EN 9/10: PHARMACOLOGICAL MANAGEMENT OF DIABETES

Diabetes facts

~830 Million people worldwide have diabetes

~40 Million in the United States

~100,000 deaths in US

1/3rd of diabetics are unaware of their disease

90% have Type 2 diabetes: Symptoms = no at the beginning

Leading cause of blindness in adults → retinopathy (lots of glucose at back of eye)

Twice as likely to develop heart disease

Diabetes = Obesity / Obesity = Diabetes ?

Chronic Complications of Diabetes mellitus

foot ulcers

can lead to gangrene + eventually amputation

diabetic retinopathy

hemmorhages and microaneruysms

Opportunistic Infections of diabetes

Lipodystrophy of Diabetes

when you inject insulin to the same place over and over

can add more fat to one place and take away the fat from another

Oral Manifestations of Diabetes

1. periodontal disease - poorly controlled diabetes, suppuration = pus

2. Acute Pseudomembranous Candidiasis, not same appearance as albicans

3. Oral candidiasis is associated with an increase in:
   • Increased salivary glucose
   • Xerostomia
   • Impaired immune response
   • Opportunistic infections
   • Poor wound healing

4. lichen planus - tx by steroids

5. parotid enlargement (extraoral) - affects facial nerve can → face pain

6. severe xerostomia

Goals of Management

Lifestyle changes (workout, eat better, etc)

Deal aggressively with comorbidities (retinopathy, neuropathy)

Cardiovascular health and risk factors

Maintain HbA1c levels consistently

Metformin…To prescribe or not to prescribe?

Shorten the duration of uncontrolled Diabetes

Lengthen life expectancy

Manage the Disease or the Syndrome?

METABOLIC SYNDROME characterized by high levels of blood
glucose resulting from-

1.Defect in insulin production/ secretion

2.Defect in insulin action/ Glucose uptake

3.Both

Chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism

Concerns: Long–term damage, system dysfunction and failure of
various organs due to gluconeogenesis can lead to Incidental / Emergent hypoglycemia in the dental environment

gluconeogenesis

creation of new glucose from fats and amino acids

Types of Diabetes

Type 1 Diabetes mellitus - immune condition

Type 2 Diabetes mellitus - 95% pt

Gestational Diabetes - no history of diabetes + no familial link, primigravida (preggo for the 1st time)

Prediabetes - elevated glucose lvls

Other types:

LADA (Latent Autoimmune Diabetes in Adults- Type 1.5)

MODY (Maturity onset diabetes of youth- Rare)

Monogenic Diabetes Mellitus (linked to chromosomal abnormalities)

What is Diabetes insipidus?

a pt lacks ADH from posterior pituitary so they constantly pee

treated w diuretics due to paradoxical effect

Gestational diabetes

A form of glucose intolerance during pregnancy.

More frequent among African Americans, Hispanic/Latino Americans, Southeast Asians

Obese women with a family history of diabetes

Normalize maternal blood glucose levels to avoid complications in the infant.

After pregnancy, 5-10% have type 2 diabetes.

Women with GD have a 20-50% chance of developing diabetes in the next 5-10 years.

LGA Babies(Large for Gestational Age)

extra glucose goes to baby and they gain weight

cannot be born vaginally due to cephalous being too big for mothers pelvis

Other types of DM

Other specific types of diabetes result from specific genetic conditions

Maturity-onset diabetes of youth

Surgery

Drugs

Malnutrition

Infections

Such types of diabetes may account for 1% to 5% of all diagnosed cases of diabetes.

Drug induced Diabetes Mellitus

Atypical Antipsychotics

Beta-blockers (-olol)

Calcium Channel Blockers (-dipin)

Corticosteroids (-sone)

Fluoroquinolones (-floxacin)

Niacin

Phenothiazines

Protease Inhibitors (-navir)

Thiazide Diuretics

Furosemide

Lithium/ Alcohol/ Opioids/ Rodenticides

Pharmacological Management of Diabetes Mellitus: ABCs

a. diet

Appropriate nutrition

Dietary treatment should aim at:

Ensuring weight control

Providing nutritional requirements

Allowing good glycemic control

Correct blood lipid abnormalities

Monitoring daily intake

Decreasing salt intake

Classification of Hypoglycemic agents: Biguanides

Reduce hepatic glucose production and increase insulin sensitivity.

do not require functioning pancreas

e.g., Metformin

Classification of Hypoglycemic agents: Sulfonylureas

Stimulate insulin secretion from pancreatic beta cells.

require functioning pancreas

e.g., Glipizide, Glimepiride

Classification of Hypoglycemic agents: Meglitinides

Stimulate rapid, short-acting insulin release

require functioning pancreas

e.g., Repaglinide, Nateglinide

Classification of Hypoglycemic agents: Thiazolidinediones (TZDs)

Enhance insulin sensitivity in muscle and adipose tissue.

do not require functioning pancreas

e.g., Pioglitazone, Rosiglitazone

Classification of Hypoglycemic agents: DPP-4 Inhibitors

Increase insulin release and reduce glucagon levels by inhibiting the DPP-4 enzyme.

Sitagliptin, Linagliptin

Classification of Hypoglycemic agents: SGLT2 Inhibitors

Reduce glucose reabsorption in the kidneys, leading to increased glucose excretion in urine.

Dapagliflozin, Empagliflozin

Classification of Hypoglycemic agents: GLP-1 Receptor Agonists

Mimic incretin hormones to boost insulin secretion and reduce glucagon
release

Semaglutide, Liraglutide

Classification of Hypoglycemic agents:

Slow carbohydrate digestion in the gut.

Acarbose, Miglitol

ways to give Insulin

types of insulin

know brands too

Combination oral agents is indicated in

Newly diagnosed symptomatic patients with HbA1c >10

Patients who are not reaching targets after 3 months on monotherapy

Consider intermediate-acting / long-acting insulin

Insulin dose can be increased until target FPG is achieved. (sliding scale method to determine insulin requirements in units)

C. Insulin Therapy: When to use?

Short-term use: (hospitalized or something)

Acute illness, surgery, stress and emergencies

Pregnancy

Breast-feeding

Insulin used as initial therapy in type 2 diabetes

In emergency hyperglycemia

Severe metabolic decompensation (diabetic ketoacidosis, hyperosmolar non-ketotic coma, lactic acidosis, severe hypertriglyceridemia)

drug of choice for type 1 diabetes

insulin

ADA:SUMMARY OF GENERAL MANAGEMENT

Assess Glycemic control

Refer patients with signs of undiagnosed diabetes to a physician for diagnosis and treatment

Obtain a consult with the patient's physician if systemic complications are present

Assess the use of medications for oral complications

Use a glucometer to avert dental chair emergencies

Aggressively treat acute oral infections

Schedule patients for frequent recall visits to monitor and treat oral complications

Maintain optimal oral hygiene and diet

Support and follow up patients in smoking-cessation programs

metformin/ glucophage max daily dose

the maximum recommended dose is typically 2000 mg per day

Treatment of Hypoglycemia