Insulin Acarbose

Other combination options Metformin or a Sulfonylurea plus Acarbose/Miglitol, or Pioglitazone/ Rosiglitazone or Repaglinide (with metformin), or Insulin... 

Coadministration Acarbose given in combination with a sulfonylurea or insulin will cause a further lowering of blood glucose and may increase the hypoglycemic potential of the sulfonylurea. 

Because its mechanism of action is different, the effect of acarbose to enhance glycemic control is additive to that of sulfonylureas when used in combination. In contrast to sulfonylureas, acarbose does not enhance insulin secretion. 

The effect of adding acarbose (maximum 100 mg tds) or placebo to insulin (20) or metformin (21) has been investigated in 1946 patients with type 2 diabetes. The results were comparable with the results of the UK Prospective Diabetes Study (22). After 3 years, 39% were still using acarbose compared with 58% using placebo. The main reasons for stopping were flatulence (30 versus 12%) or diarrhea (16 versus 8%). After 3 years the HbAic concentration was 0.5% lower (median 8.1 versus 8.6%). Acarbose was equally effective when added to diet, sulfonylurea, metformin, or insulin. 

When acarbose or placebo was given to patients with type 1 diabetes taking insulin, acarbose reduced postprandial blood glucose but there was no difference in HbAic the only adverse effects were gastrointestinal (23). 

Acarbose reduced insulin resistance in 192 patients over 65 years of age (mean age 70) in a double-blind, placebo-controlled study (27). HbAlc was significantly but modestly reduced. The most frequent adverse effect was flatulence, which caused 12 patients (9 taking acarbose and 3 taking placebo) to withdraw. 

When acarbose is combined with insulin, the greatest effects are seen with regimens that involve only once- or twice-daily administration. The alpha-glucosidase inhibitors seem to be less effective when they are combined with intensive insulin therapy (35). In combination with insulin or oral hypoglycemic drugs the frequency of hypoglycemic episodes can increase sucrose or higher carbohydrates are reported to be less effective, which can be understood from the mechanism of action. 

In a post-marketing surveillance study of 1142 patients in whom acarbose was added to insulin therapy for type 2 diabetes mellitus, HbAlc improved by 0.9% and there were 108 adverse effects in 6.9% of the patients (45). Most of the complaints were gastrointestinal (flatulence, abdominal pain, diarrhea) and more than half were reported in the first week of acarbose therapy. 

A 73-year-old man with diabetic gangrene who had used insulin and acarbose 300 mg/day for 15 months developed ileus with abdominal pain and vomiting after he took PL granules (containing salicylamide, paracetamol, anhydrous caffeine, and promethazine methylene disalicylate) for a common cold (51). The ileus subsided after acarbose and the other drugs were withdrawn. 

Kelley DE, Bidot P, Freedman Z, Haag B, Podlecki D, Rendell M, Schimel D, Weiss S, Taylor T, Krol A, Magner J. Efficacy and safety of acarbose in insulin-treated patients with type 2 diabetes. Diabetes Care 1998 21(12) 2056-61. 

Kageyama S, Nakamichi N, Sekino H, Fujita H, Nakano S. Comparison of the effects of acarbose and voglibose on plasma glucose, endogenous insulin sparing, and gastrointestinal adverse events in obese subjects a randomized, placebo-controlled, double-blind, three-way crossover study. Curr Ther Res Clin Exp 2000 61 630-45. 

Klocke KR, Stauch K, Landen H. Effect of add-on acarbose to insulin therapy in routine clinical practice. Clin Drug Invest 2003 23 621-7. 

Gentile S, Turco S, Guarino G, Oliviero B, Annunziata S, Cozzolino D, Sasso FC, Turco A, Salvatore T, Torella R. Effect of treatment with acarbose and insulin in patients with non-insulin-dependent diabetes mellitus associated with non-alcoholic liver cirrhosis. Diabetes Obes Metab 2001 3(1) 33 10. 

The different mechanisms of action of the various classes of hypoglycemic drugs makes combined therapy feasible the sulfonylureas and meglitinides stimulate insulin production by different mechanisms, the biguanides reduce glucose production by the liver and excretion from the liver, acarbose reduces the absorption of glucose from the gut, and the thiazolidinediones reduce insulin resistance in fat. It is not necessary to wait until the maximal dose of... 

A 54-year-old woman with gestational diabetes was later found to be allergic to chromium, pollen, dust, penicillin, acarbose, and metformin (130). She was treated with diet and glibenclamide, but later required insulin. With Humulin N insulin she developed a wheal of 15 mm immediately after the injection, which resolved in a few hours. However, a painful itchy induration appeared 2-3 hours after the injection and lasted a few days. She had an immediate reaction to isophane insulin, with induration, but insulin lispro was well-tolerated. 

A 38-year-old woman was given insulin when glibenclamide and acarbose failed. Troglitazone 400 mg/day was added and increased to 800 mg/day 1 month later. After 2 months her liver function tests were normal, but she developed jaundice after 4 months. Total and direct bilirubin were 127 and 101 pmol/l and alanine transaminase was 34 pkat/l. After withdrawal of troglitazone her symptoms disappeared and her liver function tests normalized within several months. Metformin 1000 mg bd reduced her insulin requirement. Rosiglitazone 4 mg bd was added and her liver function tests remained normal for 10 months. 

PENTAMIDINE ANTIDIABETIC DRUGS-INSUUN, SULPHONAMIDES, NATEGLINIDE, REPAGLINIDE, ACARBOSE Altered insulin requirement Attributed to pancreatic beta cell toxicity Altered glycaemic control need to monitor blood sugar until stable and following withdrawal of pentamidine... 

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