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Type 2 Diabetes Across Generations: From Pathophysiology to Prevention and Management

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Type 2 Diabetes Across Generations: From Pathophysiology to Prevention and Management Nolan, Christopher J., Damm, Peter, Prentki, Marc Management of Type 2 Diabetes ... – PowerPoint PPT presentation

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Date added: 20 July 2018
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Title: Type 2 Diabetes Across Generations: From Pathophysiology to Prevention and Management


1
Type 2 Diabetes Across Generations From
Pathophysiology to Prevention and
Management Nolan, Christopher J., Damm, Peter,
Prentki, Marc Management of Type 2 Diabetes New
and Future Developments in Treatment Tahrani, Abd
A., Bailey, Clifford J., Del Prato, Stefano,
Barnett, Anthony H. The Lancet, July 9th 2011
Rachel McLaughlin University of Georgia Pharm D.
candidate October 25, 2012
2
Diabetes Mellitus
  • Characterized by insufficient insulin secretion,
    resistance to insulin, or both
  • Type 1 complete absence of insulin due to
    autoimmune destruction of the ß-cells of the
    pancreas
  • Type 2 resistance to insulin, leading to
    inadequate insulin production
  • 90 of all patients with diabetes
  • Insulin resistance characterized by increased
    resistance in the muscle and liver, increased
    gluconeogenesis in the liver, hyperglycemia,
    increased lipolysis, increased plasma free fatty
    acids and triglycerides

3
Pathophysiology
  • Excess calories- but obesity does not equal
    diabetes
  • Subcutaneous adipose tissue vs. visceral adipose
    tissue and organs
  • Islet ß-cells (insulin) unable to compensate the
    excess fuel
  • Increased glucagon secretion, reduced incretin
    response
  • Inflammation of the adipose tissue (cytokine
    release)
  • Finally, development of peripheral insulin
    resistance

4
Pathophysiology
  • Genetic
  • Heritability is highly confirmed in diabetes
  • There are over 40 diabetes-associated loci in the
    genome
  • Environment
  • Intrauterine growth restriction associated with
    numerous adult diseases including DM2
  • Women with DM2 at time of pregnancy linked to
    higher occurrences of diabetes and obesity in the
    child
  • Low vitamin D and B12 implicated
  • Diet and sedentary lifestyle

5
Medications
http//healthplant.wordpress.com/2010/01/30/diabet
es-a-report/
6
  • BUT... continued ß-cell dysfunction
  • Need to sustain glycemic control, halt declining
    ß-cell function, improve insulin activity, while
    avoiding hypoglycemia and severe side effects

7
The Incretins
  • Secreted in the intestines in response to
    nutrients in order to lower blood glucose
  • Stimulates insulin secretion, glucagon
    suppression
  • Slows gastric emptying and reduces food intake
  • Animal studies reduces severity of MI and
    improves left ventricular ejection fraction
  • GLP-1 decreased amount in diabetics

8
GLP-1 mimetics
  • Exenatide (Byetta) and liraglutide (Victoza)
  • Once weekly Bydureon showed sustained weight loss
    and glycemic control for 2 years
  • Oral non-peptide agents that activate GLP-1
    receptor have been identified and some animal
    studies are being done

9
Non-incretin ß-cell stimulants
  • Glucokinase activators
  • Glucokinase phosphorylates glucose once in the
    cell and affects how fast it is metabolized and
    thus initiates insulin secretion
  • Piragliatin and other compounds increased insulin
    concentration and reduced glucose
  • But also showed some increased triglycerides and
    maybe hypoglycemia
  • Synthetic activators of certain G-protein-coupled
    receptors on ß-cells
  • Potentiate glucose induced insulin secretion and
    improved glucose tolerance in animals

10
In the Kidneys
  • The kidneys reabsorb glucose in the proximal
    tubule, mostly through sodium-glucose-cotransporte
    r 2 (SGLT2)
  • In diabetes, this may be enhanced because of
    SGLT2 upregulation so inhibiting SGLT2 can
    increase glusocuria enough to lower blood glucose
  • people with a familial renal glucosuria have a
    mutation here and have glucosuria without any
    complications
  • Dapagliflozin, canagliflozin, and others
  • Reduce fasting and postprandial plasma glucose
    and A1C
  • Low risk of hypoglycemia and can used in
    combination, including insulin

11
Bromocriptine
  • Sympatholytic D2 Dopamine agonist
  • Mediates effects via resetting of the
    dopaminergic and sympathetic tone in the central
    nervous system
  • Type 2 diabetics are believed to have a drop in
    dopaminergic tone in the early morning
  • Only the quick-release form (Cycloset) has been
    proven to lower fasting glucose and A1C, and
    reduced the risk of cardiovascular disease

12
Others
  • Bile acid sequestrants (Welchol)
  • Reduced A1C 0.5 when in combination with
    metformin, SU, or insulin
  • Metabolic surgery gastroplasty, gastric bypass,
    lap bands, biliopancreatic diversion
  • 78 of patients had resolution of their diabetes
  • Not any long-term outcomes studied

13
Conclusion
  • Type 2 diabetes will always require a
    patient-specific treatment plan
  • Side effects play a big role in the risk-benefit
    analysis for each patient
  • Promising treatments are in development to lower
    blood glucose and maybe preserve ß-cell function
  • Metformin likely to remain first-line
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