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What is diabetes?
World Health Organizations definition of diabetes
A metabolic disorder of multiple aetiology
characterised by chronic hyperglycaemia with
disturbances of carbohydrate, fat and protein
metabolism resulting from defects in insulin
secretion, insulin action, or both.
IDF (2003):
developed countries...
...there is substantial evidence that it is epidemic in
many developing and newly industrialised
nations...
is certain to be one of the most challenging health
problems in the 21st century
2003* ________
A1C
7.0%
Normal values
mg/dl
Borderline
IFG/IGT
Diabetes
(mg/dl)
FPG
80-100
100-125
126
Up to 140
140-200
200
mg/dL
Random value:
diabetes
11.1
200
Fasting value:
impaired fasting glycaemia
5.6
100
diabetes
7.0*
126*
7.8
11.1
Glucose
synthesis
Glycogen
breakdown
140
200
Overnight of fasting followed by 75g of glucose in water and testing after 1 and 2 h
if more than 200mg/dl then diabetes
Adapted from A Desktop Guide to Type 2 Diabetes Mellitus, European Diabetes Policy Group 19981999
Glycogen
breakdown
Glycogen
breakdown
Lipid (fat)
breakdown
Liver
increasing glycogenolysis
in the liver and skeletal
muscles
increasing
gluconeogenesis in the
liver
Adrenaline increases
blood glucose levels by
stimulating glycogenolysis
and lipid breakdown
(lipolysis)
Glucose
uptake
Glucose
uptake
Liver
inhibits glycogenolysis
inhibits gluconeogenesis
Stimulates peripheral
glucose uptake in skeletal
muscle and adipose tissue
Synthesised by
pancreatic beta-cells
Series of biochemical
reactions converts
the precursor
molecule,
preproinsulin, into
insulin
Insulin is stored as
hexamers in
secretory granules
before release
70
Short-lived, rapidly
generated meal-related
insulin peaks (prandial)
60
Insulin (U/mL)
Insulin secretion
50
Sustained
insulin profile
(basal)
40
30
20
10
0
6:00
10:00
14:00
18:00
22:00
2:00
Time of day
Breakfast
Lunch
Dinner
6:00
360
360
Plasma insulin
pmol/L
Endogenous
glucose
appearance
Type 2 diabetes
Healthy individuals
120
60
12
8
4
60
20
mmol/L
Plasma glucose
240
240
0
mol/kg/min
15
10
5
Diabetes types
Type 1 diabetes
Characteristics
Type 2 diabetes
Characterised by insulin resistance and insulin deficiency
Degrees of resistance and deficiency vary but insulin
deficiency is key to developing diabetes
Gestational diabetes
Glucose intolerance first detected in pregnancy that often
resolves after the birth of the baby
Age of onset
Peak age
Body weight
Type 1
Type 2
1014 years
6070 years
Usually thin
80% obese
(excluding Asian origin)
50% obese
(when of Asian origin)
Symptoms
Acute onset
of symptoms
Heredity
Treatment
No
Insulin is
mandatory
Yes
Diet and tablets
Insulin required at a certain stage
Type 1 diabetes
Cause unknown
Type 2 diabetes
Incidence:
increasing worldwide
varies among ethnic groups
Age
Ethnic group
Genetic factors
Obesity
Physical inactivity
High calorie intake
Hypertension
Dyslipidaemia
Previous diagnosis of
gestational diabetes
Diabetic
complications
microvascular complications
retinopathy, nephropathy, neuropathy
Watkins et al. In: Diabetes and its Management 2003
Dehydration
Hyperventilation
Drowsiness/confusion
Vomiting
Hypothermia
Low potasium
Incidence per
1000 patient-years
Myocardial infarction
Stroke
Cardiovascular/heart disease
Associated with:
Atherosclerotic plaque
stenosis
stenosis
Angina, myocardial
infarction (MI), heart failure
May be confused with
hypoglycaemia because of a
lack of pain
Immediate and long-term
mortality increased in
diabetes
Patients (%)
80
Diabetic
60
40
20
10
Non-diabetic
0
0
(a)
5
6
4
Serum cholesterol
(mmol/L)
Non-diabetic
subjects
Subjects with
type 2 diabetes
100
80
60
40
20
0
(b)
0
1
2
3
Number of risk factors
stop smoking
treat hypertension
treat hyperlipidaemia
improve glycaemic
control
reduce weight in the
obese
take regular exercise
Nephropathy
Neuropathy
Risk of retinopathy
progression
16
12
8
4
0
0
9 10 11 12
Risk of developing
microalbuminuria
16
12
8
4
0
0
HbA1c (%)
DCCT. N Engl J Med 1993;329:97786
9 10 11 12
Damage to the
microvascular
circulation
Retinopathy (eyes)
Nephropathy
(kidneys)
Neuropathy
(autonomic and
peripheral nerves)
Nephropathy- 5 stages
1st stage-kidney is enlarged and glomerular filteration rate(GFR) is elevated No clinical
symptoms
2nd stage-Normoalbuminuria; albumin excretion <30mg/24h
3rd stage Incipient nephropathy-clinical evediance show;
Microalbuminuria albumin loss at >30mg/24hr <300mg/24hr
BP
(a)
(b)
Probability of
microalbuminuria
(c)
2
1
0
1
2
1.60
1.85
2.10
2.35
2.60
16
Log glycated haemoglobin (log %)
12
8
4
0
0.8
6
7
8
9
10 11
Glycated haemoglobin (%)
12
6
7
8
9
10 11
Glycated haemoglobin (%)
12
0.6
0.4
0.2
0.0
antihypertensive agents
good blood glucose control
control of dyslipidaemia
monitoring renal function
lifestyle changes,
STOP smoking
Retinopathy-2 stages
Diabetic retinopathy, 2 stages;
35
30
25
20
15
10
5
0
4
10
6.7
7.7
9.8
10.8
8.8
DCCT HbA1c (%)
11.9
16
Conventional therapy
12
p<0.001
8
4
Intensified therapy
Time (years)
Diabetic foot
30
Patients (%)
Patients (%)
40
20
Conventional
Intensive
60
20
10
10
Years
10
14%*
21%*
37%*
43%*
*p<0.0001
Targets from:
ADA
IDF
AACE
Fasting plasma
glucose (mmol/
L)
<5.6
7.2
<6.0
<6.1
Postprandial
plasma glucose
(mmol/L)
<7.8
<10.0
(peak)
<8.0
(12 h)
<7.8
(2 h)
HbA1c (%)
<6.0
<7.0
<6.5
6.5
ADA, American Diabetes Association; IDF, International Diabetes Federation; AACE, American
Association of Clinical Endocrinologists
Treatment of
type 2
diabetes
Diabetes treatment
Type 1:
Pancreas
Type 2:
Hyperglycemia
Therapy:
Diet/Exercise
21%
Oral products
54%
Oral/Insulin
7%
Insulin
18%
Muscle
Liver
Increased Hepatic
Glucose Production
Decreased Glucose
Utilization
Insulin Resistance
Sulphonyl Meglitinides
Biguanides
(PGRs)
ureas (SU)
Hyperglycemia
Liver
Insulin sensitizers
Glitazones
Biguanides
Insulin Resistance
Muscle
Prandial
Glucose
Regulators
Glitazones
Pioglitazone
Rosiglitazone
-glucosidase GLP-1/DPP-IV-inhibitors
inhibitors
Acarbose
Sitagliptin
Insulin Secretion
Sulphonylureas
Sulphonyl Meglitinides
Biguanides
(PGRs)
ureas (SU)
Pancreas
Glitazones
-glucosidase GLP-1/DPP-IV-inhibitors
inhibitors
Insulin Secretion
Meglitinides (glinides)
Sulphonyl Meglitinides
Biguanides
(PGRs)
ureas (SU)
Glitazones
Pancreas
-glucosidase GLP-1/DPP-IV-inhibitors
inhibitors
Diamicron (Servier)
Glimepiride: Amaryl (Aventis)
Insulin sensitizers
- Increases glucose
uptake by the muscles
- Decreases liver glucose
production
Liver
Muscle
Sulphonyl Meglitinides
Biguanides
(PGRs)
ureas (SU)
Biguanides
Metformin
Glitazones
Rosiglitazone: Avandia
Pioglitazone: Actos
Side effects:
bowel upset
lactic acidosis
Side effects:
weight gain
water retention
Contraindicated if any history of liver disease or heart failure
Glitazones
-glucosidase GLP-1/DPP-IV-inhibitors
inhibitors
Alpha-glucosidase inhibitors
Primarily control of post-prandial
hyperglycaemia
Insulin Secretion
Pancreas
Sulphonyl Meglitinides
Biguanides
(PGRs)
ureas (SU)
Glitazones
-glucosidase GLP-1/DPP-IV-inhibitors
inhibitors
Sulphonyl Meglitinides
Biguanides
(PGRs)
ureas (SU)
Glitazones
-glucosidase GLP-1/DPP-IV-inhibitors
inhibitors
DPP-IV inhibitors
Inhibit the breakdown of incretin hormones (GLP-1)
Liraglutid
Exenatide
DPP-IV inhibitors
Sitagliptin
Weight neutral
Cause few adverse events (nausea)
Sitagliptin: Januvia (MSD)
Metformin
Glitazones
Pioglitazone
Rosiglitazone
-glucosidase
-inhibitors
Acarbose
DPP-IVinhibitors
Sitagliptin
Combination
Therapy
Sulphonyl Meglitinides
Biguanides
(PGRs)
ureas (SU)
Monotherapy
Insulin sensitizers
Insulin secretagogues
Glibenclamide Repaglinide
Gliclazide
Glipizide
Glimepiride
Others
Antidiabetic treatment
Sulphonylurea
Metformin
Repaglinide
Acarbose
Pioglitazone
Rosiglitazone
Sulphonylurea + Metformin
Sulphonylurea + Pioglitazone
Sulphonylurea + Acarbose
Metformin + Repaglinide
Metformin + Pioglitazone
Metformin + Rosiglitazone
Insulin monotherapy
Insulin + oral agents
HbA1c
FBG (mmol/l)
1.5% - 2.0%
1.0% - 2.0%
0.8% - 1.7%
0.5% - 1.0%
0.6% - 1.9%
0.7% - 1.8%
2.8 - 3.3
2.8 - 3.3
1.7 - 2.2
1.1 - 1.7
3.1 - 3.3
3.1 - 3.3
~1.7%
~1.2%
~1.3%
~1.4%
~0.7%
~0.8%
~ 3.6
~ 2.8
~ 2.2
~ 2.2
~ 2.2
~ 2.8
open to target
open to target
open to target
open to target
Contents
History of diabetes and insulin
Diabetes and
Insulin
Insulin types
Insulin treatment regimens
Designer insulins
Discovery of insulin
Experiments in Toronto
University
FG Banting, surgeon
CH Best, medical college
student
30 July 1921
Leonard Thompson
(1908-1935)
Insulin characterisation
Connecting peptide
s-s
s-s
A-chain
ss
B-chain
Origin of insulin
Animal
Beef
Pork
Human
Types of insulin
Intermediate-acting
Intermediate-acting
Mixtures of short and intermediate- acting (biphasic)
Insulin concentration
All insulin marketed in the UK is 100 IU/ml*
For example a pack with 5 x 3ml cartridges:
5 x 3ml x 100 units = 1500 units
With average daily consumption of 55 units/day (including air
shots) the pack lasts around 25 days
Type 1:
Adults:
Adolescents:
Honey moon:
Type 2:
Mainly adults
Subcutaneous injections
Intravenous administration
Injection sites must be rotated
Insulin should be injected
subcutaneously (sc)
in emergencies, only
Insulin developments
Meal
DCCT
Meal
Meal
400
pmol/min
Lispro
Human insulin
Purified insulin
Lente insulin
NPH insulin
PZI
Discovery of insulin
Insulin aspart,
Insulin glargine
200
1920
1930
1940
1950
1960
1970
1980
1990 2000
00:00 02:00 04:00 06:00 08:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 00:00
Time
Breakfast
Blood sugar
Mealtime
insulin
Lunch
Evening Meal
Onset
Peak
Duration
Background insulin
Action
Time
Soluble
Action
Clear
Onset
30 minutes
Peak
1 - 3 hours
Duration of action up to 8
hours
Time
Note: The graphical representation above is for educational and illustrative purposes only
UK/DB/0711/0351 Date of Preparation July 2011
Action
Time
Note: The graphical representation above is for educational and illustrative purposes only
UK/DB/0711/0351 Date of Preparation July 2011
Once daily
Twice daily
Onset of
action
Maximum
effect
Duration
13 hours
8 hours
Insulatard
1.5 hours
412 hours
24 hours
Monotard
2.5 hours
715 hours
24 hours
4 hours
824 hours
28 hours
0.5 hours
28 hours
24 hours
Short-acting
Actrapid
Intermediate
Long-acting
Ultratard
Premixed *
Mixtard
Introduction
to insulin
analogues
Rapid-acting
analogues
Basal
analogues
Biphasic
premixed
analogues
Generic name
Trade name
Manufacturer
Insulin aspart
NovoRapid
Novo Nordisk
Insulin lispro
Humalog
Lilly
Insulin glulisine
Apidra
Sanofi
Insulin detemir
Levemir
Novo Nordisk
Insulin glargine
Lantus
Sanofi
Biphasic insulin
aspart
NovoMix
Novo Nordisk
Biphasic insulin
lispro
Humalog Mix
Lilly
Peak (min)
Duration (h)
Regular human
insulin1
3060
120180
68
Insulin lispro
152
30702
2-5
Insulin aspart
10203
40903
35
Insulin glulisine
204
555
Not available
1Oiknine.
Drugs 2005;65:32540
2Prescribing
3Prescribing
4Becker.
5Becker.
Diabetes 2004;53(Suppl.2):A119
Hypoglycaemia
Hypoglycaemic awareness
Immunogenicity
Adverse events
Insulin Glargine
(Lantus)
Onset (h)
Peak (h)
Duration (h)
NPH insulin1
12
57
1318
Insulin
glargine
121
No peak2
20301
Insulin
detemir3
123
683
244
1Oiknine.
Drugs 2005;65:32540
2Prescribing
3Prescribing
4Heise.
Hypoglycaemia
Incidence of hypoglycaemia,
especially nocturnal hypoglycaemia,
generally lower than with human
insulin
Immunogenicity
No immunogenicity concerns
Adverse events
Similar to NPH
Rapid-acting
insulin aspart
Intermediate-acting
protamine-crystallised
insulin aspart
NovoMix 30
Premixed
suspension
rapid absorption
slower absorption
Protamine-crystallised
insulin aspart
No
vo
M
ix
ix
vo
M
No
ix
M
vo
30% soluble aspart
covers prandial insulin needs
No
30%
50%
70%
50%
70
50
70%
30%
Rapid-acting insulin
analogue together with
a basal insulin analogue
provide physiological
insulin replacement
Onset (min)
Peak (h)
Duration (h)
Biphasic
human
premixed
3060
28
1424
Biphasic
insulin aspart
1020
1-4
Up to 24
Biphasic
insulin lispro
1020
1-4
12-20
Profiles are
schematic
- basal component
NovoMix30
STAND ALONE MONOTHERAPY
Coloured cartridges
Simplicity improvements
Lower dose force
Colour-coded
cartridges
Presentation title
Modern Insulin Training Camp
May 2008
Date
Slide no 24