What are the benefits of glipizide
An overview for the practice
After the diguanidines, the sulfonylureas and the biguanides first conquered the market in the last century. Metformin is still relevant today, while the sulfonylureas are increasingly being replaced by modern substances such as DPP4 inhibitors. The following article will explain the advantages of the newer oral antidiabetic agents, why metformin is still valuable and which combinations are useful.
The history of oral anti-diabetic drugs (n.a.) is almost as long as that of insulin: In the twenties of the last century, the diguanidines Synthalin A and Synthalin B came onto the market, which - despite considerable gastrointestinal side effects and (questionable) Liver damage - lasted until after World War II. Then, in the 1950s, the era of sulfonylureas (SuH) carbutamide and tolbutamide began, and a little later that of biguanides, of which metformin alone has been able to survive to this day, while phenformin and buformin were withdrawn from the market in the 1970s due to increased lactic acidosis . In the meantime, glibenclamide and glimepiride as well as the less frequently used gliquidone, chlorpropamide, glipizide and gliclazide dominated the SuH.
At the moment, one can distinguish between insulinotropic (SuH, Glinide, DPP4 inhibitors) and non-insulinotropic (SGLT2 receptor inhibitors, acarbose, pioglitazone) and the like. What should be noted for practice? In the case of insulinotropic substances, the SuH and the glinides have rightly been overtaken by the DPP4 inhibitors (gliptins) sitagliptin and saxagliptin. The latter - in contrast to SuH and Gliniden - only lower blood sugar when there is hyperglycaemia and therefore do not lead to the dreaded dangerous hypoglycaemia. In view of other SuH side effects (risk of falling, weight gain, possible cardiovascular damage) one should start with gliptins when using insulinotropic substances. The absence of hypoglycaemia is also to be noted in the remaining o. A. This is especially true for metformin. This substance should - after initial attempts with nutrition and exercise therapy alone - be administered and, if necessary, combined with gliptins.
What should be considered with metformin?
Because of gastrointestinal side effects that sometimes occur, the following rule applies: "start low, go slow", i. H. you should start with 500 mg metformin per die for the first two weeks and slowly increase the dose up to 1,000 mg twice. It should also be noted that metformin should always be taken with the "last bite" of a meal, i.e. never on an empty stomach. This is the best way to avoid gastrointestinal side effects (stomach pressure, flatulence, diarrhea). Furthermore, the metformin dose should be halved in order to avoid the - extremely rare - lactic acidosis with a GFR between 60 and 45. With further dose reductions, metformin can now even be prescribed up to a GFR of 30. Before X-ray contrast agent examinations, metformin should be discontinued for a few days (because of the rare contrast agent nephropathy that is independent of metformin). B. in massive gastrointestinal infections. Incidentally, metformin is the ideal combination partner for everyone else, especially since it is also lipid (triglyceride) lowering, incretin-stimulating (beneficial for the incretin-based gliptin effect), appetite-reducing, weight-reducing and possibly anti-carcinogenic.
Other combination partners
In addition to gliptins, an SGLT-2 receptor inhibitor of the gliflozine type can usually be considered as a combination partner, since acarbose is relatively expensive and often associated with gastrointestinal side effects (here too, the rule "start low, go slow" applies) and pioglitazone in Germany - unfortunately - is no longer replaced by health insurances. In addition to dapagliflozin, empagliflozin is especially recommended, as it showed sensationally beneficial additional effects on cardiovascular and all-cause mortality as well as on the hospitalization rate for heart failure in the EMPA-REG Outcome® study. Microangiopathy is also favorably influenced to the same extent.
These positive effects outweigh the side effects that arise e.g. B. in 8% of women in the form of - due to glucosuria - express genital mycoses. Occasionally, the genesis of ketoacidoses (also euglycemic!), Which is unclear in terms of their genesis, leads to immediate discontinuation of the preparation. Further advantages of Gliflozine are natriuresis (lowering blood pressure!) And weight loss at the expense of the harmful visceral adipose tissue.
Of course, there is now also a very interesting "triple therapy" with metformin, gliptin and gliflozin (preferably sitagliptin and empagliflozin) that does not involve hypoglycaemia and has only one disadvantage: the high price. The BOT (basal-assisted therapy) should also be mentioned, in which basal insulin (preferably Glargine U 300) can be given over a longer period of time while maintaining the no longer sufficiently effective or similar, up to long-term type 2 diabetics insulin therapy alone is indicated with increasingly progressive restricted insulin secretion.
Conflicts of Interest: The author has not declared any.
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