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Diabetes Treatment (cont.)

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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 - (Prandin and 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.


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.


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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