Diabetic Drugs Adverse effects , Tapering

and ComplicationsDR Paawan Wadhawan

MBBS,MD(Medicine)Consultant Physician

DiabetologistCritical Care Specialist

Sujok Therapist

Anti Diabetic Drugs –OHA’s• Alpha-Glucosidase Inhibitors

• These medications help lower blood glucose by assisting the body with breaking down starchy foods and table sugar. For the best results, they’re taken before meals. Options include:

1. acarbose (Precose)-50 -100 mg2. miglitol (Glyset)-25,50, and 100 mg3. Voglibose-0.2 and 0.3 mg.

Biguanides

• Biguanides decrease glucose production in the liver. They decrease intestinal glucose absorption and increase insulin sensitivity. They also help muscles absorb glucose. • The most common biguanide

is metformin -500,1000 SR(Glyciphage,Gluconorm).

• Metformin can also be combined into a single medication with other type 2 medication types. It is included as an ingredient in:

• •metformin-alogliptin (Kazano)• •metformin-canagliflozin (Invokamet)• •metformin-glipizide • •metformin-glyburide (Glucovance)• •metformin-linagliptin (Jentadueto)• •metformin-pioglitazone (Actoplus)• •metformin-repaglinide (PrandiMet)• •metformin-rosiglitazone (Avandamet)• •metformin-saxagliptin (Kombiglyze XR)• •metformin-sitagliptin (Janumet)• •glyburide-metformin (Glucovance)

DPP-4 Inhibitors(Dipeptidyl peptidase-4 inhibitor)

• DPP-4 inhibitors help the body preserve insulin production by inhibiting the enzyme which deactivate Incretins. They work by reducing blood glucose without causing hypoglycemia. Options include:• alogliptin (Nesina)-6.25,12.5, and 25 mg• linagliptin (Trajenta,Ondero)-5 mg• saxagliptin (Onglyza)-2.5 and 5 mg• sitagliptin (Januvia)-25,50 and 100 mg.• Vildagliptin(Jalra,Galvus)-50 mg• Tenlegliptin-20 mg

Glucagon-Like Peptides

• These are similar to the natural hormone incretin. Options include: Inj.-s/c

•albiglutide (Tanzeum)-30 mg,50 mg single dose pen•dulaglutide (Trulicity)-0.75,1.5 mg •exenatide (Byetta)-2 mg•liraglutide (Victoza)-0.6,1.2,1.8 mg

Meglitinides

•These medications stimulate insulin release. Repaglinide- (Prandin,Eurepa)- 0.5, 1 and 2 mg.•Nateglinide(Starlix)-60 and 120 mg.

SGLT2 Inhibitors

• Sodium glucose transporter (SGLT) 2 inhibitors work by preventing the kidneys from holding onto glucose. Instead, SGLT2 promotes excretion through the urine. The forms of this medicine available are: • Dapagliflozin (Farxiga)-5 and 10 mg• Canagliflozin (Invokana) -100 and 300 mg.• Empagliflozin (Jardiance) -10 and 25 mg.

• High risk of foot amputation

Sulfonylureas

• These are among the oldest diabetes medications still used today. They work by stimulating the pancreas with the help of beta cells. In turn, more insulin is produced. Sulfonylureas come in the form of:

•Glimepiride-1,2 and 4 mg (Amaryl,G1,G2,Glador,Zoryl,Gemer)•Gliclazide -60,80 mg(Reclimet,Diamicron)•Glipizide (Glucotrol)-5,10 mg•Glibenclamide-2.5 and 5 mg (DiaBeta, Glynase,Daonil, Micronase)

Thiazolidinediones

• These medications work by decreasing glucose in the liver, while also promoting insulin efficacy in fat cells.

• Pioglitazone (Pioz or P in any tablet) -7.5 and 15 mg. • Many combinations in market-TRI----- P

Insulin –Anabolic Hormone• T2DM -------HYPERINSULINEMIA-high IGF

• Exogenous INSULIN-----Cells Overgrowth--- • OBESITY CANCER

• Lancet Oncology (2010), the women with high concentration of insulin and IGF in the blood have seven times higher chances of suffering from cancer than the women with low concentration of insulin and IGF in the blood.• Journal of National Cancer Institute (2000, 2002), men who produce

high level of IGF are nine times more likely to have prostate cancer.

Insulin types

Insulin Degludec

Protocol for stopping OHAs

My Experience

•Type 1 Diabetes –Insulin tapering•Unpredictable•20-30 percent cure rate•Earlier the patient comes better• Maintainance diet is better then raw diet

Case study•Amaryl M2 forte BD +• Jalra M 50/500 OD +• Invokana 300 mg Od

Case 2• Injection Insulin Tresiba 30 U HS• Inj. Insulin Human Actrapid-

10,10,10• Tab Trajenta Duo 5/500 OD

• Fasting sugar is high• PP is High

Case 3• Tab Geminor MP2 BD• Injection Insulin Lantus 30 U HS• Tab Jardiance 25 OD

Case 4• Injection Victoza 0.6 mg Od• Tab pioz 15 BD• Tab Glyciphage 500 BD• Tab Teniva 20 mg OD

Case 5• Injection Insulin Mixtard 30/70-40-----0--------35Tab Amaryl M 2 ODTab Pioz 15 OD

• Patient has CAD• LFT is high

Case 6• Injection Insulin Mixtard 30/70• 25 -----0--------20• Tab Metformin 500 BD

• Serum Creatinine is 2.5• Repeated episodes of

hypoglycemia

Cholesterol Lowering Drugs-Statins

• Stop all Cholestrol Drugs• Educate the patient about Indo-Vietnam medical board guidelines

• Be careful if Patient has Hypothyroid• If the patient was taking drugs for a long time –be slow.• Thyroid drugs should be tapered very slowly

Case study• Tablet Glador M 2 Forte BD• Tab Januvia 100 mg Od• Tablet Farxiga 10 mg OD• Tab Rosucor –F 20 HS• Tab Thyronorm 100 ug OD

• FBS is 350• Lipid are High• TSH is 6.5

Case study • Tab zerofat BD• Tab Atorva –F 40 BD• Tab Triexer 3 BD• Tab Olanax F OD

Antihypertensive Drugs

DIURETICS

Beta Blockers

Nebivolol

•2.5/5 mg

Renin and ACE Inhibitors

ARBs

Calcium Channel Blockers

Calcium Channel Blockers

Miscellanious

Tapering Antihypertensives• Intense Raw BRC diet salt free• 5drugs ------3 drugs (21 d)• 3------------1(21 d)• 1------------0(21 d)

• Vegan BRC diet• 5 drugs-----------4• Wait for 21 days• 4-----------3(21 days)• 3------------2(21 d)• 2----------1(21 d)• 1---------0(21 d)

Blood thinners in Heart patients• Aspirin 75 -100

mg,Prasugrel(10), Ticagrelor 30-60 mg), and Clopidogrel(75)

• If post stenting less then 1 year-Continue same • If more then 1 year-only Aspirin• If stable patient only Aspirin

• Try to substitute warfarin or Pradaxa(Dabigatran) with eliquis (Abcixiban)tabs.

Key points• Always try to stop beta blockers first but slowly .• Shift from others to Nebivolol• Chlorthalidone and Hydrochlorthiazide are toxic for pancreas• If kidney patient stop very very slowly.

Case study• Tab Telma Am 40/5 BD +• Tab Aten 50 BD• Tab Lasix 40 BD• Tab Clavix AS 75/75 OD• Tab Atorva 40 mg OD

Case study -T2DM –CAD –Stenting one month Ago• Tab Brillinta 90 BD• Tab Atorva 40 HS• Tab Metolar XL 25 BD• Tab Cardace 5 BD• Tab Gemer MP2 BD• Tab Jalra M OD• Tab COQ 300 OD

Case 3----Serum Creatinine is 8.0• Tab Arkamine 0.1 mg TDS• Tab Clavix As 75/75 OD• Tab Folvite 5 OD• Tab Alpha D3 ).5 OD• Tab Shelcal 500 TDS• Tab Trajenta 5 OD• Injection Insulin R 7-7-7• Tab Aten 25 BD• Tab Amlodipine 5 BD• Tab Thyronorm 100 OD• Tab Ultracet BD• Tab Zolfresh 10 HS

Patients referred to Specialist• Kidney patient• Cancer• Autoimmune problem• Type 1 Diabetes• DVT

Diabetes Emergency-Diabetic ketoacidosisTreatment -5 litre Water, cooked diet ,Drips,Insulin

Hyperosmolar Coma

Hypoglycemia• Glucagon Injection -1 mg IM/SC• Give sweets • Always Warn the Patient On BRC

diet.

Chest pain• Refer

Stroke

Breathlessness

•500 sugar without any symptoms is not emergency

•ONLY GOD CAN GIVE GUARANTEE•WE CAN ONLY HELP

•Smile Thanks