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| __NOTOC__ | | __NOTOC__ |
| {{Diabetes mellitus type 2}} | | {{Diabetes mellitus type 2}} |
| {{Diabetes mellitus}}
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| {{CMG}}; {{AE}} [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}} | | {{CMG}}; {{AE}} {{MehdiP}} |
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| ==Overview== | | ==Overview== |
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| <sup>§</sup> Not licensed in Europe for type 2 diabetes. | | <sup>§</sup> Not licensed in Europe for type 2 diabetes. |
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| ===Alternative Medicines===
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| [[Carnitine]] has been shown to increase insulin sensitivity and glucose storage in humans. <ref name="AMC study">{{cite journal | title=L-Carnitine Improves Glucose Disposal in Type 2 Diabetic Patients| journal=Journal of the American College of Nutrition| author=Geltrude Mingrone, Aldo V. Greco, Esmeralda Capristo, Giuseppe Benedetti, Annalisa Giancaterini, Andrea De Gaetano, and Giovanni Gasbarrini |year=1999 |volume=18 |issue=1 |pages=77-82 |url=http://www.jacn.org/cgi/content/full/18/1/77}}</ref>. It is important to note that this was with a constant blood infusion, not an oral dose, and that the clinical significance of this result is unclear.
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| [[Taurine]] has also shown significant improvement in [[insulin sensitivity]] and [[hyperlipidemia]] in rats.<ref name="Japanese rats">{{cite journal | title=Taurine improves insulin sensitivity in the Otsuka Long-Evans Tokushima Fatty rat, a model of spontaneous type 2 diabetes |authors=Yutaka Nakaya, Asako Minami, Nagakatsu Harada, Sadaichi Sakamoto, Yasuharu Niwa and Masaharu Ohnaka |date January 2000 |journal=American Journal of Clinical Nutrition |volume= 71 |issue= 1 |pages=54-58 |url=http://www.ajcn.org/cgi/content/full/71/1/54}}</ref>
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| Neither of these have shown permanent positive effects, nor a complete restoration to pre-diabetes conditions, only improvement. Their clinical importance in humans remains unclear.
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| ===Antihypertensive Agents===
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| {{main|Antihypertensive}}
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| The goal blood pressure is 130/80 which is lower than in non-diabetic patients.<ref name="pmid12748199">{{cite journal |author=Chobanian AV, Bakris GL, Black HR, ''et al'' |title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report |journal=JAMA |volume=289 |issue=19 |pages=2560-72 |year=2003 |pmid=12748199 |doi=10.1001/jama.289.19.2560}}</ref>
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| ===ACE Inhibitors===
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| The HOPE study suggests that diabetics should be treated with [[ACE inhibitors]] (specifically [[ramipril]] 10 mg/d) if they have one of the following <ref name="pmid10639539">{{cite journal |author=Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G |title=Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators |journal=N. Engl. J. Med. |volume=342 |issue=3 |pages=145-53 |year=2000 |pmid=10639539 |doi=}}</ref>:
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| * [[Hypertension]]
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| * [[Hypercholesterolemia]] or reduced low high-density lipoprotein cholesterol levels
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| * Cigarette smoking
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| * [[Microalbuminuria]]
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| After treatment with [[ramipril]] for 5 years the [[number needed to treat]] was 50 patients to prevent one cardiovascular death. Other [[ACE inhibitors]] may not be as effective.<ref name="pmid15262665">{{cite journal |author=Pilote L, Abrahamowicz M, Rodrigues E, Eisenberg MJ, Rahme E |title=Mortality rates in elderly patients who take different angiotensin-converting enzyme inhibitors after acute myocardial infarction: a class effect? |journal=Ann. Intern. Med. |volume=141 |issue=2 |pages=102-12 |year=2004 |pmid=15262665 |doi=}}</ref>
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| ===Hypolipidemic Agents===
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| {{main|Hypercholesterolemia#Diabetic_patients}}
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| ===Contraindicated medications===
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| {{MedCondContrAbs
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| |MedCond =Type 2 Diebetes|Eplerenone}}
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| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
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| [[Category:Needs content]]
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| [[Category:Endocrinology]] | | [[Category:Endocrinology]] |
| [[Category:Emergency medicine]]
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| [[Category:Primary care]] | | [[Category:Primary care]] |
| {{WH}}
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| {{WS}}
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Overview
The main goals of treatment are, eliminate hyperglycemic symptoms, control the long term complications and improve the patient's quality of life.
Diabetes mellitus type 2 is initially treated by life style modification and weight loss, especially in obese patients. Metformin is the first line pharmacologic therapy that usually starts once the diagnosis is confirmed unless contraindications exist. If glycemic goals does not achieved, the second agent must be add to metformin. A wide range of options are available to add as combination therapy based on patient condition and comorbidities.
Pharmacologic therapy
Medical therapy starts with metformin monotherapy unless there is a contraindication for it. In following conditions, treatment starts with dual therapy:
- If HbA1C is greater than 9, start with dual oral blood glucose lowering agent.
- If HbA1C is greater than 10 or blood glucose is more than 300 mg/dl or patient is markedly symptomatic, consider combination therapy with insulin.
Metformin
Metformin is effective and safe, is inexpensive, and may reduce risk of cardiovascular events and death. (22)Patients should be advised to stop the medication in cases of nausea, vomiting or dehydration. It's contraindications include, heart failure, liver failure, GFR ≤30 and metabolic acidosis.
Combination therapy
Any agent can be added as second drug based on patient condition but American Association of Clinical Endocrinologists recommends either incretin based therapy or sodium glucose transporter 2 (SGLT2) inhibition agents.
The following table summarize the available FDA approved glucose lowering agents that may help to individualize treatment for each patient.
Class
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Drug
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Mechanism of action
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Primary physiologic action
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Advantages
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Disadvantages
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Cost
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Biguanids
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Metformin
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Activates AMP-kinase
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↓ Hepatic glucose
production
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- Relatively higher A1C efficacy
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Low
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Sulfonylureas
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2nd generation
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Closes K-ATP channels on beta cell plasma membranes
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↑ Insulin secretion
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- Relatively higher A1C efficacy
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Low
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Meglitinides
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Closes K-ATP channels on beta cell plasma membranes
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↑ Insulin secretion
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Moderate
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Thiazolidinedione
(TZDs)
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Activates the nuclear transcription factor PPAR-gama
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↑ Insulin sensitivity
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- Relatively higher A1C efficacy
- ↓ Triglycerides (pioglitazone)
- ↓ CVD events (PROactive, pioglitazone)
- ↓ Risk of stroke and MI in patients without diabetes and with insulin resistance and history of recent stroke or TIA
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Low
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α-Glucosidase
inhibitors
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Inhibits intestinal
α-glucosidase
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Slows intestinal carbohydrate
digestion/absorption
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- ↓ Postprandial glucose excursions
- ↓ CVD events in prediabetes
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- Generally modest A1C efficacy
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Low to
moderate
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DPP-4
inhibitors
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Inhibits DPP-4 activity, increasing postprandial incretin (GLP-1, GIP) concentrations
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- ↑ Insulin secretion (glucose dependent)
- ↓ Glucagon secretion (glucose dependent)
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High
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Bile acid sequestrants
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Colesevelam
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Binds bile acids in intestinal tract,
increasing hepatic bile acid production
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- ↓ Hepatic glucose production
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- May ↓ absorption of other medications
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High
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Dopamine-2
agonists
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Bromocriptine
(quick release)§
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Activates dopaminergic receptors
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High
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SGLT2
inhibitors
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Inhibits SGLT2 in the proximal nephron
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- Blocks glucose reabsorption by the kidney,increasing glucosuria
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- Associated with lower CVD event rate and mortality in patients with CVD
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High
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GLP-1 receptor
agonists
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- Exenatide extended release
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Activates GLP-1 receptors
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- ↑ Insulin secretion (glucose dependent)
- ↓ Glucagon secretion (glucose dependent)
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- ↓ Some cardiovascular risk factors
- Associated with lower CVD event rate and mortality in patients with CVD
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High
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Amylin mimetics
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Pramlintide§
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Activates amylin receptors
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- Postprandial glucose excursions
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High
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Insulins
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Activates insulin receptors
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- ↓ Hepatic glucose production
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- Nearly universal response
- Theoretically unlimited efficacy
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- Patient and provider reluctance
- Injectable (except inhaled insulin)
- Pulmonary toxicity (inhaled insulin)
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High
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- Premixed insulin products
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‡ lnitial concerns regarding bladder cancer risk are decreasing after subsequent study.
§ Not licensed in Europe for type 2 diabetes.
References