dm - DOC by u8ONa2

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									                         2
           1.                          ( oral hypoglycemic agents )
           2.
1.                               ( oral hypoglycemic agents )1-4
                                                                      2
                      3
    1.1 Sulfonylurea                                                        sulfonylurea
receptor          ATP-dependent K+channel plasma membrane               beta cell
cytosolic calcium                                                      hepatic glucose
output          insulin sensitivity               3 generation
    First generation : Chlorpropamide
    Second generation : Glibencamide , Glipizide , Glicazide , Gliquidone
    Third generation : Glimepiride , Glicazide MR
                          Chlorpropamide
                          SIADH              hyponatremia                 hypoglycemia

     1.2        Rapid   acting          non-sulfonylurea       insulin   secretagogue
                                                     sulfonylurea             receptor
                                    sulfonylurea                               half life
                1                                            hypoglycemia
                                                                 15
                 hypoglycemia                                Repaglinide ( Novonorm )
Nateglinide ( Starlix )

2.                                  ( insulin sensitizer )
     2.1       Metformin

metformin               hypoglycemia

                                                                           lactic acidosis
                            renal insufficiency ( serum creatinine             1.5 ./ .)
                                          lactic acidosis

     2.2        Thiazolidinedione



                 Rosiglitazone ( Avandia )                      Pioglitazone ( Actos )
                                                              (        monotherapy    )
                                                                                    4-5
                                           hemoglobin

                                                     2



3.                                          ( alpha- glucosidase inhibitor )
                                a l p h a -     g l u c o s i d a s e
                                                                                (
postprandial glucose )                                                  ( fasting
plasma glucose )                                                         systemic
side effects
       acarbose ( Glucobay )                            voglibose ( Basen )

                                                             1




        1                                                                      2

                                     ( .)
                                                                 (         )
 Chlorpropamide            125 – 500               1               > 48
 Glibencamide              2.5 – 20               1–2            12 – 24
 Glipizide                  2.5 – 30              1–2            12 – 18
 Glicazide                   40 – 320             1–2            12 – 24
 Gliquidone                  30 – 240             1–2            12 – 18
 Glimepiride                  1–8                  1               24
 Glicazide MR                30 – 120              1               24
 Repaglinide            0.5 – 2 .(                                2–6
 Nateglinide              120 . (                                 2–4
 Metformin                500 – 3,000                 2–3         5–6
 Rosiglitazone                4–8                     1–2
 Pioglitazone               15 – 45                    1
 Acarbose              50 –100 . (        )                          2–4
 Voglibose             0.2 – 0.3 .(       ))                         2–4



                                                                                    2
                                                                 ( insulin defeciency
) /                          ( insulin resistance )              ( body mass index
:BMI              25         . .. . )
                                                                        sulfonylurea
                                       compliance

                                                                    chlorpropamide
                        (body mass index :BMI                       25 . . . .)
                   metabolic syndrome                 ,                     , HDL-
cholesterol
                                                                      metformin
                                                    alpha- glucosidase inhibitor

                                     140     ./ .                  rapid acting non-
sulfonylurea                                                          secretagogue

                                                                   thiazolidinedione



                                                                                  2

       1.




sulfonylurea
       metformin       thiazolidinedione                                          2

        2.                                          sulfonylurea       rapid acting
non-sulfonyourea                       insulin                        secretagogue

      metformin       thiazolidinedione                                   metformin
                      thiazolidinedione
           3.                                alpha-glucosidase                             inhibitor

           4.                                   2

                                         2
1




            1                                                 2


                At Diagnosis                               Medical Nutrition Therapy
    Fasting plasma glucose < 200 mg/dL
    Casual plasma glucose < 250 mg/dL                   And Exercise ( within 3 months)



             At Diagnosis                                   Oral Hypoglycemic Agent
Fasting plasma glucose 200-350 mg/dL
Casual plasma glucose 250-400 mg/dL

                                                          BMI > 25              BMI < 25


                                                         Metformin              Sulfonylurea
                                                                                        target not reach in 4-8 wk
                                                                   Combination
                                                           Different group of oral drugs
                                                            (Awareness of side effect)
                                                                                        target not reach in 4-8 wk
                                                    Combination of Oral Agent + Bedtime Insulin
                                                    (intermediate or long acting) : insulin stage 1
                                                                                        target not reach in 4-8 wk

            At Diagnosis                       Insulin stage 2 + insulin enhancer (BID Regimen)
Fasting plasma glucose > 350 mg/dL                         R/N-0-R/N-0, LP/N-0-LP/N
Casual plasma glucose > 400 mg/dL
          5-9
2.




                                                                      species

human insulin           biogenetic engineering ( recombinant DNA techniques )
                                                                     antibody



                                                                              2
                                                        insulin      analogue
                        insulin lispro, aspart                    basal insulin
     insulin glargine
         2 Human insulin
Insulin preparation trade names             onset       peak           effect     maximum
                                          of action   of action       duration    duration
Rapid acting
   Lispro , aspart Humalog,Novorapid 15-30 min        30-90 min        3-4 hr      4-6 hr
Short acting
   Regular          ActrapidHM,HumulinR 30-60 min     2-4 hr           3-6 hr       6-8 hr
Intermediate acting
   NPH (isophane) HumalinN,InsulatardHM 1.5-4 hr      4-12 hr         10-16 hr    14-24 hr
   Lente ( zinc ) Monotard HM           3-4 hr        6-12 hr         12-18 hr    16-24 hr
Long acting
   Ultralente       Ultratard HM        6-10 hr       10-16 hr         18-20 hr   20-24 hr
   Glargine         Lantus              4-12 hr       No peak          18-20 hr   20-24 hr
Combinations
   NPH/Regular
   80/20,70/30, Mixtard 20,30,40,50 30-60 min           Dual           10-16 hr 14-18 hr
   60/40, 50/50 Humulin80/20,70/30,
                    60/40,50/50


     -
     -                               1                   ,          diabetic ketoacidosis,
hyperosmolar non-acidotic diabetes ,




                             human insulin
         -       ( allergy )      ( resistance )
         -



         -
             human    insulin

         -           lipoatrophy                                conventional

     -
     -
       -
       - Lipodystrophy
       -
       -
                                                                    aqueous humor



  1.
       1.1
                                                                           bleeding
disorder
      1.2 Diabetic ketoacidosis, hyperosmolar non- acidotic diabetes
      1.3 Severe hyperglycemia        fasting plasma glucose         300-350     ./ .



        2.                                                                     1.1-1.3

                            1                                                       2

        3.                                                                          2




      -                           diabetic ketoacidosis, hyperosmolar non- acidotic
diabetes
                                ( multiple sucutanious injection )
        -             1                           2

                          titration
20                                    2/3            1/3
                                                                1/3



                                                            3        4
                            NPH             RI
70/30           50/50
        -   2

        -            2
                                                    100
                 0                                                2
                                                    thiazolididione

        -
                                 2



                                                                     1

        -                                                      3
                                                   basal insulin

        -         2              mixed and split           premixed
hypoglycemia        3               3               NPH
hypoglycemia                                    short acting
     -                   2              ( multiple injection )
                                                                 home     monitoring

1
            -

                                            0.6                           mixed and
split

10-20
            -                                                                3
                                                         7



                -                                                                  RI
                                                                                 NPH
                                                                                   RI
                                                                                 NPH

                                                                            multiple
injection               algorithm                                                1-2
                                                                  40-50       ./ .

post-receptor       defect




        -           metformin
        -            alpha-glucosidase inhibitor
     -                            sulfonylurea                                       2




                           (0.1                        1          .)

         -            thiazolidinedone

Reference
1. American Diabetes Association. Pharmacologic intervention. In management of type
   2 diabetes,4th edition.Verginia : Library of congress, 1998:56-72.
2. Williams G, Pickup JC. Management of type 2 diabetes. In handbook of diabetes,2 nd
   edition.Oxford: Blackwell Science Ltd, 1999:87-94.
3. Schnell U, Mehnert H, Standl E. Oral antidiabetic agents: Sulfonylureas. In diabetes
   in the new millennium. Sydney: Pot still press,1999:195-202.
4. Kikuchi M. New antidiabetic drugs. In diabetes in the new millennium. Sydney: Pot
   still press,1999:239-50..
5. American Diabetes Association: Insulin administration ( Position statement )
   Diabetes Care 2001; 24 ( Suppl 1 ):S94-S97.
6. Linde B. The pharmacokinetics of insulin. In : Pickup J, Williams G,eds. Textbook of
   diabetes. Oxford: Blackwell Science Ltd,1991:371-83.
7. European diabetes policy group. A desktop guide to type 1 ( insulin dependent )
   diabetes mellitus. Diabet Med 1999;16:253-6.
8. Yki-Jarvinen H, Kauppila M, Kujansuu E, Lahti J, Marjanen T, Niskanen L, et al.
   Comparison of insulin regimens in patients with non- insulin dependent diabetes
   mellitus.N Engl J Med 1992;327(20):1426-33.

								
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