Tip Sheets
Diabesity Cheat Sheet (Rich Siegel presentation)
Rich Siegel, M.D., co-director, Tufts Medical Center's Diabetes Clinic, spoke on the Health Journalism 2013 panel "Diabetes: Latest in diagnosis, treatment, prevention."
Types of Diabetes
- Type 1 diabetes – autoimmune destruction of pancreatic beta cells
- Type 2 diabetes - combination of insulin resistance and relative insulin deficiency with dysfunction of multiple organs including liver, fat, muscle, endocrine pancreas, kidney; most common type of diabetes
- Gestational Diabetes - diabetes which occurs during a pregnancy and resolves with delivery; very high risk for future type 2 diabetes
- Maturity Onset Diabetes of Youth (MODY) – diabetes caused by a single gene defect, presenting usually under the age of 40 in multiple generations
Diagnosis of Diabetes
- Fasting blood glucose (FBS) greater than or equal to 126 mg/dl
- Hemoglobin A1C (HbA1C) greater than or equal to 6.5%
- 2 hour blood glucose greater than or equal to 200 mg/dl after a 75 gram glucose challenge (oral glucose tolerance test)
- Casual blood glucose greater than or equal to 200 mg/dl with symptoms
- All tests should be confirmed by the same or a different test
- “At risk for diabetes”
- Impaired fasting glucose - FBS 100-125 mg/dl
- Impaired glucose tolerance – 2 hour blood glucose 140-200 mg/dl after glucose challenge
- HbA1C 5.7-6.4%
Medications for Diabetes
Insulins
- Basal (background) insulins – keeps glucose levels down between meals and overnight
- NPH insulin (Humulin or Novolin N)
- Insulin Glargine (Lantus)
- Insulin Detemir (Levemir)
- Bolus (mealtime) insulins – keeps glucose levels down after meals
- Regular insulin (Humulin or Novolin R)
- Insulin Lispro (Humalog)
- Insulin Aspart (Novolog)
- Insulin Glulisine (Apidra)
- Premixed insulins – combination of basal and bolus insulins
- Humulin or Novolin 70/30 – 70% NPH and 30% Regular
- Humalog 75/25 – 75% Long acting Lispro and 25% Lispro
- Humalog 50/50 - 50% Long acting Lispro and 50% Lispro
- Novolog 70/30 - 75% Long acting Aspart and 25% Aspart
Non-insulin medications
- Insulin secretagogues – oral meds increasing insulin secretion from pancreatic beta cells
- Glyburide, Glipizide, Glimepiride (all generic) – once or twice daily
- Repaglinide (Prandin), Nateglinide (Starlix) – dosed at each meal
- Risk for hypoglycemia and weight gain
- Biguanide – oral medication which reduces glucose production at the liver
- Metformin (Glucophage and generic) as the only drug in the class
- First line medication indicated with lifestyle in guidelines for type 2 diabetes
- Weight neutral to minimal weight loss
- No hypoglycemia risk by itself or with medications other than insulin or insulin secretagogues
- ? Cardiovascular benefit, ? Benefit in selected cancers
- Thiazolidinediones (TZDs) – oral medication which improves insulin resistance at fat and muscle
- Pioglitazone (Actos and generic)
- Rosiglitazone (Avandia) - very restricted access making it effectively off the market; possible increased cardiovascular risk
- Pioglitazone showed CV event benefit as secondary outcome in PROACTIVE trial
- May lead to weight gain, especially together with insulin
- Contraindicated in mid to late stage heart failure
- Risk for bone loss; ? risk for bladder cancer (taken off the market in France and Germany)
- Incretin related agents – on the market only since 2005; awaiting cardiovascular outcome trials
- GLP-1 agonists – injectable medications which increase insulin release but only when sugars are high, slows stomach emptying and inhibit appetite working at endocrine pancreas, GI tract and brain
- Exenatide (Byetta twice daily, Bydureon once weekly)
- Liraglutide (Victoza)
- Reduce glucose and weight
- Expensive at $200-300 per month
- Possible risk for pancreatitis, ? pancreatic cancer
- DPP-IV inhibitors – oral medications increase insulin release but only when sugars are high
- Sitagliptin (Januvia)
- Saxagliptin (Onglyza)
- Linagliptin (Tradjenta)
- Alogliptin (Nesina)
- Expensive at $200 per month
- Minimal side effects but also possible pancreatitis risk
- GLP-1 agonists – injectable medications which increase insulin release but only when sugars are high, slows stomach emptying and inhibit appetite working at endocrine pancreas, GI tract and brain
- Other medication classes
- Alpha glucosidase inhibitors – reduce postmeal glucose working in the intestines
- Acarbose (Precose), Miglitol (Glyset)
- Bile acid sequestrant – unknown mechanism of action
- Colesevelam (Welchol) – primary effect is to lower LDL cholesterol
- Amylin mimetic – reduce postmeal glucose by inhibiting glucagon, slowing gastric emptying
- Pramlintide (Symlin)
- Dopamine agonist – action in the brain though mechanism to lower glucose is not entirely clear
- Bromocriptine mesylate (Cycloset)
- Alpha glucosidase inhibitors – reduce postmeal glucose working in the intestines
Medications for Obesity
- Appetite suppressants – works within the brain (mostly hypothalamus) to inhibit appetite
- Phentermine (Adipex) – about 8-10% weight loss over 6 months
- Generic
- Not approved for long term use
- Class IV drug with no clinical addiction potential
- Requires monitoring for stimulant related side effects
- Phentermine/Topiramate ER (Qsymia)
- Greater weight loss potential (10 %) but also greater risk for side effects (mostly neuropsychiatric)
- Expensive at $100 per month
- Risk for birth defects (cleft palate)
- Only available through selected mail order pharmacies
- Lorcaserin (Belviq)
- ? In pharmacies in March
- About 5% average weight loss
- Questions about long term safety lingers
- Older meds used by some include diethylpropion, benzphetamine, mazindol, phendimetrazine
- Phentermine (Adipex) – about 8-10% weight loss over 6 months
- Gastrointestinal lipase inhibitor – works in the small intestine to limit fat absorption
- Orlistat (Xenical, OTC Alli)
- 5-8% weight loss
- Effectiveness depends on baseline intake of fat
- Side effects of malabsorption (fecal oiliness) unacceptable to many
- Need multivitamin taken usually at bedtime
- Orlistat (Xenical, OTC Alli)
Surgeries for Diabetes and Morbid Obesity
- Roux- N-Y Gastric Bypass
- Combination restrictive and malabsorptive surgery
- Usually 50-70% of excess weight loss(about 30-35% of absolute weight)
- Vertical Sleeve Gastrectomy
- Restrictive surgery with removal of over 75% of greater curvature of the stomach
- Laparoscopic Adjustable Gastric Banding
- Restrictive surgery
- Biliopancreatic diversion with duodenal switch
- Malabsorptive surgery