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              Dr. Shashank Jain

Diabetes Modern Management

         Jains Clinic, A-54 Freedom Fighters Enclave, New Delhi-68

               Tel Clinic: 32003074; 26922890   Res: 9810198650

                            E-mail: [email protected]

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MANAGEMENT

DRUG THERAPY

                         Stepwise plan for treatment of type 2 Diabetes

 

OVERALL MANAGEMENT PLAN.

                                        Drug therapy

 

     Diagnosis                   Hyperglycaemia (high blood sugar)

                                                         

    Non drug treatment         Diet and Exercise            OK

                                                                          failed

                        Decision on pharmacological (drug) treatment

     Patient selection.                      

                         Non Obese           Obese        Post-Prandial Hyperglycaemia   

                                                                                     (high blood sugar after meals)       

                                                                                                                                                

                                                      Insulin resistant                                    

  1st drug selection                                                                                          

          Sulfonylureas     Biguanides    Insulin sensitizers     Acarbose    OK

                                                                    (Metformin)            (Alpha Glucosidase Inhibitors)

                                                                               failed

Combined oral therapy    Sulfonylureas  + Biguanides        OK

                                            or Insulin sensitizers 

                                                       or Alpha Glucosidase Inhibitors

                                                                             failed

                                       Failure of oral combined therapy

                                                Insulin 

Combined Insulin & Oral therapy         

   Sulfonylureas       Biguanides      Insulin sensitizers         Acarbose        

 

 (if residual insulin)  (if weight excess)        (if insulin resistance)   (if glucose instability)

 

 

Guidelines for usage of Oral hypoglycemic agents (OHA).

 

Most Type 2 patients should be given a trial with diet and exercise for an adequate period (usually 4-6 weeks) before using oral hypoglycemic agents (OHA).

In patients with fasting blood glucose levels more than 200 mg %, or in patients with significant symptoms, OHA therapy can be started along with diet and exercise. This will allow a more rapid relief of symptoms.

Oral hypoglycemic agents (OHA) are contraindicated (not indicated) in pregnancy.

The initial dose of oral hypoglycemic agents  must be small (usually half to one tablet daily).

Oral hypoglycemic agent's dose increments must be made in small amounts (half to one tablet at one time ) and gradually (every 1-2 weeks), till optimal control is reached.

If expected response is not seen with these dosages, it would be prudent to "review" the patient clinically, check diet and exercise compliance, look for presence of conditions which may interfere with ,or antagonize, the action of oral agents, rather than keep on blindly increasing the dose of the oral agent.

 

Conditions which can interfere with the action of oral hypoglycemic agents are:

  1. Presence of any infection; specially tuberculosis and urinary tract infection etc.

  2. Associated use of drugs which increases the blood sugar levels.

  3. Endocrine (hormonal) causes associated with hyperglycemia, etc. 

 

When a OHA does not show the desired effect, a change to another OHA of the same class is usually unlikely to improve control. Consider addition of another type of OHA or insulin.

It may be preferable to add insulin to those failing on OHA alone in normal weight, and especially, underweight patients.

 

Once optimal control is achieved:

  1. Re-enforce the importance of diet and exercise.

  2. Efforts must be made to reduce the dose  of OHA slightly, to see if the control is maintained; the rationale for this is to try and obtain the optimal target level for the individual with the smallest possible dose.

 

 

 

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