management diabetes tipe 2

Diabetes Mellitus - Nutritional Guidelines
 
 
 
  #        Desirable
body weight:
  - Males: 106 lb
for 1st 5 feet, then 6 lb per inch
  - Females: 100 lb
for 1st 5 feet, then 5 lb per inch
  - Add or subtract
10% for large or small frames
  - Physician should
write the diet prescription indicating total calories, nutrient distribution,
and special requirements
 
 
 
Diabetes Mellitus- Nutritional Guidelines
 
 
 
              #        Carbohydrate:
  - 40 - 60% Reduce for hypertriglyceridemia
            #        Protein:
  - 10 -20%
  #          Fat:
            - Less than 30%
            a.             
Saturated less than
10%
            a.             
Polyunsaturated less than
10%
            a.             
Monounsaturated less than
20%
            - Cholesterol less than 300mg/dy
            - Sodium less than 300mg/dy
            - Fiber 20-35g/dy
 
 
 
Exercise and Diabetes
 
 
 
  #        Adjunct to
diet and/or drug therapy
  #        Improves
glycemic control
  #        Maintains
weight loss
  #        Reduces
cardiovascular risk factors
  #        Psychological
well being increased
  #          Pre
exercise evaluation important
  #        Stress ETT
if indicated
 
 
 
Pharmacologic Therapy of Type 2 Diabetes
 
 
 
  #          Oral
hypoglycemic agents
  #        Sulfonylureas
  - 1st generation
  - 2nd generation
  - "New"
second generation agents - Glucotrol XL; glimepiride
  #        Biguanides
  - Metformin
  #        Alpha
glucosidase inhibitors
  - Acarbose
  #        Thiazolidinediones
  - Troglitazone
  #        Insulin
  #        Insulin
plus oral agents
 
 
 
Sulfonylureas: Mechanisms of Action
 
 
 
  #        Enhanced
insulin secretion
  - Direct beta cell
effects
  #        Proposed
enhancement of insulin action
  - May potentiate
glucose metabolism in muscle and insulin-stimulated glucose uptake
  #        Effects
correlate with reduced hepatic glucose production
 
 
 
Sulfonylureas
 
 
 
  #          1st
generation
  - Relatively low
potency
  - Some with long
duration of action (chlorpropamide)
  - Many drug-drug
interactions
  #          2nd
generation
  - Higher initial
efficacy (60-80%)
  - Fewer drug-drug
interactions
  - Still with
likelihood of hypoglycemia with long acting agents (glyburide)
 
 
 
Sulfonylureas - 1st Generation
 
 
 
  #        Multiple
agents: tolbutamide, tolazamide, chlorpropamide, acetohexamide with active
metabolites
  #        Drug-drug
interactions
  #        Hyponatremia
(chlorpropamide)
  #        Prolonged
hypoglycemia
  #        Alcohol
flush
 
 
 
Sulfonylureas - 2nd Generation
 
 
 
  #          High
efficacy: 60-80% effective
  #          Free
water diuresis
  #        Inactive
metabolites
  #          No
alcohol flush
  #        Fewer
drug-drug interactions
  #          Still
potential for prolonged hypoglycemia
  #          New
formulations with altered absorption profiles
  - Glucotrol XL
  - Glimepiride
 
 
 
 
Sulfonylureas: Administration
 
 
 
  #          Start
with lowest effective dose
  #        Increase
dose every 1 - 2 weeks until control achieved
  #        Patients
who respond to therapy usually respond to submaximal dose of agent
 
 
 
 
Sulfonylureas- When to Avoid
 
 
 
  #        Allergy
  #        Severe
renal or hepatic disease
  #        Recurrent
hypoglycemia
  #        Alcoholism
  #        Avoid
long-acting, potent agents in the very elderly or malnourished
  #        Sulfonylureas
and cardiovascular disease
  - No clear
evidence of potentiation of myocardial disease with OHAs despite early study
(UDGP) to the contrary
 
 
 
 
Metabolic Effects of Metformin
 
 
 
  #        Lowers
fasting plasma glucose by 20-30% mainly by reducing hepatic gluconeogenesis
  #        Improves
insulin sensitivity- may increase insulin levels because of reduction in
glucose toxicity
  #        Combination
therapy with sulfonylureas has additive effects with further lowering of blood
glucose by 20-30%
  #        Lowers
total and LDL cholesterol and triglycerides by about 5%
  #          May
cause some weight loss - mainly adipose tissue
  #          No
change in BP
  #          No
change in serum lactate concentrations -
  - increases lactate
oxidation -
  - decreases lactate
conversion to glucose
  - reported
incidence of lactic acidosis - 3 per 100,000 patient years (patients had renal
dysfunction)
                                #        Lowers
vitamin B12 levels but anemia is rare
 
 
 
 
Adverse Effects of Metformin
 
 
 
  #        Common and
persistent:
  - Early satiety
and anorexia
  - Abdominal
bloating and discomfort
  #        Common and
usually transient:
  - Flatulence
  - Nausea Diarrhea
  - Metallic taste
in mouth
  #        Rare:
  - Vitamin B12
deficiency
  - Persistent
diarrhea
  - Lactic acidosis
 
 
 
 
Metformin - Contraindications
 
 
 
  #        Metabolic
acidosis
  #        Renal
disease
  - Creatinine >
1.5 (males); > 1.4 (females)
  #        Liver
disease
  #        Alcohol
abuse
 
 
 
Contraindications to Metformin
 
 
 
  #        Acute
renal failure
  #        Hypoxia
  #        Cardiovascular
collapse
  #        Acute
myocardial infarction
  #        Severe
infection
  #          Use of
contrast iodine media
  #        Surgery
 
 
 
Acarbose(Precose)
 
 
 
  #        Alpha-glucosidase
inhibitor
  #        Delays
carbohydrate absorption and reduces postprandial hyperglycemia
  #        Preprandial
administration
  #        Starting
dose at 25 mg (before one or all meals) to a maximum of 100 mg with the first
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