Diabetes Treatment (cont.)
Medications that increase the insulin output by the pancreas - sulfonylureas
and meglitinides
Sulfonylureas
Historically, increasing insulin output by the pancreas has been the major
area targeted by medications used to treat type 2 diabetes. Medications that
increase the output of insulin belong to a class of drugs called sulfonylureas.
Sulfonylureas primarily lower blood glucose levels by increasing the release of
insulin from the pancreas. Older generations of these drugs include
chlorpropamide and tolbutamide, while newer drugs include glyburide (DiaBeta),
glipizide (Glucotrol), and glimepiride (Amaryl). These drugs are effective in
rapidly lowering blood sugar but run the risk of causing hypoglycemia
(abnormally low and dangerous levels of blood sugar). In addition, they are
sulfa-containing drugs and should be avoided by patients who are allergic to
sulfa .
Meglitinides - repaglinide (Prandin) and nateglinide
(Starlix)
The class of drugs known as meglitinides is relatively new. Meglitinides also
work on the pancreas to promote insulin secretion. Unlike sulfonylureas that
bind to receptors on the insulin producing cells, meglitinides work through a
separate potassium based channel on the cell surface. Unlike the sulfonylureas
which last longer in the body, repaglinide (Prandin) and
nateglinide (Starlix)
are very short acting, with peak effects within one hour. For this reason, they
are given up to three times a day just before meals. Since these drugs also
increase circulating insulin levels, they may cause hypoglycemia, but the
literature suggests this is less frequent than the hypoglycemia seen with
sulfonylureas.
Prandin
In a three month study, repaglinide (Prandin) dropped fasting blood glucose
values by 61 mg/dL and post meal blood glucose values by 100 mg/dL. Because
Prandin is short acting and given before meals, it is particularly beneficial in
lowering blood glucose after meals and does not tend to lower fasting glucose
levels to the same degree. Prandin has been used in combination with other
medications, such as metformin (Glucophage), with impressive results. In 83
patients with type 2 diabetes, blood sugar control improved significantly with
the addition of Prandin to Glucophage.
Prandin interacts with other medications. Therefore, the doctor must be aware
of all other medications a patient is taking before prescribing Prandin. The
usual starting dose is 0.5mg before each meal and can be increased to 4mg. The
maximum daily dose is 16mg. Prandin is used with caution in people with kidney
or liver abnormalities. Since Prandin increases insulin levels, it has the risk
of causing abnormally low blood sugars. Blood sugars that remain severely low
can result in sweating,
tremors,
confusion, and may lead to
coma and
seizure. In
addition, the use of Prandin has been associated with headaches, muscle and
joint aches, along with sinus infections in some individuals. This drug should
not be used in pregnancy or
by nursing mothers. The dose may need to be adjusted in older people, since the
elderly may metabolize (eliminate) medications at a slower rate.
Starlix
Nateglinide (Starlix) has
essentially the same profile of side effects and interactions as Prandin. The
major benefit of Starlix is that the starting dose of 120mg does not need to be
adjusted upward, but rather remains constant. These medications are also
relatively safe to use in people with impaired kidney function.
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