Diabetes Mellitus Overview and Treatments

Andrew P. VogtChemistry 6116

Diabetes Mellitus : a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both

20.8 million in US ( 7% of population) estimated 14.6 million diagnosed (only 2/3) Consists of 3 types:

1) Type 1 diabetes

2) Type 2 diabetes

3) Gestational diabetes

Complications :- Stroke- Heart attack- Kidney disease- Eye Disease- Nerve Damage

Diabetes Mellitus Type 1 Diabetes

- cells that produce insulin are destroyed - results in insulin dependence- commonly detected before 30

Type 2 Diabetes- blood glucose levels rise due to

1) Lack of insulin production

2) Insufficient insulin action (resistant cells)

- commonly detected after 40

- effects > 90%

- eventually leads to β-cell failure (resulting in insulin dependence)

Gestational Diabetes 3-5% of pregnant women in the US develop gestational diabetes

Testing :

Fasting Plasma Glucose Test

(FPG) - (cheap, fast)

*fasting B.G.L. 100-125 mg/dl signals pre-diabetes

*>126 mg/dl signals diabetes

Oral Glucose Tolerance Test

(OGTT)

*tested for 2 hrs after glucose-

rich drink

*140-199 mg/dl signals pre-

diabetes

*>200 mg/dl signals diabetes

80 to 90 mg per 100 ml, is the normal fasting blood glucose concentration in humans and most mammals which is associated with very low levels of insulin secretion.

A.K.A.: Glycated Hemoglobin tests A1C

Diabetes - Insulin Discovered in 1921 by Banting

and Best Consist of A & B chains linked

by 2 disulfide bonds

(plus additional disulfide in A)~ ~ ~ ~ A = 21amino acids B = 30 amino acids

Diabetes – Insulin(synthesis, storage, secretion) Produced within the pancreas by β cells islets of Langerhans insulin mRNA is translated as a single chain precursor called preproinsulin removal of signal peptide during insertion into the endoplasmic reticulum generates proinsulin Within the endoplasmic reticulum, proinsulin is exposed to several specific endopeptidases which excise the C peptide, thereby generating

the mature form of insulin

Stored as β granules

This light micrograph of a section of the human pancreas shows one of the islets of Langerhans, center, a group of modified glandular cells. These cells secrete insulin, a hormone that helps the body metabolize sugars, fats, and starches. The blue and white lines in the islets of Langerhans are blood vessels that carry the insulin to the rest of the body.

Zn

Diabetes – Insulin(Biochemical Role)

-Tyrosine Kinase receptors are the locks in which the insulin key fits- Involved in signal transduction(insulin hormone being 1st messenger)

Diabetes – Oral Medications

Sulfonylureas Biguanides Sulfonylureas and biguanide combination

drugs Thiazolidinediones Alpha-glycosidase inhibitors Meglitinides

6 Classes :

Sulfonylureas : stimulate β cells to produce more insulin

1st generation– (1)Orinase (tolbutamide)– (3)Tolinase (tolazamide)– (6)Diabinese (chlorpropamide)

2nd generation– (75)Glucotrol (glipizide)– (150)Glucotrol XL (ex. rel. glipizide)– (150)Micronase, Diabeta (glyburide)– (250)Glynase (micronized glyburide)

3rd generation– (350)Amaryl (glimepiride)

2-(p-aminobenzenesulfonamido)-5-isopropyl -thiadiazole (IPTD) was used in treatment of typhoid fever in 1940’s hypoglycemia

Currently > 12,000

Re

l. P

oten

cy

bin

d to

pro

tein

may become dislodged delayed activity

*Hydroxylation of the aromatic ring appears to be the most favored metabolic pathway*Hydroxylated derivatives have much lower hypoglycemic activity

Biguanides : improves insulin’s ability to move glucose into cells (esp. muscle)

Metformin- Glucophage®, Fortamet®, Riomet®

*only anti-diabetic drug that has been proven to reduce the complications of diabetes, as evidenced in a large study of overweight patients with diabetes (UKPDS 1998).

- Metformin was first described in the scientific literature in 1957 (Unger et al). - It was first marketed in France in 1979 but did not receive FDA approval for Type 2 diabetes until 1994.

NN

NN

N

RR R

R

RR

R

N N

N

N

N

H

H

H

H H

+ HCl

- mechanism improves insulin sensitivity by increasing peripheral glucose uptake and utilization. - Zhou et al (2001) showed that metformin stimulates the hepatic enzyme AMP-activated protein kinase

Sulfonylurea & Biguanide Combo drugs/ Cocktails

Glucovance® (Glyburide & Metformine HCl)

NH

O

NH

SO

O

O

O

NH

Cl

1-[[ p-[ 2-( 5-chloro-o-anisamido) ethyl] phenyl] sulfonyl]-3-cyclohexylurea

N N

N

N

N

H

H

H

H H

+ HCl

&

&

Thiazolidinediones (TZD’s) : make cells more sensitive to insulin (esp. fatty cells)

Pioglitazone- Actos®, Avandia®

- binds to and activates the gamma isoform of the peroxisome proliferator-activated receptor (PPARγ).

- PPARγ is a member of the steroid hormone nuclear receptor superfamily, and is found in adipose tissue, cardiac and skeletal muscle, liver and placenta

PPAR - γ

- upon activation of this nuclear receptor by a ligand such as a TZD, PPARγ–ligand complex binds to a specific region of DNA and thereby regulates the transcription of many genes involved in glucose and fatty acid metabolism.

S

NH

O

O

ON

5-{4-[2-(5-Ethyl-pyridin-2-yl)-ethoxy]-benzyl}-thiazolidine-2,4-dione

- Marketed in USA in August of 1999

Αlpha – glycosidase inhibitors :Block enzymes that help digest starches slowing the rise in B.G.L.

AGI’s- Precose ® (acarbose),

- Glyset ® (miglitol)

N

OO

OO

O

H

H H

H H

1-(2-Hydroxy-ethyl)-2-hydroxymethyl-piperidine-3,4,5-triol

Meglitinides : Stimulate more insulin production ; dependant upon level of glucose present

Meglitinides- Prandin ® (repaglinide)

- Starlix ® (nateglinide)

O

OHO

NH

N

O

2-Ethoxy-4-{[3-methyl-1-(2-piperidin-1-yl-phenyl)-butylcarbamoyl]-methyl}-benzoic acid

O

OH

NH

O

2-[(4-Isopropyl-cyclohexanecarbonyl)-amino]-3-phenyl-propionic acid

Diabetes – Oral MedicationsSummary

6 Classes :

Sulfonylureas stimulate β cells

Biguanides improves insulin’s ability to move glucose

Sulfonylureas and biguanide combination drugs BOTH

Thiazolidinediones cells more sensitive to insulin

Alpha-glycosidase inhibitors Block enzymes that help digest starches

Meglitinides stimulate β cells (dependant upon glucose conc.)

In Conclusion :

2 major types of diabetes

(3 with Gestational) Type 1 => insulin dependant (5-10%) Type 2 => may treat with oral medication

which may alter insulin production &/or sensitivity ; disease often succumbs to insulin dependence (>90%)

References:http://www.webmd.com/content/article/59/66840

 

http://hms.harvard.edu/public/disease/diabetes/diabetes.html

 

http://focus.hms.harvard.edu/2005/May20_2005/immunology.shtml

 

http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

 

http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/pancreas/insulin_struct.html

 

http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/pancreas/insulin.html

 

http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/moaction/surface.html

 

http://www.cancure.org/insulin_potentiation_therapy.htm

 

http://www.diabetes.org/about-diabetes.jsp

 

http://www.diabetesnet.com/diabetes_treatments/sulfonylureas.php

 

http://www.people.vcu.edu/~urdesai/sulf.htm

 

http://en.wikipedia.org/wiki/Glucohexal

 

http://www.drkoop.com/druglibrary/93/glucovance-warnings_precautions.html

 

http://en.wikipedia.org/wiki/Actos

 

http://www.answers.com/topic/peroxisome-proliferator-activated-receptor

 

http://www.mja.com.au/public/issues/176_08_150402/omo10828_fm.html

 

http://www.univgraph.com/bayer/inserts/precose.pdf

 

http://www.drugs.com/pdr/ACARBOSE.html

 

http://www.pfizer.com/pfizer/download/uspi_glyset.pdf

 

http://www.rxlist.com/cgi/generic2/miglitol.htm

 

http://en.wikipedia.org/wiki/Prandin

 

http://redpoll.pharmacy.ualberta.ca/drugbank/cgi-bin/getCard.cgi?CARD=APRD00593.txt