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Perfect. I think it's 1 30. So we'll just start. So let thin take it away. Yeah. Okay. Um Hi, good afternoon, everybody online. Thank you so much for, I just want to first thank you for the Rachel Innovation for arranging uh webinar session and then thank you all for attending today. Uh I just want to introduce myself Mondays thing. Uh I'm one of the diabetes and you wanna destroy at the moment in the line, London Hospital. Uh So today I'm going to talk about the diabetic medication especially or a diabetic medication but talking a little bit boring. So just for the, just only for the pharmacology, but I'm not going to dive into the pharmacological uh like the pharmaco dynamics or anything like that. So let's talk about uh uh that's why I'm going to do that teaching. It said to I think you all know about that medication using the effective management, but I just want to refresh your memory about the pharmacology, especially like the mechanism of action there, usage contra indication and other things you need to know about that medication. And also when you also know about that and these knowledge or to apply this knowledge in the clinical practice in management or diabetes. Yeah. Um, so you all know that it's an indoor effective. We have the aura and insulin. I'm not going to talk about the insulin today because they will become with another webinar session. So I'm focused on the oral medication, especially when you don't know that it's used in the type two management of the type two diabetes that these are the top and the Metformin cellphone a area. Um Click tonight, thiazolidinedione, acarbose. And then uh popular medication nowadays like this SGLT two inhibitor DPP four inhibitor and GLP one agonists. So I focused all the oral or agent only today. So uh I believe you all know about the mechanisms of the pathophysiology of the type two diabetes. Uh I'm not going deep into that thing. So I just focus on the medication. I know it is due to the uh insulin resistant and these names. So insulin for the type one diabetes maybe. And I just start with the Metformin. So uh this is a very old medication but all that's their goal for that management in the type two diabetes. Uh It is a main group is a biguanide group. What we want to, I want to talk about today is uh sometime we know that medication but sometimes we forgot about the what's the mechanism, election? What uh which medication at which uh area? So I just refresh your memory your memory about that. So the Metformin is mainly uh add on the, it inhibits the, you know, the habit tic gluco neogenesis and also increased guy pollicis and increase the paper uptake of the glucose private issue up to the glucose. So the net effect causing the the blood glucose load to lower the blood glucose level. Uh So it is a first line therapy uh using the management of the type two diabetes. But in combination with the most important of the lifestyle intervention and also uh it can also combined with the other agents including the insulin. So we need to know about the while to give that medication, the dose, we can start with a low dose 500 mg once a day and then titrate up to the maximum. It's a two grand per day. So usually give 1 g twice a day and you, we usually get the 500 mg or 1 g. But you, you can see some patient taking the 8 50 mg as well as some uh available in the 8 50 mg dose as well. Another one is that you can see that it's a sanitation, taking a slow release form, Metformin slow release. Uh because what the special use for the slow release is a for patient who experienced a significant side of probably the standard Metformin formulation. And so it has a less gi side effect or is that slow release form so that you can use as a patient complain about the gi side effect, you can change the Metformin because it's need for that patient. So you can change it up my forming normal standard form to the slow release form. Mhm. Um And so we all know that it's a cipher is a very common side for the gi and nausea and vomiting and altered taste, rare side. We need to worry about the hepatitis and lactic acidosis, some skin reaction and also the between the absorption. So we need to have the think about this thin contra indication. So any cute metabolic acidosis and uh hemodynamically unstable due to the any infection or any other cause, including elected acidosis or the K A. Uh Metformin is a calm predicated and also arena function. If the E G F is less than 30 we don't use that Metformin. And also that because of his rare side for the hepatitis with the active or progressive severe liver deceit, you're not using that uh sometime because of the risk of the hyperperfusion, uh unstable or the acute heart failure. We just hold that platform uh at the and stable stage and then it's not giving the contract medication. And so we need to use with the caution because of the Metformin if it's a very good effect on the management. So if E D F R less than 30 we stopped them at forming. But between the 13 is more than 45 you can use the freely. But between 30 and 45 44 we can reduce the dose you can give because of the uh good effect. And then, but you can reduce the dose to half. And so between the 30 and 40 for the dose should be normal than 1 g per day. And also some people go into the the contrast investigation. So we prefer to hold if the, if the patient has an increased rates of elected acidosis and also those with vascular instability and hypertension and then potential hyperperfusion. So in that case, we can hold that that forming during after the procedure and then we monitor the renal function and you can restart that each if E G F more than 30 and also in the patient taking the Metformin, how we monitor that is the HB one C for the diabetes control at three assessment. And we need to monitor the serum creatinine at least annually. Uh because of the risk of the vitamin D tour malabsorption. So you can check the vitamin D tour annually, particularly as the patient at risk of the B 12 deficiency by the vegan or after bariatric surgery patient. So these are the uh words we need to know about them for me. So I just refreshed that with the mechanism of action because it's a bit different with this other medication, it increase the proper uptake including insulin sensitivities for that. So let's move on to the sector also there is that the other thing is that why we get that is the outcome is the glycemia advocates is uh, is good with about the 1% reduction of HB one C management of uh diabetes. In terms of weight, it is mostly neutral and some weight reduction effect, not very much as a GLP one. And in terms of the car universal effect because type two diabetes manage and it's a cardio respect to we need to think about the uh later micro and microvascular complications. So cardio verse will have any uh kidney effect of these things they think, think about. So in terms of the cardiovascular effect, there's no adverse effect on taking the Metformin. No adverse effect sometime appear to decrease the cardiovascular event in this obtain population according to this uh study. And also uh later uh some meta analysis uh say that the use of the Metformin decrease the cancer incident because of that. Nowadays. Uh what is the cause of death in the type two diabetes? Uh previously usually think about is the risk of the cause of death in a type two diabetes occur a rescue like that. But interestingly uh recent year or the studies show that cause of death in the type two diabetes is a cancer because of the people have a long uh prolong life expectancy because of the new oral medication. So risk of the cancers are increased. So they, some matter analysis said that Metformin have can reduce the cancer incident, possible mechanism. Ship maybe the regulation of the, that Amp Carney's uh education through the L K B one as a L K D one. Is this a tumor suppressor? So it's oppressor said, so by that's possible mechanism can decrease the cancer in this incident. It's a bit interesting that so these all are the mat forming. So just to know about um then uh if let's go to the NACE, it's the second thing is a sulfonylurea, it also the old medication if we use the management of the diabetes for a long time. So mechanism of action is a bit different from the Metformin because of the uh cellphone areas, uh add on to stimulate the insulin secretion from the pantry to be to say by binding to the uh potassium ATPase dependent channel on the pancreatic beta set and that it decreased. Uh So it stimulated has increased calcium infrasound into the pancreatic beta set. And that has in concentration and also stimulated increased release of the insulin. But we got the insulin that also reduce the blood glucose level and it also decreased the hepatic clear and your insulin as well. So by net effect is high insulin level in the blood and causing maintaining the blood glucose level, reducing the blood glucose level. It has a two generation of that medication. The first generation we no longer use because of the uh some side effects and long duration of actions. Uh The names are just to know about the pro proper might and tolbutamide. You may see some people taking tolbutamide uh moment but we no longer use that. And second generation, we all know the popular medical drug is uh flightless. I we usually use the course is also very cheap and also effect is very good. And other second generation of the glimepiride glipiZIDE and also the back and right. So these are the name of the psa phone area. The most used used Kamala you is the glipiZIDE. And so what dose we can get yourself an eye area. So we usually use the clicker side 42 80 mg daily. We get the twice a day dose. Um start with the 14 mg baby and increasing uh dose uh everyone to four weeks depending on the what blood glucose level and the maximum dose you can give a 3 20 mg a day. So it is a 1 60 mg twice daily. So Gliclazide has also has a modifying release form. It came in with the 30 mg. Uh you can get that 30 mg maximum 1 2011 because I'm a 30 million grant is equivalent to publicas. I'm 18 mg. So you can adjust some people take that. So if if the ones that they do so that the Cozaar and not a form. So the side effects all the side, all the Medicare oral medication reviews and diabetes medication helps the side for the hypoglycemia depending, less or more on the different class of medication that the cell phone I area is the most common side effect is hypoglycemia. And also the weight gain. And that, that is a PSA for Nigeria group. And I'll talk about another three groups of the medication we, uh, let's commonly used but just to, uh, no about the knowledge just to share all the, no about that medication, but we really not commonly using the clinical practice. Now, uh that flu is a big late tonight. The medication name is the Republic night and particular night we usually use commonly use the Republican. I, you may see some patient taking the Republic night. What is the mechanism of action of the magnetic? It is quite similar to the sulfa Nigeria Axion. Um uh it increased the release of insulin from the uh comparatively to say, but South Nigeria bind to the uh potassium, the planet ATPs China. But the Republic like that *** Latino group is a different binding site from uh uh bank critically to set its increase. The same actions is the increased release of the insulin and it has the rapid onset and then shorter duration of action, then it's after my area. So that effect is causing and also so that you can get the dose before each meat. Uh so to reduce the postprandial hypoglycemia, so that if you can, it's quite similar to that doctor Sulfonylurea, the side effect is also the same hypoglycemia. Um So what are the use of that if some people have the allergy to the South China area blue? So you can use that because of that action mechanism of action. Application is quite similar. So you can use if the patient is allergic to their cellphone a area and also similar risk like the hypoglycemia weight gain quite the same. But because of directive onset of action and short duration on the Axion, that is a possible less risk of hypoglycemia with that neglect Tonight group. So previously, you usually say that it is uh 1,000,001 dose, know me know dose. Because if you want, if you will take that to me, you can take that tablet before me to prevent that postprandial hypoglycemia. If you don't have lunch, you can skip the dose like the short acting insulin you give before me. So it is the Republic not use. So what is, what are the dose we used to give the Republican? Right? 0.5 mil it one before each me. And so you can give maximum 4 mg before issuing. So 4 mg, tvs something we start with a five minute. Well, TVs, if the patient just have the only to meet, you can get the baby. So it is metabolized in the liver. Mostly uh renally excreted is just only less than 10%. So if they, the studies advised if E D F R is more than 14, you don't even dose adjustment but easier for less than 20. There's no study of using that repaglinide. But between 20 and 14, you can use the low dose. Uh because of the uh some people with a renal failure is they cannot secretes the metabolites from the arena. So the duration of Axion longer, a risk of hypoglycemia is high. So, but that is 10, less than 10% is the renal excreter. So let's raise for the high programs senior. Okay. Um If you have any questions or anything, you can type in the job and I will take our answer that. Okay. So let's go on tonight. It is a thiazolidinedione. It end with the glitizone, uh pioglitazone loss ability zone, that mechanism that uh medication. Um What is the mechanism is a bit different? It didn't stimulate the insulin uh stimulate the nuclear receptor in the edible side call the people gamma. It's a process, own proliferator, activator receptor gamma. So that is just short term is that people gamma is fine, it stimulates the people gamma. It in the medical side. What to do is that it promotes the edible genesis and a TSH uptake. In by, in terms of that stimulation, it enhance the stimulus, insulin sensitivity uh by improving that the glucose and lipid metaphor, I think. Uh so by altering the adipo consecration and reducing the adipose tissue information. So it is not directly uh stimulate the insulin secretion, it just to increase that enhance the insulin sensitivity. So people with the type two diabetes and insulin resistance. So, so to that effect, causing the uh using in the diabetes, type two diabetes, you all know that it is not a first line medication, which is the second of the line therapy and management of the type two diabetes. Uh what we can use the pioglitazone, we usually use a 50 mg once a day maximum is a 45 mg. Uh It has a side effect is uh so many side effects like that is a water retention weight gain and then there's sometimes high side problem and hypoglycemia. So, uh and also the less common side effect that dangerous or the heart problem because of the water retention, fluid retention, causing a heart failure, heart problem and effect on the liver function and liver failure. Um Julia edema is causing a high problem and some won't reduce the bone density causing a bone fracture. So these are the side effect of the bars and within die alone group. Um They have some study, some education uh withdraw from the market because of the some of the side effects. But pioglitazone is we can use the pioglitazone. So, contra indication clearly that is a heart failure with evidence of the fluid overload and history or the risk of the fracture, active liver, dizzy or some effect on study show with the some has a history of the bladder cancer. We cannot use that actually Dema we don't use that. That was a doll. Um Let's move on to the next. Uh It's also the not, not usually used. Now today is that another group is that f public sidey inhibitor? Um It is the, it inhibits as, as the name, it inhibits a glucose a day which is the entering anxi found in the brush border, the small industry. Um What is the action of the enzyme it hydrolysized. Uh when it is with the illegal supply or the supply uh in your fruit into the glucose. And motorcycle is the normal mechanism of the effort, glucose sitting. So by inhibiting this Amazon, it's uh it's slow down the digestion of the carbohydrates. So to keep your blood glucose level rising after me. So it is also good for the postprandial hypoglycemia because by inhibiting that anxiety, your digestion is slow down. So keeping your blood glucose level very high to prevent very high. So the name of that medication is that a Kabul's is uh common, usually commonly used and not usually used. And that the other name just for the knowledge is a big Lichter. Uh levels were not usually use that. Um uh clearly it's not the first line medication that type two diabetes. Uh you can use the combination therapy for the especially for the people with some people have a postprandial hypoglycemia. So you can use with the high postprandial glucose. Uh level. So the doses you actually start with 50 mg initially and and increase to the 50 mg tvs maximum is 200 mg tvs. So inside of most of the medication side effect effect on the enzyme and the entry Anzai suicide as a gi side effect, mostly that discomfort and diarrhea. Okay. So that previous to like the uh fabric Cosseted inhibitor type isolating dialogue and neglect tonight uh not uh commonly used nowadays. And so I can move to the NACE uh with the SGLT two inhibitor. These are the popular and uh very good effect on the medication nowadays used in that type two diabetes. So what is the SGLT two inhibitor, sodium glucose transporter to uh it's a spread in there's SGLT two and S E R T one in the S E R T two in the, it's a spread in the arena tube you especially in the proximal convoluted review. And it's usually uh responsible for the 50% 90% of the glucose reabsorption from the proximal convoluted Trib you in the uh crossing a convoluted review is a S E R T two but inhibiting that transporter. Uh So it's increase the glucose excretion through the arena to view. So let's glucose in the blood. It's great to the arena to view. So that is causing uh that is a fact of the S E R T two. Yeah, it brought the reabsorption and increase that a glucose security solution through the women to you. So it's only uh as yet to inhibit a not only effect on the blood glucose, they have the multi uh multiple good effect on the different parts of the body by causing it, causing the glycosuria uh through the vein. And also has uh reduced oxidated stress and also the arena protective effect on the kidney and also on effect on heart because of that, it reduced the pre, pre load and it reduce the BP so that reduce pressure on the heart. And so, so that effect is uh it's sort of impatient with the heart failure. So it is a good effect on the heart failure, reduced preload. And then that the 30 S A utilizing nation that ketone utilization also half failure, reduced half failure in medical tissue is increase the life policy. So, reduced fat must and reduce weight effect on the weight as well. So we lost and probably under bankruptcy be to set, maybe likely there's some vituz preservation effect and on the labor is increased, hypothetically close, helpful and that fatty essay utilization. So it reduces uh but uh petty asteatosis. So these S E R T to affecting different parts of the body, not only the blood glucose. Some cardiologists said that S T R T to have them. So many um study in the heart failure with reduced ejection fraction or heart failure with preserved ejection fraction. So they have any cardiovascular disease. So as your t to has a very good affair. So they said that um it is not a diabetic medication, which is the cardiovascular drug. So anyway, it is that has a many good effect on the management of the diabetes with the cardiovascular risk factor. So, so when we use that, the S E R G to inhibit us, so we start with the Metformin, all these things and other medication, but your glycemia control is not uh achieved the target even though that you're taking the Metformin and lifestyle changes. And and also with the patient has the following conviction like atherosclerotic cardiovascular disease or patient with the heart failure, patient with the kidney disease and high B M I. So these are the indication to use the S E R T to inhibit them in the type two diabetes. So what medication I just mentioned that's a very common three medication uh currently use and that is a public floating uh start with the 10 mg and then you can increase to the 25 mg and kind of like closing is the you can start with 100 mg and increase to the maximum. It's a 300 mg and that public flows in is the only 10 mg. So it's very easy to remember. The is a 10 mg Dog Park. This, that's it. So these three medications are commonly used. And so what other side of, you know that is a glucose excretion is increased to the renate review. So the glucose is a very good uh medium for the back to your blow. So that's clearly you have glycosuria. So in the urinary tract is a very easy to grow bacteria. So you're tract infection is a very common and Volvo vaginitis and phelonitis and also the least infection. And you also know about that is the keto acidosis. What we call is a you glycemic keto acidosis if in case we discontinue, use that S E R T to uh if the D K happened. And in that, in some study is the with the kind of the closing that is a risk of the lower leg amputation. So take care with that kind of your floating and because it reduce the preload is that that risk of the hypertension. Uh so need to take about the patient taking the S E R G two inhibitor. So uh with all the hypertension but so we not recommended for usually not recommended for the initiation of the SGLT two inhibitor if the E G F is less than 30. But the reason study with the DARPA Arena study like that you can start it more than E G F 15 15. But uh take care with E G F R is low. So, so what is a euglycemia keto acidosis? Why causing that euglycemia ketoacidosis? So that that is a mechanism. So SGLT two inhibitor effect on the kidney is a glycosuria natural us is and then also it reduces like glucose, reduce glucose reabsorption. But the increased ketone body be absorption from the kidney. And by causing the plasma ketone body is hard in the plasma and in the pancreas, it reduce the including secretion and increased group called consecration to that the medical tissue increased like policies and free fatty acids detail all sedation coca and the liver. So it's causing the liver is the key to geneticist increase. So, increased, key to genesis from the liver and increased ketone body re absorption from the kidney and net effect is causing an increased plus know ketone level. But the glucose level is not high is the usual decay diabetes, keto acidosis because it's uh glycosuria and blood glucose level is not hard even in the normal range. A patient is aware s adopted and he took it. So what that is causing like that you guys M E D K with that SGLT two inhibitor. If that happened, we stop. Uh we do not restart the uh SGLT two inhibitor. So what we need to monitor that usually with the HBA one C for the diabetic control and also the kidney function monitoring the E G F R. And before starting that, we need to monitor the patient rolling status because of the base of the hypertension. So, and you know that it's a type two diabetes have not only diabetes, they have the other cardiovascular rates like they have to tension, heart failure, kidney disease. So that patient may have the polypharmacy including the directive and anti hypertensive. So we need to think about those adjustment needed for the directive or anti hypertensive because of the risks of hypertension with the SGLT two inhibitor. And also the patient should be uh explained about the sinus in terms of the genital urinary tract infection and some food aspiration. And also before starting that as the attitude inhibitors, they spend the patient about the race of the whole side effect. And if the patient is a cube it at work, uh they asked to stop that medication and and then if feeling better, if you go back to normal, you can restart the medication. So these are the important apply uh to start the Asiatic to inhabit. But is that a very good a pledge for that? Okay. Um Another one is also the very uh good medication very commonly used. Now today is the G F you want agonist. Is that blue carbon like pet type one? Uh Before talking about how we need to know what, what is that increasing effect? You are hard about. There's some increasing effect talking about from that GLP one as increasing uh gap or more uh produced from the small industry like the GLP one another is the G I P uh G R P blue carbon like pat type one is uh increased uh secrete from the small intestine. And also it uh affect bind to the receptor. GLP one receptor. That GLP one receptor is spreading various tissue, not only uh not only in the pancreas, it also has a hard hypothalamus kidney and also the liver or all several, multiple size. And that's every organ have a GLP one receptor. So that GLP one add on the receptor and net effect is that it increases insulin secretion and reduce oblique program secretion. And that case, maintaining the blood glucose level uh within normal. So what is that increasing effect whenever you eat the food or anything glucose load coming into the blood glucose body mechanisms to maintain the blood glucose. When you had, the black people have realized to uh to maintain the normal range is the insulin secretion, increase the flu coupled with the psa the vision is reduced to maintain the blood glucose. It's the normal physiology. Uh So what is that increasing effect? Is that increasing uh secretion or the insulin is a greater greater when you uh respond to uh taking the oral glucose rather than the IV glucose. This phenomenon is called increasing effect. So when you eat the food and your gi tract has that sense like the home increase to secrete that GLP one and G I P that is a gut hormone, uh they produced from that when you have the, when you eat that, so your blood levels ever heart. So to maintain that is a hormone produced, the G F you want G I P is from the pancreatic peter set. It stimulate the increased insulin secretion and reduce regard um secretion and uh causing the net effect is the blood glucose level to control. Yeah. So that the increasing effect is that when you give, you have the all glucose and uh respond to in secretion, insulin secretions increased to all the glucose rather uh rather than the uh glucose. That phenomenon is called the increasing effect. So, as I say before, is a GLP, one researcher expressed in different parts of the body so that TLP one agonists can affect on the different parts of the body. And in, in the Sistine reduced from the uh decrease from the industry, it affect on the brain. So what causing is increasing your protection. It acts on the hypothalamus is uh advertised uh center. So reduce the appetite and understanding what is causing the gastric and teen, reduce gastric and teen. So you feel you feel full, just eating small mouth. So not eating too much. So they can causing the weight looks um and also the pancreas, it increases insulin secretion, reduce glucagon secretion also increase the insulin sensitivity. So that effect on the diabetes management. And uh in terms of the glucose uptake from the paper and ethnikos tissue, it increase the paper vehicles uptake and reduce the glucose production from the liver. And so so many good effect on a different part of the body on the heart I also had a cardio protective Axion cardio functions, increase, improving the cardio function. So then you have to think about as a patient with the cardiovascular risk and cardiovascular disease, as your T two or T F B one should be add on that patient. So what, how we can get the does. Uh as I say that I'm talking about the oral medication, but except that the GLP one is came with the injection form. Uh apart from the aura semaglutide, uh it's the first uh the first medication came out is the zenit type. Uh can give them with the twice a day injection or once weekly injection. And little blue tide is just only once a day, once daily injection. It's called Victoza. We usually use that uh durable. Thai is also once weekly injection. Semaglutide is uh latest one is uh not the latest, one is a commonly used. One is the Ozempic is also one weekly injection. 0.2. Far, you can start with a little dose and, and then increase every four weeks and the platform and 21 mg and semaglutide has also the or a form. This is the only or a form of the GLP one agonist uh called the rib X is uh it can take the once daily orally and the anti stomach Kenyan with the 3 mg, 7 mg and 14 mg because of the same patient is a like the injection. No, I don't, I hate the injection. I uh fear of that needle, I don't like needles. So in that case, you can use that semaglutide all of on. And the latest one is a test. Uh zip, a type is a combination of the G F C one and D I P researcher and agonist. It will be available in the NHS maybe this year by approved by the N H S and the nice guidelines, it in void a nice guideline later on and that the DLP one is have a very good effect on the reduction. So lira blood type is a re Tozer is reusing the type one, type two diabetics or and also, you know, weight management, we can use the liver blue type high dose different dose using the type two diabetes is called the suspenders. Very uh popular medication as a day for the weight management, weight loss and the semaglutide. Also the weight loss usually use for the weight management. And uh appetite is also may be available this year for the weight management and also the type two diabetes management. So these are the newer medication, very good effect on the diabetes and also for the weight management. So the outcome is uh have the reduction of the HBA one C by the 1 to 1.5%. And is that the weight weight loss, moderate weight loss and also the reduced cardiovascular disci impatient with the existing Metro Skeleton cardiovascular disease. So we need to know about what are the adverse effect when you need to have the precaution. So that just common side effect is it just nausea, vomiting is common, but it is what can tolerate patient. Most of the patient can tolerate continue taking that. And also that some, there are some cases of the actual pancreatitis after using the GLP one because it affect on the pancreas. So and also the risk of the goblet up and be really dizzy as well. And uh every medication like a high percentage of the reaction. And in terms of the retinopathy, what is because before starting the GLP one, we need to check the uh retina screening. Uh diabetes because of very rapid glycemic control can affect on the uh retinopathy. So it wasn't the retinopathy if patient has uh retinopathy already. So we need to check the retinal screening before that the contract education as that is sanitize cannot use it. E G F are less than 30. But nowadays, if they are allowed to use it, they can uh study uh that is the E G F R more than 51 part you can use with caution if uh if the net clinical effect is very a good effect or for that patient. So it's because of the GLP one reduced against really emptying. So clearly, if a patient with uh gastroparesis, you can't use because it was and the gastro police or due to the reduced gastric MT. And if a patient has a history of acute pancreatitis, not give uh GLP one. And also that some studies in the with the liver, we talk show that some uh cases of the medullary thyroid carcinoma. So we have to ask about the medication has uh thyroid cancer before that. So we need to think about this uh adverse effect of precaution for that GLP one. Apart from that is the very good effect on both cardiovascular and we can really affect okay. Um Then the last one I had to talk a power talk about is the DVT before inhibitor. These are related to the GLP one and G D P four are also on the that uh got hormone that is that I petty die appetite is for uh where's that came in? So as I talk for like that, when you take food, your small industry in producer got hormone called the GLP one, it has a stimulate insulin secretion, suppress Glucagon secretion. So is the GLP one is very good. So too uh but that di di before enzyme is inactivate the GLP one Axion. So it is not. So, so we need to inhibit that DB before eggs I'm from, but it's also from God. So, so D D before inhibitor inhibit that be be before anxiety. So, so DFP one are expressing more and it's good effect of that being that effect DFB one effect. So what are the medication is? Okay? And with the medication and with the Gliptin. So we aim with the Gliptin group at the sector, Britain glitter, Gliptin, salsa, Britain, Alogliptin and linaGLIPtin. So these all are the DPP four inhibitor. Uh W well, usually get start with 50 mg once a day and you can increase with 100 mg once a day pill, a black teens and 50 mg twice a day. Uh subjecting 5 mg once a day. Alogliptin is a 25 mg once a day, Lena Bloating is a 5 mg once a day. So these old medication, we need to think about the E G F R or anything. Those a judgment in the arena impairment, the only uh linaGLIPtin is the only one we don't need to. Uh we don't need uh those adjustments in arena impairment. So you can use any E F uh with that linaGLIPtin. So very easy to remember just only 5 mg once a day. Uh If the patient on the other Gliptin or the other medication with the renal impairment, if they need some, you can change the limit grip to inform you can run state. So very easy to remember that. Um So effect is um this has a very, compared to the other medication that is of Nigeria. It has a low result hypoglycemia in terms of weight. It is not uh causing weight gain definitely, but it's also not affect on the work block. So it is neutral or wait and very many men drug interaction is usually well tolerated. So that thing is that effect on the glycemia control is not very good at by the SGLT two or GLP one. So uh the other thing, other uh side effects are nausea, dahlia the same or other gi side effects because of the uh on the garden normal gut. So the stomach pain that blue light's in terms some skin rush uh side effect of that bloating. So S E R D to uh end with glitch flows in all the blood flows in our sche to all the GLIP teams uh the D D before. Uh So yeah, so I've talked about all these medication in management of the type two diabetes. We all know that. But what medication you choose, how to choose that medication? Which one is good? Which one you need to start with that? So I would like to talk about the recent uh nights guideline for the management of the type two diabetes. It updated last up to dated in August last year. So recently updated not Skyline for the how to choose, start choosing the medication in management of the type two diabetes. You on our, our medication, which medication for which patient? So these are the most important in in clinical practice uh to use. So for press guiding guidance is that we need to uh before that, that uh nice guidelines here. Um So that's a recent guidelines show that the first thing important. Most important thing is the diet and lifestyle changes is very important, even though you've taken at all medication. If you don't follow that, the diet and lifestyle changes, it will not be the good effects. So, uh we need to emphasize and enforce uh patient at every uh consultation, at every point, we need to reinforce the voice for the diet and lifestyle changes. Um Also the uh the Night Skyline mentioned that the rescue therapy. So for the patient with a symptomatic hypoglycemia, we can consider uh like the polyuria politics. Here, we can consider the insulin or sulfonylurea first to, to control the blood glucose level. And then when the blood work, there's more uh improve, we can consider again, they need that insulin or not. These are the rescue therapy that time using that nice guideline. So in terms of choosing medications based on the uh individual, every case because of the individual plan, in case that comes in, for example, like any commodity or the patient contra education weight is that patient body weight, uh any other the rest of the polyp pharmacy and also individual patient preference and meat. And we also need to think about any affected naps. Uh in terms of the that glycemia control, in terms of cardiovascular effect, in terms of the protection effect. So we need to think about all uh multifactorial things and also need to think about any safety and confirm indication and some people cannot tolerate that medication, we can't get up and, and also the monitoring how we monitor that patient. And then the course finally that and of course, the cost is the same class is the same effect that we choose. The. Uh these are the guidelines from the nice guidelines, how to choose that medication. And also in terms of the reviewing the medication, we need to think about each point uh discuss with the patient when, if the medical invitation cannot tolerate you, stop it. Uh if the patient has no effect on the no impact on the glycemic control, um so you need to stop it or change other medication. So unless they have the other additional can get back and feel like the cardiovascular renal protection of these things. And then we optimize the medication. So we start with the low dose and we need to rather than adding newer medication will increase the maximum both of the medication and the monitor effect even. Uh yeah, and then we uh add on the other medication, monitor their address, effect, any compliance of the medication. And these all need to think about that. Okay. So in management of the type two diabetes, we just know we not only think about the bicycle control, we need to think about the uh macro and micro vascular complication and the cardiovascular respecter. How hard is it? So what are the high risk of a cardiovascular duty? So, I mean, is the patient will dealt with the type two diabetes if the quit school is a car diverse very school, uh, is my more than 10% with over age of 40 or is there any life cardiovascular risk factors such as the hypertension diabetes, dyslipidemia, smoking, obesity, and any family history of the cardiovascular premature cardiovascular disease in the family. So we need to think about all these things together. Also treat all these thing is management of the type two diabetes. So I will go to this is a nice uh type two diabetes therapeutic part way. I appreciate that my credit go to the, my professor for Charlie would give us that very clear flow chart. Uh The nice guidelines if you can see the nice guy and he's uh colorful and complicated. So he gives that is a very clear futures to use. That is uh thank you so much for my professor for that. And then so we start with the diet and lifestyle in the every case of the management of the type two diabetes. And if the HB one C is a more than 48 and you need to think about any kind of vascular race at that patient. If you're not at high race and no known cardiovascular disease, heart failure or remitted, you can start with the back for me. If it's not tolerated side effect, you can go with a slow release form. And if the Metformin is intolerant or contract education. You can use the DPP four uh pioglitazone sulfonylurea on that they're closing SGLT two inhibitor. And if a patient has a heart failure, already, heart failure, known cardiovascular disea green a disease. So you can start off the refuse and S 2 82. But it's a new uh uh indication for the NATS guideline. If the patient already on the Metformin, you add on that blood flow thing. If the patient has uh patient uh Metformin is intolerant or contra indication, you can only start with the blood closing alone. So and then we monitor the HBA one C glycemia target pricing. The target is individualized. Uh actually the depending on patient commodity reality, everything uh if the target is not reached but that medication. So you can think about Julia or a therapy. So, Metformin plus any one of these medication and you monitor the HBA one C still not control, not get the target uh like the less than uh more than 58 million more for more and try to have a trip or a therapy uh for the add on the insulin therapy or not. It's still have that trip treatment. Your HBA one C is still high more than 58 or all the individualized target is not achieved. We have to think about what is the, the MRI of the patient. It's A B M are less than 35 in the Asian population is at 33. You can start the insulin if not started yet. Uh If the patient is A B M I is more than 35 the Asian of Black is 33 you can start the G F one even though the B M I is less than 35 with the other uh commodity of the obesity related comorbidity. So you can start the GLP one. You have to consider the G F P M therapy. So at any point, you need to think about any cardiovascular heart failure or you know disease develop, we offer the great floating if not already taking if the patient is not already taking. And also the quit school is more than 10%. You can consider the that blood flows in and also the arena. What is arena dizzy mean we checked that your your uh urine uh us er creatinine ratio is less than uh 32 30. You can consider play clothing if the three more than 30 for the great closing. So uh two inhibitor role is uh increasingly in the management of the type two diabetes. Okay. Sorry, slow. Okay. So I want to talk about the slightly about the target. Um So generally is the individualized targets. Generally I can say is that we know have a fixed target of the HBA one C target. Usually if the patient has a lifestyle and only diet and single agent and no hypoglycemia A is uh HBA one C of 14 million more promote the 6.4%. But it is very rare associated with the hypoglycemia thing is the 53 or 7% but it's uh HBA one C target mostly is the individualized. Uh you know, it depends on the is the patient flavor tea and also the just like any life expectancy. Anybody commodity like that, impair hyper awareness, driver and uh heart disease, renal disease. These often need to think about the target HB one C targets, uh, any uh punisher need to discuss with the individual patient for the target. Hb one C. Mhm. So, um, I just want to just about, uh, think about the, maybe the bit more boring topic. And then, so if the patient came in with the, uh, the 52 year old man type two diabetes for two years, he's already on the mat forming 11 B B because I follow up in the clinic. HB one C 76 E G F A normal USF that you want. What do you want to add that point? You can type on in the chart just to think about it. Yeah, I can see later. I didn't see it. Yeah, I do think. Okay. Uh, just, uh, that's my reference today. A nice line. So some people have answered for D P uh DPP four inhibitors and also difficult frozen. Two people have voted for difficult frozen. You can't operate. I don't know why I can see that. Oh, Yeah. Okay. Yeah. So the thing is that I, I think it's just that you a cr is a human creatinine ratio is uh slightly high, more than 30. So I suggest, yeah, I agree with that. Is that mostly that I just want to start with uh as you have 22 inhibitor? Yeah, that's right. Thank you. So these are my referendums and my scout line on these things. Thank you so much for uh joining this weather. Now, I hope that will be a little bit careful in your clinical practice. Any questions? I'm very happy to answer the any questions from the floor. And I put on the slide if you can be very grateful, if you can scan back to your code for anything that thank you so much. Then that's an excellent talk on um or diabetic agents. Um I've also post the link in the chat, so there's two different ways of um given us some valuable feedback. Um Please do typing the questions into the chat as well. But whilst we wait, um I just wondered what your thoughts were on stopping the S L G two inhibitors when since acutely unwell on the medical take. Yeah. If the patient came in with acutely and warren acute medical tape, you need to call any any acute world patient, we need to stop the S E R T two inhibitor, the pole and at the moment and then if we don't know any word condition, any peculiar hour, maybe the infection or the A P R everything. So at that point, we will stop that as you attitude inhibitor and then everything that if a patient that become getting better or the infection clear, everything's back to normal, you can restart that. I've just posted a link for next week's session. So next week sessions unfortunately can have to take place on Friday at lunchtime. So 1 30 to 2 30 the topic of discussion will be hike. So, um we'll stick around for any further questions that you have on this talk. But thank you so much for joining. Thank you. Yeah, if after that is any question, just how did you answer the QR code? Fixed talk is also uploaded as well. So you can register for the next session next week.