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Clinician’s Corner: DIABETES MELLITUS OVERVIEW Type-2

DIABETES MELLITUS OVERVIEW Type-2

We all know what Type-2 diabetes looks like.  We all know this is a rapidly growing disease.  Lots of your friends and family have it.  I won’t spend a lot of your precious time discussing the incidence of this very common disease.  One factor stands out.  The incidence of T2DM was about 1% of our nation when the sulfonylureas came to market in the mid 1950’s.  Just in that short span the incidence of diabetes mellitus Type-2 is now almost ten times that. Your Thompson Pharmacist spends a lot of time filling medications for this disease.

A Center for Disease Control and Prevention (CDC) report finds that as of 2015, 30.3 million Americans – 9.4 percent of the U.S. population –have diabetes. Another 84.1 million have prediabetes, a condition that if not treated often leads to type 2 diabetes within five years. The patient profile is typically adults over 40, with a higher frequency in overweight teens.

Cause: poor insulin metabolism in the body, or reduced insulin production by pancreas, or both.

After several years of insulin resistance, insulin production decreases.  The result is the same as Type-1, glucose builds up in blood and body cannot make efficient use of its source of fuel.

Sulfonylurea history:  1950’s medicine!

The first oral diabetes medications became available in the 1950’s.  These drugs push insulin out of the pancreas whether blood sugars are high or low.  Therefore, they run the risk of hypoglycemia (low blood sugar)

Common adverse events: include weight gain, hypoglycemia, and water retention. First-generation sulfonylureas tend to produce an increase in adverse events, ionically bind to plasma proteins, and lead to more drug–drug interactions.

FIRST GENERATION SULFONYLUREAS    (still available as of 2019-seldom used)

GENERIC NAME Available in USA DAILY DOSE RANGE DURATION of ACTION “EQUIV.

DOSE”

Tolbutamide

(Orinase®)

May 1957 500-2000mg/day in divided doses 6-12 hours 1000mg
Tolazamide

(Tolinase®)

July 1966 100-1000mg/day in divided doses Up to 24 hours 250mg
Chlorpropamide

(Diabinese®)

Oct 1958 100-500mg single dose 24-72 hours 250mg
Acetazolamide

Dymelor®

1964 Not available    

SECOND GENERATION SULFONYLUREAS

GENERIC NAME Available in US DAILY DOSE RANGE DURATION of ACTION “EQUIV

DOSE

Glyburide

(Micronase)

(Diabeta)

May 1984 1.25- 20mg/ day in single or divided doses Up to 24 hours 5mg
Micronized Glyburide (Glynase®) March 1992 1.5-18mg/day in single or divided doses Up to 24 hours 3mg
Glipizide (Glucotrol®) May 1984 2.5-40mg/day in single or divided doses 6-12 hours 10mg
Glipizide-XL Glucotrol-XL® April 1994 Up to 20-30mg daily Up to 24 hours 10mg
Glimepiride

Amaryl®

Nov 1995 1-4mg as a single dose Up to 24 hours 2mg

Who’s at risk for sulfonylurea induced hypoglycemia?

(Duration of hypoglycemia in overdose of some sulfonylurea agents can be up to 72 hours.)

  • A single tablet of glipizide or glyburide can cause dangerous hypoglycemia in infants or toddlers.
  • Risk factors for sulfonylurea-induced hypoglycemia include young age, malnutrition, alcohol use, and kidney or liver disease.

SULFONYLUREAS?  Yeah, they are cheap, but should we be practicing 1950’s medicine?

  • Metformin is always first line for type 2 diabetes. Start at first visit when first diagnosed
  • Don’t trash Sulfonylureas completely as they lower A1C about 1% and cost about $10/month instead of up to $800/month for the newer meds like the GLP-1’s (Ozempic, Trulicity and Victoza).
  • Consider sulfonylureas when cost is a concern, such as with uninsured patients.
  • Since they’re likely cranking out insulin sulfonylureas may be a good choice for patients within about 5 years of diagnosis.
  • Caution about use in elderly patients or those with lower kidney function. Avoid glimepiride and glyburide. Glipizide is least likely to cause hypoglycemia in these patients.

Your Thompson Pharmacist is a great resource for affordability with all medications, especially medications to control diabetes.  Go Ahead and ASK, at Thompson Pharmacy… it’s all for YOU!