Category: Diabetes/Prediabetes/Hypoglycemia

ACHIEVEMENT OF THE GLYCEMIC TARGETS AFTER SWITCHING FROM GLIMEPIRIDE TO GLICLAZIDE- PARADOXICAL APPROACH TO A CASE EXPERIENCE OF TWO YEARS

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

Sulfonylureas as insulinotropics that directly close K(ATP)-channels differ in their pharmacokinetics and dynamics that could translate to meaningful clinical differentiation and are the basis to choose the appropriate sulphonylurea 


Methods : N/A


Results :

52 year old male, with sedentary lifestyle, normotensive was diagnosed as type 2 diabetes on incidental investigations with Fasting Blood Glucose (FPG) 156 mg/dl, Post Prandial blood Glucose (PPG) 218 mg/dl, HbA1c 11.8%. Biochemical parameters serum urea, creatinine, lipid levels, thryroid were within normal limits. Mild elevations in LDL-C levels (113 mg/dl) and triglycerides (155 mg/dl) were effectively treated with rosuvastatin 10 mg OD. Tretment was initiated with metformin 1 gm OD as sustained release formulation with lifestyle modification of daily brisk walk for 40 minutes with diet modification to a high protein and a low carbohydrate diet. At the first follow up visit, at 4 months, based on the glycemic indices of FPG 120 mg/dl, PPG 180 mg/dl, HbA1c 8.1, to target the glycemic goals, glimepiride 1 mg OD as monotherapy was added. After four months the daily glimepiride dose was doubled to 1 mg BID as the glycemic parameters were still not within the targeted goals as FPG 126 mg/dl, PPG 184 mg/dl and after 3 months the glycemic targets improved but were still not at the goals as FPG 108 mg/dl, PPG 164 mg/dl HbA1c 8.2 %, the dose of glimepiride was further uptitrated to 2 mg BID with the uptitration of metformin to 1 gram BID and after four months, the FPG was 94mg/dl, PPG 148 mg/dl and HbA1c 6.7 % and the patient had achieved the glycemic goals. After six months of follow up on the fifth visit, the patient continued to achieve the glycemic goals with FPG 114 mg/dl, PPG 166 mg/dl, HbA1c-6.4%. After six months the patient was not on the glycemic goals as the FPG 148 mg/dl, PPG 192 mg/dl and HbA1c 7.4 and glimepiride was replaced by gliclazide  80 mg BID with metformin 1 gm BID. After three months FPG was 112 mg/dl, PPG 154 mg/dl and HbA1c 6.8%


Discussion : Insufficient response to the sulphonylurea can result in sub optimal threshold of depolarisation leading to inadequate release of insulin from the beta cells. The precise mechanism of gliclazide with selective binding to SUR-1 receptor could be attributed for the adequate response in this case


Conclusion :

Mechanistic differences for the action at the receptor levels can clinically translate into differential benefits and be a guide to choosing to shift sulphonylurea, rather than adding a new therapeutic class. It is important to distinguish and establish the causal relationship before labelling the case as of sulphonylurea failure   

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Mridul Das

Director
Diabetes Clinic and Diagnostic Laboratory, Agartala, Tripura

I am senior diabetes practitioner in Diabetes Clinic & Diagnostic Laboratory, Agartala, Tripura.

MBBS from RIMS, Imphal,
MD in Biochemistry from RIMS Imphal,
1year CMD Course on Diabetes from Medversity, Hyderabad and trained in Diabetes Dept., Apollo Hospital, Chennai.

Shashank Joshi

Senior Endocrinologist
Lilavati and Bhatia Hospital
Mumbai, Maharashtra, India

Prof Shashank R. Joshi MD, DM, FACP, FACE, FRCP
Endocrinologist, Lilavati & Bhatia Hospital
Consultant and Advisor, Apollo Sugar Clinics
President, Indian Academy of Diabetes, Past President, Endocrine Society of India
Past President, Research Society for Study of Diabetes in India(RSSDI)
Past President, All India Association for Advancement of Research in Obesity Past President, Association of Physicians of India, Emeritus Editor, JAPI
Indian Chapter Chair, AACE
He was honored by the Government of India, in 2014, by bestowing on him the Padma Shri, the fourth highest civilian award, for his services to the field of medicine. He is also a recipient of the International Clinician Award, received at the 21st American Association of Clinical Endocrinologists (AACE) Annual Scientific and Clinical Congress, Philadelphia. This is an annual award given to practicing endocrinologists, outside the US

Prabhat Agrawal

Associate Professor
Dept of Medicine, S N Medical College, Agra

Associate Professor, Dept of Medicine, S N Medical College, Agra

NK Singh

Director
Diabetes and Heart Research Centre, Dhanbad, Jharkhand

Diabetes and heart Research Centre Dhanbad, Jharkhand

Usha Wadhwa

Consultant
Wadhwa Mediclinic

Mediclinic