GLP -1 (gut hormone) + GIP = incretin effect

=Augmentation of insulin after oral glucose

Type 2 diabetics little incretin effect Reduced GLP-1 secretion GIP lost insulinotropic property

GLP-1 broken down by DPP-4

Only for type 2 diabetes

Inhibits incretin breakdown

Indirectly increase own insulin secretion

Moderate HBA1c reduction (~1%)

Which one to choose?

Start– 2nd line: Metformin or Sulphonylurea +

HBA1c ≥ 6.5% + not suitable for other one

– 3rd line: Metformin + Sulphonylurea + HBA1c ≥ 7.5%

– Thiazolidinedione is an alternative in 2nd line case but not 3rd

• Continue–HBA1c reduces by ≥ 0.5% in 6 months

DPP-4 Inhibitor if:Weight gain would cause significant problem

Thiazolidinedione contraindicated eg heart failure

Previous intolerance or poor response to Thiazolidinedione

GLP -1 (gut hormone) + GIP = incretin effect

=Augmentation of insulin after oral glucose

Type 2 diabetics little incretin effect Reduced GLP-1 secretion GIP lost insulinotropic property

GLP-1 broken down by DPP-4

Only for type 2 diabetes

Effects: Stimulates post-prandial insulin

secretion Slows gastric emptying Reduces appetite

Administered: Subcutaneous injection Twice daily

Less hypos compared to insulin BIG benefit of weight loss Only licensed to lower blood

sugars, not as weight loss agent Nausea and vomiting

£830 per person per year

Start:BMI ≥ 35 (+ probs assoc. with high wt)BMI < 35 + insulin unacceptable or weight loss beneficial to co-morbidities

Continue Metformin and SulphonylureaCombination with insulin

Continue:HbA1c reduction ≥ 1.0% AND Initial body weight reduction ≥ 3%

Metformin still first line

DPP-4 Inhibitors alternative where Thiazolidinediones were previously only other oral option

Exenatide - good for weight loss but ?help in sugar control

Further new drugs on their way