Symposium on 10th June, 2013. Presented by Dr. Nazma Akhter (Phase B Resident, Endocrinology)

1. GLICLAZIDE MR IN THE
MANAGEMENT OF TYPE 2 DM
Dr. Nazma Akhtar
Resident phase B
Department of Endocrinology
BSMMU

3. 3/28/2013 3

4. 3/28/2013 4

5. SULFONYLUREA: OAD agent
Mode of action:
• Sulfonylureas act directly on the β - cells of the islets of
Langerhans to stimulate insulin secretion
• They enter the β – cell and bind to the cytosolic surface of the
sulfonylurea receptor 1
• Binding of a sulfonylurea closes the K + ATP channel, reducing
the efflux of potassium enabling membrane depolarization
• Localized membrane depolarization opens adjacent voltage -
dependent L - type calcium channels
• Increasing calcium influx and raising the cytosolic free
calcium concentration
• Mediate the exocytotic release of insulin granules

7. Classification
• Divided into first and second generation
agents
• In general, the second-generation agents
– Are more potent
– Have fewer adverse effects and drug-drug
interactions

8. Extended release preparations
• Extended-release glipizide and glimepiride are
preferred agents because
- they can be given once daily
- involve a relatively low risk of
hypoglycemia
-low weight gain

9. Modified release preparations
• A “ modified release ” (MR) formulation of
gliclazide has been introduced for once - daily
dosing
• Interestingly, the 30 mg preparation of
gliclazide MR gives similar efficacy to 80 mg of
unmodified gliclazide and reduces risk of
severe hypoglycemia

11. Target HbA1c <7% instead of <6.5%
Evidence based alternative approach
SU as 1st line, irrespective of BMI
TZD & DPP-4 inhibitor are 3rd option
What’s NEW in the treatment
algorithm of IDF Guideline 2012?

12. Which SU to choose-
gliclazide 80,
glimepiride or the new
Diamicron MR 60?
?

13. One of the largest clinical studies
ever performed in type 2 diabetes
N Engl J Med. 2008;358:2560-2572

14. More than 11,000 type 2 diabetic
patients from 20 countries worldwide
4 Asian countries- China, India, Malaysia & Philippines
N Engl J Med. 2008;358:2560-2572

15. Aim of the study
What benefits can be gained from
intensive glycemic control (HbA1c
≤6.5%) versus standard control?
N Engl J Med. 2008;358:2560-2572

16. Strategy & Timeline
Mean duration 5 years
Strategy: treatment initiation with 60 mg
Diamicron MR, increase up to 120 mg then add
other therapy
June
2001
January
2002
January
2003
January
2004
January
2005
January
2006
January
2007
January
2008
Blood glucose lowering comparisonRecruitment period
N Engl J Med. 2008;358:2560-2572

17. Results & Outcomes
N Engl J Med. 2008;358:2560-2572. Diabetes Care 32:2068–2074, 2009. Diabetes Res Clin Pract. 2010;89:126-133.

18. Reduces HbA1c ≤7% within 6 months
N Engl J Med. 2008;358:2560-2572

19. Reduces HbA1c by more than 4%
unlike other SU
N Engl J Med. 2008;358:2560-2572

20. Reduces HbA1c ≤7% irrespective of
BMI
N Engl J Med. 2008;358:2560-2572

21. Lowest episodes of hypoglycemia
compared to other large scale clinical
trials
1. N Engl J Med. 2008;358:2560-2572. 2. N Engl J Med. 2008;358:2545-2559. 3. Lancet. 1998;352:837-853.

22. Lowest hypoglycemia
compared to DPP4-inhibitor
Int J Clin Pract. 2011;65:1132-1140. Curr Med Res Opin 2012; 28:1–8
Middle East
India & Malaysia

23. Weight neutral unlike other SU
N Engl J Med. 2008;358:2560-2572

24. Significantly reduces combined
micro & macro vascular complications
N Engl J Med. 2008;358:2560-2572

25. Opposite outcome compared to
other trials using glimepiride
N Engl J Med. 2008;358:2545-2559. N Engl J Med. 2008;358:2560-2572. N Engl J Med. 2009;360.

26. Better CV protection
than Metformin & glimepiride
Eur Heart J. 2011 Aug;32(15):1900-8.

27. Reduces End-stage Kidney Disease
unlike any other OAD
Diabetologia. 2011;54(suppl 1):S23.

28. Reduces Beta cell apoptosis
unlike glimepiride
Metabolism. 2008;57:1038-1045.

29. Prolongs insulin free period
Diabetes Res Clin Pract. 2005;70:291-297.
While maintains HbA1c <7% for 14.5 years!!

30. FACT: EFficacy & tolerAbility of DiamiCron
MR60
at the dosage of 1.5 to 2 tablets at breakfast
over
Bangladeshi Type 2 diabetic patients

31. A clinical study conducted by Bangladeshi
clinicians over Bangladeshi type 2 diabetic
patients

32. Objective of the study
To observe efficacy and tolerability
of Diamicron MR60 at the dosage
of 1.5 to 2 tablets over Bangladeshi
type 2 diabetic patients

33. Findings

34. Patient characteristics
Characteristics (N=
359)
Male (166) 166 (n)
Female (193) 193 (n)
Mean Age (279) 51 yrs ± 11
Mean Height (75) 1.5 m ± 0.6
Mean Weight (219) 64 kgs ± 9
Mean BMI (96) 26 ± 3

35. Efficacy: Reduction of HbA1c (Total Patients)
5
5.5
6
6.5
7
7.5
8
8.5
9
Base line After 6 months
-1.9% HbA1c reduction within 6 months
-
1.9%
n= 359
8.9%
7.0%

36. Tolerability
Only 1.0% hypoglycemia was found!!
Baseline After 6
months
Change
Weight (kgs) 63.7 63.3 -0.4

37. As per the FACT study, Diamicron MR 60
reduces HbA1c by -1.9% in 6 months at the
dosage of 1.5 to 2 tablets
With least hypoglycemia as well as no
weight gain
Findings of FACT study

38. Clinical Evidences on use of
OAD in Ramadan

39.  Prof. Hajera Mahtab
Professor Emeritus
Ex-Director
Clinical Services, Research & Academy
Dhaka, Bangladesh
 Prof. Abdul Hamid Zargar
Professor & Head
Department of Endocrinology
SK Institute of Medical Sciences
Srinagar, India
 Prof. Abdul Basit
Director & Head of the Department
Baqai Institute of Diabetology & Endocrinology
Baqai Medical University
Karachi, Pakistan
RESEARCH ANALYSIS

40. Sulphonylureas in the management of type 2 diabetes during the fasting
month of Ramadan
 Among the 2nd generation SUs considering efficacy and safety,
which one is more suitable during Ramadan
 Sulfonylureas as a first line used by majority of patients
 Many of Muslim type 2 diabetic patients fast in Ramadan
 Alteration of energy intake, physical activity & drug pattern
associated with greater risk of hypoglycemia & ketoacidosis

41. Among the two once daily Sulphonylureas hypoglycemia is -50% less
with Diamicron MR60 than glimepiride
Diamicron MR Glimepiride

42. Diamicron MR60 is associated with less hypo and
less CV events than glimepiride

43. Objective:
To evaluate the efficacy &
safety of Diamicron MR60
at the dosage of 1 tablet
in Ramadan
Participating countries:
Bangladesh, India &
Pakistan

44. Prof. Hajera Mahtab BIHS
Prof. Zafar A Latif BIRDEM
Prof. Tofail Ahmed BIRDEM
Prof. M A Mannan DMCH
Prof. Md. Farid Uddin BSMMU
Dr. Saghir Abdur Rahim BIRDEM
Dr. Sarker M Saiful Islam MEDINOVA
Dr. ABM Rahmatullah HCDP- Jurain
Dr. Sufia Khatun NHN- Mirpur 10
Dr. Umme Sadia Mili NHN- Darus Salam
Dr. Md. Wahiduzzaman NHN- Darus Salam
Dr. MA Sabur DAB- Khulna
THE RAMADAN STUDY GROUP- BANGLADESH

45. Inclusion Criteria:
 Newly diagnosed type 2 diabetic patients: start with 60 mg
 Patients uncontrolled with 1 tablets of Diamicron MR/
Gliclazide 80/MR or 1 mg of Glimepiride: up-titrate to 60 mg
Diamicron MR60
 Patients well controlled on 60 mg of Diamicron MR60
 Patients well controlled on 2 tablets of Gliclazide 80/MR or 2
mg of Glimepiride: switched to 60 mg of Diamicron MR60
THE RAMADAN STUDY

46. Total number of patients:
136 fasting type 2 diabetic
(35 Bangladeshi+ 50 Indian+ 51 Pakistani)
Duration:
90 days (45 before Ramadan+ 30 Ramadan+ 15 after
Ramadan)
Result:
- Around 1% (0.8%) HbA1c reduction within 3 months
- 3.7% hypoglycemia before, 2.2% during & 1.5% after
Ramadan
THE RAMADAN STUDY

47. Conclusion:
Diamicron MR60 maintains tight glycemic control, safely before,
during & after Ramadan

48. Objective:
To compare the incidence of
symptomatic hypoglycemia in
fasting Muslim patients with type
2 diabetes treated with DPP-4
inhibitor or SU during Ramadan.

49. Conclusion:
Risk of hypoglycemia is lowest with Diamicron MR60, whereas
double with glimepiride

50. IDF guideline (October’12) recommends
sulfonylurea to initiate treatment irrespective of
BMI
But all sulfonylureas do not provide same
outcome
Therefore, selection of sulfonylurea is a major
issue to be considered before initiating treatment
Take home messages

51. As per the clinical evidences Diamicron MR 60
 provides effective glycemic control irrespective
of BMI
 with least risk of hypo & without weight gain
 significantly reduces vascular complications
 ensures cardiovascular protection unlike
glimepiride,
also better than metformin
 preserves beta cell through anti-oxidant
properties
Take home messages

52. Acknowledgement
• Prof. Md. Fariduddin
• Asso. Prof. M A Hasanat
• Dr. Mashfiqul Hasan
• Dr. Yasmin Aktar
• Sponsoring body

53. Thank you