Tip 2 diabetes mellitusta kombinasyon tedavisi

Year 2012, Volume: 29 Issue: 1s, 39 - 43, 21.06.2012

Elif Kılıç Kan Ramis Çolak

Abstract

Antidiyabetik ilaçların sayısının artışı tip 2 diyabette hedeflenen HbA1C seviyesini düşürmüştür. Diyabetin uzun dönem komplikasyonlarını azaltmak için sıkı HbA1C kontrolü oldukça önemlidir. Oral antidiyabetiklerin çoğu glisemik kontrolü iyileştirmede etkilidirler ancak açlık hiperglisemisi ve HbA1C ≥ %7 seviyeleri olan tip 2 diyabetli hastalarda glisemiyi normale yakın seviyelere indirmede ender olarak başarılı olurlar. Farklı etki mekanizmalı oral ilaçların kombine kullanımı HbA1C düzeylerini düşürmede ilave etki sağlar. Aynı zamanda daha fazla terapötik güç, daha fazla kolaylık, daha az doz ve yan etki sağlanabilir. Metformin ve yaşam stili değişikliği ile başarısız olunan hastalarda tedavi seçenekleri ya ikinci bir oral ya da enjektabl ajan eklemektir. Eğer HbA1C değeri metformin ve sülfonilüre veya bazal insülin ile başarılamazsa, intensif insülin tedavisi başlanması önerilmektedir. Geleneksel basamaklı yaklaşım basamaklar arasında önemli gecikmelerin yaşanabileceği ve glisemik kontrolün sağlanamadığı sürenin uzayabileceği bir yaklaşımdır. Kısa süreli hiperglisemi dönemleri bile komplikasyon riskini büyük oranda artırır. Basamaklı tedavi yaklaşımdan uzaklaşarak kombinasyon tedavisine erken başlamayı içeren yeni bir tedavi anlayışına geçmek gerekir.

Combination treatment of type 2 diabetes mellitus

The increasing number of antidiabetic drugs decreased HbA1C levels in type 2 diabetes. Strict HbA1C control is very important to decrease the long term complications of diabetes. Although most of the oral antidiabetic drugs are adequate for glycemic control, they are not successful to control patients whose HbA1C levels are more than 7% and who have fasting hyperglycemia. The combined use of the oral drugs that affect in different ways provides additional success to lower HbA1C levels. Moreover, not only are they useful and provide additional power but also they have less side effects with lower doses. In patients whose medical treatment is unsuccessful with metformin and altered life style, adding a second oral or an injectable drug are the other therapeutic alternatives. If the HbA1C levels could not be decreased with metformin, sulfonilurea and basal insulin, intensive insulin therapy must be started. Traditional “step by step” approach may cause worse glycemic control and delay the steps of the therapy. Although hyperglycemia pe¬riods last in short periods it may increase the complications. Traditional “step by step” approach should be avoided and new therapeutic approachs should be preferred including early combined therapy.

J. Exp. Clin. Med., 2012; 29:S39-S43

Keywords

Diabetes mellitus; Oral antidiyabetik ilaçlar; Kombinasyon tedavisi; İnsülin (Diabetes mellitus; Oral Antidiabetic drugs; Combination treatment; Insulin)

References

• Aviles-Santa, L., Sinding, J., Raskip, P., 1999. Effects of metformin in patients with poorly controlled, insulin-treated type 2 diabetes mellitus. Ann. Intern. Med. 131, 182-188.
• Chiasson, J.L., Josse, R.G., Hunt, J.A., Palmason, C., Rodger, N.W., Ross, S.A., Ryan, E.A., Tan, M.H., Wolever, T.M., 1994. The efficacy of acarbose in the treatment of patients with non-insulin-dependent diabetes mellitus. Ann. Intern. Med. 12, 928-935.
• Chow, C.C., Tsang, L.W., Sorensen, J.P., Cockram, C.S., 1995. Comparison of insulin with or without continuation of oral hypoglycemic agents in the treatment of secondary failure in NIDDM patients. Diabetes Care. 18, 307-314.
• DeFronzo, R.A., Goodman., A.M., 1995. Efficacy of metformin in patients with non-insulin-dependent diabetes mellitus. N. Engl. J. Med. 333, 541-549.
• Diabetes mellius ve komplikasyonlarının tanı, tedavi ve izlem kılavuzu. Türkiye Endokrinoloji ve Metabolizma Derneği, 2009.
• Gerich, J., Raskin, P., Jean-Louis, L., Purkayastha, D., Baron, M.A., 2005. PRESERVE-beta: Two-year efficacy and safety of initial combination therapy with nateglinide or glyburide plus metformin. Diabetes Care. 28, 2093-2099.
• Johnston, P.S., Feig, P.U., Coniff, R.F., Krol, A., Davidson, H.A., Haffner, S.M., 1998. Long-term titrated-dose alpha-glucosidase inhibition in non-insulin-requiring Hispanic NIDDM patients. Diabetes Care. 21, 409-415.
• Kipnes, M.S., Krosnick, A., Rendell, M.S., Egan, J.W., Mathisen, A.L., Schneider, R.L., 2001. Pioglitazone hydrochloride in combination with sulfonylurea therapy improves glycemic control in patients with type 2 diabetes mellitus. Am. J. Med. 111, 10-17.
• Lebovitz, H.E., 2001. Oral therapies for diabetic hyperglycemia. Endocrinol. Metab. Clin. North. Am. 30, 909-933.
• Monami, M., Lamanna, C., Marchionni, N., Mannucci, E., 2008. Comparison of different drugs as add- on treatments to metformin in type 2 diabetes. Diabetes Res. Clin. Pract. 79, 196-203.
• Nathan, D.M., Buse, J.B., Davidson, M.B., Ferrannini, E., Holman, R.R., Sherwin, R., Zinman, B., 2009. Medical management of hyperglycemia in Type 2 diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 32, 193-203
• Ovalle, F., Bell, D.S., 1998. Triple oral antidiabetic therapy in type 2 diabetes mellitus. Endocr. Pract. 4, 146-147.
• Patel, A., MacMahon, S., Chalmers, J., Neal, B., Billot, L., Woodward, M., Marre, M., Cooper, M., Glasziou, P., Grobbee, D., Hamet, P., Harrap, S., Liu, L., Mancia, G., Mogensen, C.E., Pan, C., Poulter, N., Rodgers, A., Williams, B., Bompoint, S., de Galan, B.E., Joshi, R., Travert, F., 2008. Intensive blood glucose control and vasculer outcımes in patients with type 2 diabetes. N. Engl. J. Med. 358, 2560-2572.
• Raskin, P., Jovanovic, L., Berger, S., Schwartz, S., Woo, V., Ratner, R., 2000. Repaglinide/troglitazone combination therapy: Improved glycemic control in type 2 diabetes. Diabetes Care. 23, 979-983.
• Raskin, P., Rendell, M., Riddle, M.C., Dole, J.F., Freed, M.I., Rosenstock, J., 2001. A randomized trial of rosiglitazone therapy in patients with inadequately controlled insulin-treated type 2 diabetes. Diabetes Care. 24, 1226-1232.
• Turner, R.C., Cull C.A., Frighi, V., Holman, R.R., 1999. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: Progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA. 281, 2005-2012
• U.K. Prospective Diabetes Study (UKPDS) Group., 1995. Overview of 6 years' therapy of type II diabetes (UKPDS 16). Diabetes. 44, 1249- 1258.
• U.K. Prospective Diabetes Study (UKPDS) Group., 1998. Effect of intensive blood-glucose control with metformin on complications in over- weight patients with type 2 diabetes (UKPDS 34). Lancet. 352, 854-865.
• Wulffele, M.G., Kooy, A., Lehert, P., Bets, D., Ogterop, J.C., Borger van der Burg, B., Donker, A.J., Stehouwer, C.D., 2002. Combination of insulin and metformin in the treatment of type 2 diabetes. Diabetes Care. 25, 2133-2140.
• Yki-Jarvinen, H., Ryysy, L., Nikkila, K., Tulokas, T., Vanamo, R., Heikkila, M., 1999. Comparison of bedtime insulin regimens in patients with type 2 diabetes mellitus. Ann. Intern. Med. 130, 389-396.