Oral Hypoglycemic Drugs (OHD)

Group
Insulin secretagogue

Sub-group
Sulphonylurea (SU)

Generic name
Chlorpropramide Glibenclamide

Brand-name
Diabenese Daonil Euglicon Minidiab Glucotrol-XL Diamicron Diamicron-MR Glurenorm Amaryl

(mg/tab)
100 250 25 5 5-10 80 30 1 2 3 4 0,5 1 2 120 4 15 30 50 100 500 850

Daily dosage
100 - 500 2,5 - 1,5

D.O.A
24 - 26 12 - 24

Freq/ daily
1 1-2

p.o

Glipizide Gliklazide Glikuidone Glimepiride

5 - 20 80 - 240 30 - 120 0,5 - 6

10 - 16 10 - 20 24

1-2 1 1-2 1

15-30 mins a.c

d.c / p.c 24 24 100 - 300 250 - 3000 24 24 6-8 3 1-3 a.c / d.c / p.c 3 d.c / p.c 3 independ to meal schedule w/ 1st (suapan)

Glinid

Repaglinide

NovoNorm

Insulin sensitizer

Tiazolidindion

Nateglinide Rosiglitazon* Proglitazon

Starlix

Actos Glucobay Glucophage Glucovance

a-Glucosidase Inhibitor Biguanid Combination

Notes :

Acarbose Metformin Metformin + Glibenclamide

Biguanid + SU

Start OHD on small dosage and increase base on BG level response into pre-maximum dosage * not sold in Indonesia yet

Drug mechanism, Primary side-effect and A1c (Hb-glycocylate) decrease-effect

Group
Insulin secretagogue Sulphonylurea (SU) Glinid Biguanid / Metformin Tiazolidindion a-Glucosidase Inhibitor Insulin

Primary mechanism
Increase insulin secretion Increase insulin secretion Depress hepatic gulocose production Increase sensitivity to insulin Inhibit glucose absorption Depress hepatic glucose production, glucose-using stimulation

Primary side-effect
BW , hypoglicemic BW , hypoglicemic Diarrhea, Dyspepsia, Lactate-acidosis Oedema Flatulence, soft-fecal Hypoglicemic, BB

A1c %
1,5 2,5 % 1,5 2,5 % 1,5 2,5 % 1,3 % 0,5 1,0 % Normal potency

Insulin sensitizer Insulin

Type and D.O.A of Insulin drugs

O.O.A*
Regular NPH Lente Lispro** Aspart** Glargine
Notes :

P.O.A* Human-Insulin
23 1 10 4 12

Effective Duration*
36 10 16 12 18 34 34 24

Maximum Duration*
46 14 18 16 20

0,5 1,0 24 34 0,25 0,25 45

Analogue-Insulin
12 12 no peak 24

* in hour ** not sold in Indonesia yet

Insulin drugs sold in Indonesia

Type of Insulin
Fast-acting

Brand-name
Novo-Rapid** Humalog Actrpid Humulin-R Insulatard Human Monotard Human Humulin-N Mixtar 30/70 Humulin 30/70 Lantus**

Pharmaceutical
Novo (U-40 and U-100) Eli Lily (U-100) Novo (U-40 and U-100) Eli Lily (U-100) Novo (U-40 and U-100) Novo (U-40 and U-100) Eli Lily (U-100) Novo (U-40 and U-100) Eli Lily (U-100) Aventis

Peak effect*
24

D.O.A*
68

Short-acting

Intermediate-acting

4 12

8 24

Mixed-type

18

14 15

Long-acting

no peak

24

Notes :

* in hour

Treatment Management Algorthm for NIDDM

OVERWEIGHT TYPE
Penyuluhan DM menyeluruh Suggestion of Dietary & Physical exercise TA# TNA Evaluate 2 4 wks (based on clinical condition)

LOW-WEIGHT TYPE
Penyuluhan DM menyeluruh Suggestion of Dietary & Physical exercise TA# TNA Evaluate 2 4 wks (based on clinical condition)

Re-emphasize Dietary & Physical exercise TA# TNA Evaluate 2 4 wks (based on clinical condition)

Re-emphasize Dietary & Physical exercise + Insulin secretagogues (IS) TA# TNA Evaluate 2 4 wks (based on clinical condition)

1 OHD : B / PGa* / T**** TA# STT Evaluate 2 4 wks TA#

Combination*** of 2 OHD : Insulin secretagogues + PGa* / B / T Evaluate 2 4 wks

Combination*** of 2 OHD : between B / PGa* / T TA# TNA Combination*** 3 OHD : B + PGa* + T TA# TNA Combine*** 4 OHD : B + PGa* + T + Insulin secretagogues TA# TNA Evaluate 2 4 wks

TNA Combination*** 3 OHD : Insulin secretagogues + PGa* + B / T TA# TKOI ** TNA Insulin TNA Combine*** 4 OHD : Insulin secretagogues + PGa* + B + T TA# TKOI ** TNA Insulin TNA

TKOI **

TNA

Insulin

Evaluate 2 4 wks

Evaluate 2 4 wks

TKOI **

TNA

Insulin

Evaluate 2 4 wks

Evaluate 2 4 wks

Insulin

TKOI **

TNA

Insulin

Insulin

TKOI**

TNA

Insulin

TA TNA # * ** ***

Target is achieved Target is not achieved Target achieved when match the DM control criteria PGa is given only in normal fast BG level OICT = OHD and Insulin Combination Therapy (OHD at noon and Insulin at night) OHD combination theoritically can be given up to 4 type of OHD but so far theres only EBM (Evidence Base Medicine) for up to 2 type of DHO combination **** : In present day, Tiazolidindion is not given as a single medication in Indonesia

: : : : : :

TA TNA # * ** ***

Target is achieved Target is not achieved Target achieved when match the DM control criteria PGa is given only in normal fast BG level OICT = OHD and Insulin Combination Therapy (OHD at noon and Insulin at night) OHD combination theoritically can be given up to 4 type of OHD but so far theres only EBM (Evidence Base Medicine) for up to 2 type of DHO combination **** : In present day, Tiazolidindion is not given as a single medication in Indonesia

: : : : : :

Urinalysis 24 H ( mg.24H ) Oral and Insulin Combination Therapy (OICT)

OHD# Normal Microalbuminuria Macroalbuminuria < 30 30299 300

Urinalysis spesific ( /min )

< 20 20199 200

Urinalysis at time ( /mg creatine )

< 30 30299 300

Hypertensive Treatment On Diabetes

TD sistolik 130 140 mmHg TD diastolik 89 90 mmHg TD sistolik > 140 mmHg TD diastolik > 90 mmHg

TNA OHD + 5 IU of Intermediate-acting Insulin before night sleep

Lifestyle modification OHD can be stopped when the patient is already comfortable with Insulin therapy

If necessary, obtain dosage of 2-4 IU after day 3-4

3 Months TNA

If Insulin dosage > 30 IU/day, stop OHD Mixed-type Insulin (premixed) Night 1/3 of TID of Dietary & Physical exercise
TNA : Target is not achieved # : Oral Hypoglycemic Drugs TID : Total Insulin Dosage

Lifestyle modification

Selective b-Inhibitor

Diuretics

ACE Inhibitor

a-Inhibitor

AIIRA

1 2 Months TNA

Morning 2/3 of TID Incrase dosage

Replace with another 1st line OHD

Add another 1st line OHD

DM CONTROL CRITERIAS Good

Fast Blood Glucose (mg/dL) Post-prandial Blood Glucose (mg/dL) A1c (%) Total Cholesterol (mg/dL) LDL Cholesterol (mg/dL) HDL Cholesterol (mg/dL) Triglyceride (mg/dL) BMI (kg/m2) Blood Pressure 80109 80144 < 6,5 < 200 < 100 > 45 <150 18,523 130/80

Add another OHD (one of it is diuretics)

Microalbuminuria (+) or Clinical aluminuria / nephropathy

Intermediate
110125 145179 6,58 200239 100129 150199 2325 130140 / 8090

Bad
126 180 >8 240 130 200 >25 > 140/90 ACE Inhibitor / AIIRA Calcium antagonist non dihydropyridin group

Albuminuria Classification