1. Drugs used in Diabetes Dr Sally Hudson

2. BIGUANIDES reduce output of glucose from the liver and enhances uptake and use of glucose by muscle cells ExampleADVANTAGESDISADVANTAGESCOSTCaution Metformin 500mg/850mg/1g ORAL Weight reduction No hypo’s UKPDS evidence Hba1c 1.5% Nausea, vomiting abdo. Pain, diarrhoea,anorexia/ loss apetite Risk lactic acidosis Avoid eGRF<30 CHEAPRenal failure Hepatic failure and alcoholism as increase risk of lactic acidosis Metformin M/R 500mg,750mg,1g ORAL Once daily Weight reduction No hypo’s Still GI side effects Less than standard formulation Risk lactic acidosis ModerateRenal failure

3. SULPHONYLUREAS stimulate insulin release from the pancreas. ExampleADVANTAGESDISADVANTAGESCOSTCaution GLICLAZIDE 80MG RAPID ONSET ACTION ORAL Hba1c HYPO’S WEIGHT GAIN GI SIDE EFFECTS LIVER FUNCTION CHEAPELDERLY DRIVERS GLICLAZIDE m/R 30MG ONCE DAILY ORAL

4. Postprandial glucose regulators Postprandial glucose regulators stimulate a rapid, short duration release of insulin from the pancreas. This helps to restore the normal physiological insulin response to meals. Example ADVANTAGESDISADVANTAGESCOSTCaution Repaglinide 500mcg 30min before meals Up to 4mg as single dose Reduce post prandial BG Reduce Hba1c up to 2% Suitable patient erratic lifestyle or hypo’s on sulphonylureas Weight gain hypoglycaemia cheapRenal impairment hepatic impairment

5. THIAZOLINDIONES(GLITAZONES) Thiazolidinediones reduce insulin resistance in adipose, skeletal, and hepatic tissues by increasing transcription of insulin sensitive genes in these cells. ExampleADVANTAGESDISADVANTAGESCOSTCaution PIOGLITAZONE 15MG.30MG, 45MG ONCE DAILY ORAL IMPROVED LIPID PROFILE 0.5-1.5% Hba1c WEIGHT GAIN Fracture risk Risk heart failure Anaemia maculopathy EXPENSIVECi HEARTFAILURE

6. DPP-4 INHIBITORS block the action of DPP-4 which increases the availability of GLP-1. ExampleADVANTAGESDISADVANT AGES COSTCaution SITAGLIPTIN (januvia) WEIGHT NEUTRAL ONCE DAILY 100mg ORAL Improves fasting glucose Improves B cell function (Triple therapy licence metformin,gliclazide,glitaz one) Mono therapy licence if unable to take metformin. GI SIDE EFFECTS NASOPHARY NGITIS EXPENSIVEAdverse effects pancreatitis Vildagliptin (galvus) Saxagliptin (onglyza)

7. INCRETIN MIMETICS Beta cells: Enhances glucose-dependent insulin secretion Stomach: Helps slow gastric emptying Liver: ↓ Glucagon which reduces hepatic glucose output Alpha cells: ↓ Postprandial glucagon secretion Promotes satiety and reduces appetite. ExampleADVANTAGESDISADVANTAGESCOSTCaution EXENATIDELOW HYPO RISK WEIGHT LOSS INJECTED TWICE DAILY NAUSEA BLOATING EXPENSIVEPANCREATITIS Severe renal impairment LIRAGLUTIDEONCE DAILY LOW HYPO RISK WEIGHT LOSS BP REDUCTION INJECTED NAUSEA BLOATING EXPENSIVEPANCREATITITS MEDULLARY THYROID CA Severe renal impairment

8. INSULIN ExampleADVANTAGESDISADVANTAGESCOSTCaution LONG ACTING ANALOGUES LANTUS AND LEVEMIR Effective Tailored regime HYPO RISK WEIGHT GAIN Lantus cancer risk moderateHGV/PSV DRIVERS Short acting Humalog novorapid Reduces postprandial glucose Rapid Use as part of basal bolus Weight gain Hypo’s moderate Mixed Humalog mix 25 Novomix 30 Only twice dailyLess flexible Hypo’s moderate

9. Erectile impotence PDE5 inhibitors NameDosedurationCautionCISE Sildenafil Viagra 25-100mg Single dose 1 hour before intercourse Take on empty stomach Onset action 25 min delayed if taking food Duration action 4-5 hours CVD Anatomical deformation penis Predisposition to priapism Not in patients on nitrates. Within 4 hours of alpha blockesr Indigestion Headache facial flushing Tadalafil Cialis 10mg-20mg at least 30min before max- 20mg in 24 hours Onset action 16-45 min Duration 36 hours Not in patients on nitrates. Alpha blockers Indigestion Headache Vardenafil levitra 5-20mg 25-60 min before Can eat/drink Onset action 25 min. Delayed by fatty meal. Duration 4-5 hours Not in patients on nitrates. Alpha blockers Headache facial flushing