2.  GLP -1 (gut hormone) + GIP = incretin effect =Augmentation of insulin after oral glucose  Type 2 diabetics little incretin effect  Reduced GLP-1 secretion  GIP lost insulinotropic property  GLP-1 broken down by DPP-4  Only for type 2 diabetes

3.  Inhibits incretin breakdown  Indirectly increase own insulin secretion  Moderate HBA1c reduction (~1%)  Which one to choose?

4.  Start – 2 nd line: Metformin or Sulphonylurea + HBA1c ≥ 6.5% + not suitable for other one – 3 rd line: Metformin + Sulphonylurea + HBA1c ≥ 7.5% – Thiazolidinedione is an alternative in 2 nd line case but not 3rd Continue – HBA1c reduces by ≥ 0.5% in 6 months

5.  DPP-4 Inhibitor if:  Weight gain would cause significant problem  Thiazolidinedione contraindicated eg heart failure  Previous intolerance or poor response to Thiazolidinedione

6.  GLP -1 (gut hormone) + GIP = incretin effect =Augmentation of insulin after oral glucose  Type 2 diabetics little incretin effect  Reduced GLP-1 secretion  GIP lost insulinotropic property  GLP-1 broken down by DPP-4  Only for type 2 diabetes

7. Effects:  Stimulates post-prandial insulin secretion  Slows gastric emptying  Reduces appetite Administered:  Subcutaneous injection  Twice daily

8.  Less hypos compared to insulin  BIG benefit of weight loss  Only licensed to lower blood sugars, not as weight loss agent  Nausea and vomiting  £830 per person per year

9.  Start:  BMI ≥ 35 (+ probs assoc. with high wt)  BMI < 35 + insulin unacceptable or weight loss beneficial to co-morbidities  Continue Metformin and Sulphonylurea  Combination with insulin  Continue:  HbA1c reduction ≥ 1.0% AND  Initial body weight reduction ≥ 3%

11.  Metformin still first line  DPP-4 Inhibitors alternative where Thiazolidinediones were previously only other oral option  Exenatide - good for weight loss but ?help in sugar control  Further new drugs on their way