

Insulin Therapy
o Long-Term Use:
If targets have not been reached after optimal
dose of combination therapy or BIDS, consider
change to multi-dose insulin therapy. When
initiating this, insulin secretagogues should be
stopped and insulin sensitisers e.g. Metformin
or TZDs, can be continued.
DOSING: 0.3 1.5/KG
BW
Rapid-acting Insulin: Lispro 100IU/ml 3mL
(P705.00/cartridge or pen); aspart 100IU/ml
3mL (P724.00/pen): immediately before meals

Short-acting: Humulin-R 100IU/mL, 3mL vial

(P1,200): 30 mins before meals

Intermediate-acting: Humulin-N 100IU/mL, 3mL

(P526.00/cartridge): AM and PM

Long-acting: glargine 100IU/mL, 10mL

(P2303.00/vial); detemir 100IU/mL, 3ml
(P844.00/pen) PM or bedtime
PRE-MIXED

Humulin 70/30 (70% NPH 30% regular

insulin) Combination of int. acting + SA

Novomix 30 (70% aspart protamine 30%

aspart )

Humalog mix 25 (75% lispro protamine, 25%

lispro)
INSULIN REGIMEN

To augment beta cell function (0.3 U/kg)

prevents gluconeogenesis during bedtime
- BIDS (Bedtime Insulin dailytime SU)
- Example: Gliclazide 80mg OD + Humulin N 10U SC at
bedtime

To replace beta cell function (0.6-1.0 U/kg) basal

and meal-related (bolus) requirements
- Split dose 2/3 1/3 rule given before breakfast/dinner
respectively
- Split-mixed: Insulatard (int.) 20U + Actrapid
(S.A) 6U before breakfast then Insulatard (int.)
10U + Actrapid (S.A) 6U before dinner

- Modified split-mixed: Humulin N 16U

(intermediate acting) + Humulin R 4 U (short
acting) before breakfast then Humulin R 6 U
at lunch then Humulin N 8U (intermediate
acting) + Humulin R 4 U (short acting) before
dinner

- Basal plus Regimen: Lantus 20U (basal

insulin) OD + Humalog (S.A) 10U before lunch
- Basal Bolus Regimen: Pre-meal SA + basal
insulin i.e., Actrapid 10U SC premeals TID +
Humulin N 20U at bedtime
TREATMENT ALGORITHM FOR
PEOPLE WITH T2DM (IDF)
THANK YOU!