Medications for Diabetes Mellitus (Chapter 49)

To increase insulin production from the pancreas. Therefore, hypoglycemia is the major side effect with sulfonylureas.

• glipizide (Glucotrol, Glucotrol XL)
• glyburide (Micronase, DiaBeta, Glynase PresTab)
• glimepiride (Amaryl)

 Increase insulin production from the pancreas. However, unlike sulfonylureas, they are less likely to cause hypoglycemia. When taken before meals, pancreatic insulin production increases during and after the meal, mimicking the normal blood glucose response to eating (should be taken 30 minutes prior to eating).

• repaglinide (Prandin)
• nateglinide (Starlix)

Reduces glucose production by the liver. It also enhances insulin sensitivity at the tissue level and improves glucose transport into the cells. 

metformin ( Glucophage, Glucophage XR, Riomet, Fortamet, Glumetza)

 Do not use in patients with kidney disease, liver disease, or heart failure.

Do not use in people who drink excessive amounts of alcohol

Metformin

 Also known as Starch Blockers. Work by slowing down the absorption of carbohydrates in the small intestine. Taken with the first bite of each meal, they are the most effective in lowering post-prandial blood glucose. Effectiveness of these medications is measured by checking 2-hour postprandial glucose levels.

Sometimes referred to as "insulin sensitizers". They are the most effective for the people who have insulin resistance. They improve insulin sensitivity, transport, and utilization at target tissues. Because they do not increase insulin production, they will not cause hypoglycemia when used alone.

• Increased risk of myocardial infarction and stroke
• Do not use in patients with heart failure

Endogenous dipeptyl peptidase-4 normally inactivates the incretin hormones that increase insulin synthesis and decrease glucose production.  DPP-4 Inhibitors slow the inactivation of incretin hormones. Since the DPP-4 inhibitors are glucose dependent, they lower the potential for hypoglycemia.

Simulates one of the incretin hormones (Glucagon-like-peptide-1) found to be decreased in people with type 2 diabetes. Stimulates the release of insulin from the pancreatic B-Cells. 1) Suppression from the pancreatic B-cells, which reduces glucose output from the liver, 2) Reduction of food intake by increasing satietym thereby reducing caloric intake, and 3) slowing gastric emptying. It is NOT indicated for use with insulin.

• Amylin is a hormone normally co-secreted with insulin by the pancreas in response to food intake. It is indicated for type 1 diabetes and type 2 diabetics who have not achieved glucose control despite taking insulin at mealtimes. It is an adjunct to therapy, not a replacement for it. When taking concurrently with insulin, it provides for better glucose control. Works by 3 mechanisms: 1) slows gastric emptying, 2) reduces postprandial glucagon secretion, 3) increases satiety, thereby leading to decreased caloric intake. 
• *It is administered subcutaneously into the thigh or abdomen. It cannot be injected into the arm because absorption from this site is too variable. It CANNOT be mixed with insulin.

Can cause severe hypoglycemia when used with insulin.

B-adrenergic blockers

Thiazide and loop diuretics

• arcabose (Precose)
• miglitol (Glyset)

• pioglitazone (Actos)
• rosiglitazone (Avandia)

• sitagliptin (Januvia)
• saxagliptin (Onglyza)

• exanatide (Byetta)
• liraglutide (Victoza)

pramlintide (Symlin)

Weight gain, hypoglycemia

Weight gain, Hypoglycemia

Diarrhea, lactic acidosis; Needs to be held 1-2 days before IV contrast media given and for 48 hours after.

Gas, Abdominal Pain, Diarrhea

Weight gain, edema; Increased risk for cardiovascular events such as myocardial infarction and stroke.

Upper respiratory tract infection, sore throat, headache, urinary tract infection, diarrhea

Nausea, vomiting, hypoglycemia, diarrhea, headache

Hypoglycemia, nausea, vomiting, decreased appetite, headache.

• lispro (Humalog)
• aspart (Novolog)
• glulisine (Apidra)

Regular (Humulin R, Novolin R, ReliOn R)

NPH (Humulin N, Novolin N, ReliOn N)

• glargine (Lantus)
• detemir (Levemir)

• Onset: 15 min
• Peak: 60-90 min
• Duration: 3-4 hours

• Onset: 1/2 to 1 hour
• Peak: 2-3 hours
• Duration: 3-6 hours

• Onset: 2-4 hr
• Peak: 4-10 hr
• Duration: 10-16 hr

• Onset: 1-2 hr
• Peak: no pronounced peak
• Duration: 24+ hr

• Rapid-Acting
• Short-Acting
• Long-Acting

• Intermediate-acting insulin
• Combination Therapy (premixed)