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Diabetes mellitus: drug
treatment
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Stepped care
- Think: rapid onset, thin, no truncal obesity ?type
1
- Aim for HbA1c of 7.0-7.5%. Move to next step early if no improvement.
- Control BP to 140/85
- Consider aspirin for all patients with a risk over 3% -
use Framingham calculator
- Message to patient: "diabetes is a progressive condition".
- Metformin
- Start with 500mg/day increasing fortnightly with
or after food, up to 3g daily.
- Care if creatinine approaches 200 - danger of
lactic acidosis.
- Diarrhoea can be treated with loperamide. Nausea
tends to settle.
- Sulphonylurea
- Gliclazide up to 160mg bd.
- Tolbutamide up to 2g/day.
- Take 30mins before food.
- Acarbose?
- Improves HbA1c by 0.5%
- Increase dose slowly to limit
flatulence/diarrhoea up to 200mg tds.
- Take immediately before or with first mouthful of
food.
- Interferes with sucrose absorption so patients
must carry glucose to counteract
hypoglycaemia.
- Rosiglitazone
- Insulin
- Insulin + metformin
- If obese or insulin resistance.
Rosiglitazone is licensed for use as a third line drug in Type 2 diabetes. It can be
recommended
- at a dose of 8mg in combination with Metformin
- at a dose of 4mg
in combination with a sulphonylurea.
But not for use
- in combination with insulin therapy
- in combination with more
than one kind of oral agent.
Rosiglitazone is contraindicated
- in people with heart failure. By this we suggest anyone who has a
diagnosis of heart failure or has been previously treated for this.
- in
people with renal failure
- in people with hepatic failure (as below)
Monitoring
If Rosiglitazone is to be prescribed:
- LFTs should be measured at baseline.
- If the ALT is more than
2.5x the normal range avoid Rosiglitazone.
- LFTs should be monitored
every 2 months in those prescribed Rosiglitazone.
- Rosiglitazone should
be stopped if ALT rises to more than 3x the normal range.
Remember you will usually be taking a patient off one drug
(Metformin or Sulphonylurea) which acts quickly and replacing it by
Rosiglitazone which acts slowly (because proteins have to be changed). The
patient should be advised to monitor blood glucose daily over the
changeover and report steadily rising results.
Diabetes