DIABETES MELLITUS

TODAY
DIANA W. GUTHRIE RN, PhD
2006
DEFINITION & THE PROBLEM
• CRITERIA FOR DIAGNOSIS
• DEFINITION
• PATHOPHYSIOLOGY
• PREVALENCE
• OBESITY
• METABOLIC SYNDROME
 Glucose Tolerance Categories
FP 2-hr PG on
G OGTT
mg/d mg/d
L Diabetes L Diabetes
Mellitus Mellitus

100 and <126 Prediabet

Glucos
140 and Prediabet
Toleranc
e es es
e

<100 Norm < Norm

al 140 al

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care.
2002;25(suppl):S5
 Etiologic Classification of
Diabetes Mellitus
Type 1 -cell destruction with
lack of
insulin
Type 2 Insulin resistance with
insulin
deficiency
Other specific Genetic
defects in -cell Types exocrine pancreas
diseases,

Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-
Diabetes Trends* Among Adults in the
U.S.,
(Includes Gestational Diabetes)

19 19
90 95

20
01

Source: Mokdad et al., Diabetes Care 2000;23:1278-83;

J Am Med Assoc 2001;286:10.
Prevalence of Diabetes in
Adults

<4%         4–6%            

 Obesity Trends* Among U.S. Adults
BRFSS, 1991-2002
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4”

1 1

No Data <10% 10%–14% 15%–19% 20%–24%

DNPA
DNPA
Graphics:
Diabetes Trends* Among Adults in the
Graphics:

U.S.,
(Includes Gestational Diabetes)

Source: Mokdad et al., J Am Med

Assoc 2001;286:10.
 Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI(*BMI
≥30, oror~
30, 30lbs
~ 30 lbs overweight
overweight for 5’4” for 5’ 4”
person)

No Data <10% 10%–14% 15%–19% 20%–24%

Source: Behavioral Risk Factor Surveillance System, CDC

 GLOBAL  PROJECTIONS FOR THE 
DIABETES EPIDEMIC: 2003­2025 (millions)

World
2003 = 194 million
2025 = 333 million
Increase 72%
 Diabetes Today: An Epidemic
• 20.8 million Americans have
diabetes
• 1.5 million new cases in 2005
more than 3500 each day
• Complications of diabetes are
a major cause of mortality and
morbidity (2002 statistics)
90% of patients with diabetes are
treated by primary care
physicians

ADA National Diabetes Fact Sheet. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf. Accessed April 11, 2005;
ADA Diabetes Statistics. Available at http://www.diabetes.org/utils/printthispage.jsp?PageID=STATISTICS_233181. December 29,
2005.
 Total Cost of Diabetes in the US, 2002

Total Cost
$132 billion

Nursing home & hospice

$14.4 billion Mortality Disability
Outpatient care/
home health & $21.5 billion $18.3 billion
medications
$37.1 billion
Inpatient care
$40.3 billion

Indirect Costs
Health Care Expenditures $39.8 billion
$91.8 billion
American Diabetes Association. Diabetes Care. 2003;26(3):917-932.
The Problem
 Modern Life Has Both
Conveniences

Illustration taken from: Lambert C, Bing C. The Way We Eat Now. Harvard Magazine. May-June, 2004;50.
 METABOLIC SYNDROME
• Obesity- high waist to hip ratio
• Hyperlipidemia
• Hyperinsulinemia
• Hypertension
• Hyperglycemia
• Acanthosis Nigricans
• PCOS
ACANTHOSIS NIGRICANS
ACANTHOSIS NIGRICANS
ACANTHOSIS NIGRICANS
 Waist/Hip Ratio
An Index of Abdominal Versus

High WHR Low WHR

( (
 

American Diabetes Association

Visceral Fat Distribution
Normal vs Type 2 Diabetes

Normal Type 2 Diabetes

Courtesy of Wilfred Y. Fujimoto, MD.

And America Continues to Enjoy
Strong Economic Growth……………………………..
 Course of Type 2 Diabetes Uncontrolled
Obesit I Diabet
Hyperglyce
y FG es
mia
350
–
300 Postmeal Glucose
–
250
Glucos –
200 Fasting Glucose
e –
150
(mg/dL –
100
–
50
–
250
–
200 Insulin
Relativ – Resistance
e 150
–
Functio 100
n –
50 -cell Failure
–
0
– -1 - 0 5 1 1 2 2 3
0 5 0
Years of Diabetes 5 0 5 0
*IFG=impaired fasting glucose.
Burger HG, Loriaux DL, Marshall JC, Melmed S, Odell WD, Potts JT, Jr., Rubenstein AH. 2001. Diabetes
Mellitus, Carbohydrate Metabolism, and Lipid Disorders. Chap. in Endocrinology. 4th ed. Edited by Leslie J.
DeGroot and J. Larry Jameson. Vol. 1. Philadelphia: W.B. Saunders Co. Originally published in Type 2
Diabetes BASICS. (Minneapolis, International Diabetes Center, 2000).
 Factors That May Drive the
Progressive Decline of Beta-cell
Hyperglycemia Insulin
(glucose Resistanc
toxicity)
e

 - “Lipotoxicity”
(elevated FFA*,
TG*)
cell
*FFA=free fatty acids; TG=triglycerides.
Adapted from: Kahn SE. J Clin Endocrinol Metab. 2001;86(9):4047-4058.
Adapted from: Ludwig DS. JAMA. 2002;287(18):2414-2423.
 Progression to Type 2 Diabetes
Insulin Acquired:
Genetic Factors •Obesity
resistance
•Sedentary lifestyle
Hyperinsuline •Aging
mia
Compensated insulin
resistance
Normal glucose tolerance
ß-cell
decompensation
Impaired glucose
tolerance
Glucose and/or
Genetic Factors ß-cell fat toxicity
“failure”
Kruszynska Y, Olefsky JM. J Invest Med.
1996;44:413-428.
Med. Type 2
Weyer C, et al. J Clin Invest. 1999;104:787-794. diabetes
The Importance of Targeting Insulin
Resistance
Over 90% of type 2 diabetics are Insulin Resistant

Complex Endothelia
Dyslipidem l Systemic
ia Dysfuncti Inflammati
 TG, on
sdLDL

Disordere Insulin
Atheroscleros
d
Fibrinolys
Resistance is

Viscer
Hypertensi al
on Obesit
Adapted from the Consensus Development Type 2 of the American
Conference
Diabetes Association. Diabetes
Diabetes Care. 1998;21(2):310-314.
ETIOLOGY OF T1DM

DQ* D C B A

SHORT ARM # 6 CHROMOSOME

 IMPORTANCE OF GLUCOSE
CONTROL
• DCCT
• KUMAMOTO
• UKPDS
• IN-PATIENT CONTROL
 Complications of Diabetes
Macrovascul Microvascul
ar ar
Brain
Cerebrovascular disease Eye
• Transient ischemic Retinopathy
attack Cataracts
• Cerebrovascular Glaucoma
accident
• Cognitive impairment

Heart
Coronary artery disease
• Coronary syndrome
• Myocardial infarction
• Congestive heart
failure
Kidney
Nephropathy
• Microalbuminuria
• Gross albuminuria
• Kidney failure

Extremities
Peripheral vascular Nerves
disease Neuropathy
• Ulceration • Peripheral
• Gangrene • Autonomic
• Amputation
 Good Glycemic Control (Lower
HbA1c) Reduces Incidence of
DCCT Kumamoto UKPDS
HbA1c   

Retinopathy 63% 69% 17-21%

Nephropathy 54% 70% 24-33%
Neuropathy 60% – –
Macrovascular 41%* – 16%*
disease

* not statistically significant

Diabetes Control and Complications Trial (DCCT) Research Group. N Engl J Med.
Med. 1993;329:977-986.
Ohkubo Y et al. Diabetes Res Clin Pract.
Pract. 1995;28:103-117. 29
UK Prospective Diabetes Study Group (UKPDS) 33: Lancet.
Lancet. 1998;352:837-853.
Glycemic Goals For Diabetes
 IN-HOSPITAL MANAGEMENT
• PREVALENCE
• SURGERY
• MI
• INFECTION
• ICU
 Consensus:
Glycemic Targets in the Hospital
• Intensive care unit
– 110 mg/dL (6.1 mmol/L)
• Medical/surgical floors
– 110 mg/dL (6.1 mmol/L) preprandial
– 140 mg/dL (7.78 mmo/L) maximal
glucose
Values above 180 mg/dL (10 mmol/L) are an indication to monitor glucose levels
more frequently to determine the direction of any glucose trend and the
need for more intensive intervention. Achieving these targets may require
consultation with an endocrinologist or diabetes specialist.
American Association of Clinical Endocrinologists. Available at:
http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.
 Diabetes in Hospitalized
Patients
• Fourth most common co-morbid
condition among hospitalized
patients
• 10–12% of all hospital discharges
• 29% of all cardiac surgery patients
• 1–3 days longer hospital stay

Hogan P, et al. Diabetes Care. 2003;26:917–932.

American Association of Clinical Endocrinologists. Available at:
http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.
 Hyperglycemia in Patients
With Undiagnosed Diabetes
• Hyperglycemia occurred in 38% of patients
admitted to the hospital
– 26% had known history of diabetes
– 12% had no history of diabetes
• Newly discovered hyperglycemia was associated
with:
– Higher in-hospital mortality rate (16%) compared with
patients with a history of diabetes (3%) and patients
with normoglycemia (1.7%; both P < 0.01)
– Longer hospital stays; higher admission rates to

Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–

982.
 Higher Costs:
Diabetes in Hospitalized
• Higher rate of hospitalization
• Longer stays
• More procedures, meds.
• Chronic complications
• More arteriosclerotic disease-
• More infection
Hyperglycemia Is an Independent Marker of
Inpatient Mortality in Patients With
P < 0.01

P < 0.01

In-hospital
Mortality Rate
(%)

Patients Patients Newly

With With History Discovered
Normoglycemia of Diabetes Hyperglycemia

Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–

982.
 Hospital Mortality Rate and
Mean Glucose Levels in

Mortality
Rate (%)

Mean Glucose Value (mg/dL)

Retrospective review of 1,826 consecutive intensive care unit
patients
at The Stamford Hospital in Stamford, Connecticut.
Krinsley JS. Mayo Clin Proc. 2003;78:1471–1478.
 Intensive Insulin Therapy in
Critically Ill Surgical Patients
100

Intensive treatment
96

92
Survival
Conventional treatment
in ICU (%)
88

84

80
0
0 20 40 60 80 100 120 140 160
Days After Admission
Conventional: insulin when blood glucose > 215 mg/dL.
Intensive: insulin when glucose > 110 mg/dL and maintained at 80–110
mg/dL.
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
Copyright ©2001 Massachusetts Medical Society. All rights reserved.
 Intensive Insulin Therapy in Critically
Ill Surgical Patients: Morbidity and
• Intensive therapy to achieve blood glucose levels of 80–
110 mg/dL reduced mortality (-34%), sepsis (-46%),
dialysis (-41%), blood transfusion (-50%), and
polyneuropathy (-44%) Blood
Mortality Sepsis Dialysis Transfusion neuropathy

Reduction
(%)
34%
41%
46% 44%
50%

van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

 Hyperglycemia and Risk of
Infection in General Surgery
• Glucose > 220 mg/dL on
postoperative day 1 is
– A sensitive predictor of nosocomial
infection
– Associated with
• 2.7 times higher rate of infection
• 5.9 times higher rate of severe infection

Pomposelli JJ, et al. J Parenter Enteral Nutr. 1998;22:77–

81.
 Portland Diabetic Project:
Rate of Deep Sternal Wound Infection
Rates With Different
2.0% Insulin Protocols
P = 0.01

Deep Wound
Infection 0.8%
Rate (%)

SQI = subcutaneous insulin; CII = continuous insulin infusion.

Anthony Furnary MD 1999 CCNM
Furnary AP, et al. Ann Thorac Surg. 1999;67:352–362.
 Glucose Control Lowers Risk of Wound
Infection
67%

P = 0.002

Deep Wound
Infection
Rate (%) 25%
16%
13%

Day 1 Blood Glucose

(mg/dL)
Reprinted from Zerr KJ, et al. Ann Thorac Surg. 1997;63:356–361 with permission from
Society of Thoracic Surgeons.
 Portland Diabetic Project:
Incidence of DSWI and Impact of
Implementation
4.0 of Insulin Infusion
CII
3.0

Patients with diabetes

DSWI
(%) 2.0 Patients
without
diabetes

1.0

0.0
87 88 89 90 91 92 93 94 95 96 97
Year
DSWI = deep sternal wound infection; CII = continuous insulin infusion.
Reprinted from Furnary AP, et al. Ann Thorac Surg. 1999;67:352–362 with permission
from Society of Thoracic Surgeons.
 Cost-Effectiveness in First
DIGAMI

For every 9 patients treated with

intensive insulin regimen, one life was
saved

DIGAMI = Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction.

Almbrand B, et al. Eur Heart J. 2000;21:733–739.

 Indications for Intravenous
Insulin Therapy: Summary
• Diabetic ketoacidosis • Labor and delivery
• Nonketotic • Glucose exacerbated
hyperosmolar state by high-dose
• Critical care illness glucocorticoid
(surgical, medical)
• Postcardiac surgery therapy
• Myocardial infarction • Perioperative period
or cardiogenic shock • After organ
• NPO status in Type 1 transplant
diabetes
• Total parenteral

American Association of Clinical Endocrinologists. Available at:

http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.
 Yale Insulin Infusion Protocol
Insulin infusion: Mix 1 U regular human insulin per 1 mL
0.9% NaCl Administer via infusion pump in
increments of 0.5 U/h

START INSULIN AT O.O5 U/KG/HR

Subsequent rate adjustments:

Changes in infusion rate are determined by the current infusion
rate
and the hourly rate of change from the prior BG level; see table
for instructions
OR ORDER-TITRATE TO KEEP BG 70-140 MG/DL

Goldberg PA, et al. Diabetes Care. 2004;27:461–

467.
 Insulin Requirements in Health
and Illness

Correction
Nutritional
Prandial
Units Basal

Healthy Sick/Eatin Sick/NPO

g

Copyright © 2004 American Diabetes Association. From Clement S, et al. Diabetes Care.

2004;27:553–591. Reprinted with permission.

 TREATMENT OF DIABETES
• IV INSULIN THERAPY
• ORAL HYPOGLYCMIC AGENTS
• INSULINS
• NEW AGENTS
– SYMLIN
– BYETTA
– DPP-IV INHIBITORS
– ALPHA-GAMMA TZD
 Timeline for Utilization of
Therapies
Metformin, TZD, AGI

Lifestyle SU Insulin
35 Meglitini
0 de Post Meal
30
0
25 Glucose
Glucos 0
20 Fasting
0
15 Glucose
e
0
10
05
0
25
0
20 Insulin
Relative 0
15 Resistance
Function 0
10
05 At risk Insulin
for Beta cell Level
00 Diabetes failure
-1 - 0 5 1 1 2 2 3
0 5 Years of0 Diabetes
5 0 5 0
© International Diabetes Center. From Kendall D, Bergenstal R.
 Oral Agents

Drug Class Principal Mode of Key Issues

Examples
Action
Glimepiride Hypoglycemia
Stimulate insulin Weight gain
Sulfonylureas Glipizide secretion from
Glyburide
pancreatic ß-cells

Stimulate insulin Hypoglycemia

Repaglinide
secretion from Weight gain
Meglitol
pancreatic ß-cells
Meglitinides
 Oral Agents
•

Principal Mode of
Drug Class Examples
•
Key Issues
Action
•

Metformin Decreases hepatic

Biguanides
• glucose GI upset
Renal dis.
Improve peripheral Liver
•

• enzymes
Rosiglitazone Weight gain
TZD
•
insulin sensitivity
Pioglitazone
•

Alpha- Acarbose
Delay carbohydrate Flatulence
•

glucosidase Miglitol
 Mimicking Nature With Insulin
Basal/Bolus Concept
Physiologic Insulin Secretion
24-hr
5
0
(µU/mL)
Insulin

2 § Suppresses glucose production

5 between meals and overnight
0 Basal insulin
§ Nearly constant levels
B L D
§ 50% of daily needs
15
0
Glucose
(mg/dL)

10
0
5
0 Basal
0 glucose
7 8 9 1 11 1 1 2 3 4 5 6 7 8 9
A0
M
2
Time of Day P M
Adapted with permission from Bergenstal RM et al. In: DeGroot LJ, Jameson JL, eds. Endocrinology.
 Comparison of Human Insulins

Onset of Duration of
Insulin Preparations Action Peak Action
Lispro,Asparte,Apidra 5 to 15 min 1 to 2 hr 4 to 6 hr
Human Regular 30 to 60 min 2 to 4 hr 6 to 10 hr
Human NPH 1 to 2 hr 4 to 6 hr 10 to 16 hr
Glargine 2 hr none 22 to 24 hr
Detimir 2 hr none 8 to 24 hr

* The time course of action of any insulin may vary in different individuals, or at different times in the same individual.
Because of this
variation, time periods indicated here should be considered as general guidelines only.
 Mimicking Nature:
Endogenous
insulin
Bolus
insulin
Basal
insulin
Insulin
Effect

B L D H
S

Adapted with permission from McCall A. In: Insulin Therapy. Leahy J, Cefalu W, eds. New York, NY:
Marcel Dekker, Inc; 2002:193
 Short-Acting Insulin Analogs:
Lispro and Aspart
Insulin aspart
Aspartate at position
Human Insulin B28 instead of proline

 1 2
S S Cy

5 Cy S


Cy 1 Cy 1
1
S 3
Ly
Pr
5 S
Cy 2
S
1
1 Cy 2

Insulin lispro
Adapted with permission from Barnett A, Owens D. Positions of proline and
Lancet. 1997;349:47 lysine reversed at B28 and
Bolli G et al. Diabetologia. 1999;42:1151
B29
GLULISINE-APIDRA
GLULISINE-APIDRA VS
REGULAR
APIDRA VS HUMALOG VS
REGULAR
Dissociation & Absorption of
NovoLog
Peak Time = 40-50

Subcutaneous
Insulin
Aspart

Tissue
(NovoLog
 ) Capillary
Membra
Peak Time = 80-120 ne

Regula
r
Human
Glucose Response to a High Caloric Meal in
Patients with Type 1 Diabetes

25 Regular insulin
0 (n=10)
Insulin lispro
Injectio
(n=10)
20
0
Blood 15
Glucos 0 Mean +
e SE
(mg/dL) 10
0
5
0 0.2 mU/min/kg insulin
0 infusion
-6 0 6 12 18 24 30 36 42 48
0 Me 0 0 0 0 0 0 0 0
Time
al
(minutes)
 Insulin Glargine
A- S S
Gl
y
Gl Il Va Gl Gi Cy Cy Th Se Il Cy Se Le Ty Gi Le Gl As Ty Cy As
y e l u n s s r r e s r u r n u u n r s n

1 2 3 4 5 6 7 8 9 1 11 1 13 1 15 16 17 18 1 20 21

S
S

S S

Ph V As Gi Hi Le Cy Gl Se Hi Le Va Gl Al Le Ty Le Va Cy Gl Gl Ar Gl Ph Ph Ty Th Pr Ly Th Ar Ar
e al n n s u s y r s u l u a u r u l s y u g y e e r r o s r g g

1 2 3 4 5 6 7 8 9 1 11 1 13 1 15 1 17 1 19 2 21 22 2 24 25 2 2 28 29 3 31 32

B-
Produced by recombinant DNA technology; 2 modifications in amino acid sequence of insulin
molecule create stable molecule

Bolli GB, Owens DR. Lancet.

2000;356:443
Mechanism of Action
Clear solution pH
4.0 pH
7.4 Injection
acidicofsolution (pH
4.0)

Microprecipitation of
Microprecipitati glargine in SC
insulin
on (pH
tissue
Dissolutio 7.4)
n
Slow dissolution
stabilized
into
aggregates

Protracted
Capillary
membrane action
Insulin in
blood

Seipke G et al. Diabetologia. 1992;35:A4; Hilgenfeld R et al. Diabetologia. 1992;35:A193

 INSULIN TACTICS
Glargine vs NPH Insulin in Type
1 Diabetes
6

5
Glucose Utilization Rate

4 NP
(mg/kg/h)

H
3

2
Glargin
1 e
0
0 1 2 3
0 (h) After SC
Time 0 0
Injection
End of observation
period
Lepore, et al. Diabetes. 1999;48(suppl 1):A97.
 Insulin detemir
LysB29(N-tetradecanoyl)des(B30)human insulin

C14
 f
(My atty ac
rist i
ic a d cha
cid in Ph Gl
) Ph Arg
Tyr Glu
Thr Gl
Pro Cys
Lys
Thr Val
Lys A2 Asn Cy
B2
9 1 Tyr Leu
A Gl Asn Tyr
1
Ile Glu Leu
Val Leu Ala
Glu
Gln Glu
Gln
Tyr Val
Cys Leu Leu
Cy Thr Se Ile Cy Se
His
Se
Gl
Cy
Leu
B Ph Val Asn Gln His
1
 INSULIN IN DIABETES
• INSULIN REQUIREMENTS
– 1-2 UNITS/KG/DAY FOR CHILDREN-1/2-
1UNITS/KG/DAY FOR ADULTS DEPENDING
ON DEGREE OF KETOSIS &/OR GROWTH
RATE
– DISTRIBUTION FOR INJECTABLE INSULIN
• BREAKFAST 20% OF TOTAL AS FAST ACTING
• LUNCH 13% OF TOTAL AS FAST ACTING
• SUPPER 17% OF TOTAL AS FAST ACTING
• BEDTIME 50% OF TOTAL AS LONG ACTING
EXAMPLE – 24 Units/day
CASE K.M.
EXUBERA INHALABLE INSULIN
Photograph reproduced with permission of
Continuous Glucose Monitoring System
(CGMS)
Physician Diagnostic System
 Interstitial Fluid Measurement

✦ Interstitia
l fluid
glucose
(G2) is ?
comparab
le with
blood
 Amylin the Hormone
• Reported in 1987
• 37-amino acid peptide
• Co-located and co-secreted with insulin
from pancreatic β-cells
• Neuroendocrine hormone
• Deficient in diabetes T
N
A
T
C
A
T
Q
R
L
A
N
F
L
V
C H
K S
Amide Y S
T L A F N
S S I G N
N
T
S V N
G

Adapted from Unger RH, Foster DW. Williams Textbook of Endo (8th edition) 1992; 1273-1275
 SYMLIN Reduces Glucose
Fluctuations Baseline (Insulin Only)
6 Months (Insulin + 120 mcg
220 SYMLIN)

200
Glucose (mg/dL)

180

160
* * * *
140
* *
*
120
pr

be
po

pr

po

pr

po
e

dt
s

s
-b

-lu

-d
t-b

t-l

im
st
re

in
un
nc
re

-d

e
ne
ak

ch
ak

in
fa

ne
fa
st

r
t

n = 166 at baseline; observed cases; Mean (SE); *P-values for all data points <0.05
Data on file, Amylin Pharmaceuticals, Inc.
See safety information with Boxed Warning in this presentation and the accompanying Prescribing Information
GILA MONSTER-ORIGINAL
SOURCE OF EXENATIDE
 GLP-1 Effects in Natural Role of
Incretins
GLP-1 secreted upon  Beta-cell
the ingestion of food workload
Promotes satiety and
reduces appetite

Alpha cells:
 Postprandial
 Beta-cell glucagon secretion
response
Liver:
 Glucagon reduces
Beta cells: hepatic glucose output
Enhances glucose-dependent
insulin secretion
Stomach:
Helps regulate

Adapted from Flint A, et al. J Clin Invest. 1998;101:515-520

Adapted from Larsson H, et al. Acta Physiol Scand. 1997;160:413-422
Adapted from Nauck MA, et al. Diabetologia. 1996;39:1546-1553
Adapted from Drucker DJ. Diabetes. 1998;47:159-169
 Prescribing Consideration
BYETTA Dosing
• 2 fixed-dose prefilled pens
– 60 doses per pen (30-day supply)
– Ready to use, easy to teach

See Important Safety Information included in this presentation

 Summary
• The evidence is overwhelming that good
control does count
• Morbidity and mortality can be reduced
• There is nothing inevitable about the
complications of diabetes
 Summary (cont)
• The cost of diabetes is in its complications
• Any expense paid up front in better
management will pay off handsomely in
the long run
• The tools for good diabetes care already
exist
• No tool is more important than the
services of a certified diabetes educator
 Summary (cont)
• Assessment tools include Self Monitoring
of Blood Glucose and HbA1C
• Targets should be established for each of
these for each patients within the national
guidelines
• When targets are not reached the help of
a specialist should be sought
• Christopher D. Saudek MD. Pres. ADA
2002
 Summary
• Insulin administration should mimic nature
• Natures way is basal insulin 24 hrs. a day
• And bolus insulin with every feeding
• Insulin lispro, asparte or glulisine can
supply bolus
• Insulin glargine or detemir can supply the
basal with one injection per day
• Control of blood sugar will prevent the
complications of diabetes