Insulin Resistance Medication

  • Author: Samuel T Olatunbosun, MD, FACP; Chief Editor: George T Griffing, MD   more...
 
Updated: Aug 2, 2011
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Medications that reduce insulin resistance include biguanides and thiazolidinediones, which have insulin-sensitizing and antihyperglycemic effects. Large quantities of insulin are also used in overcoming insulin resistance. Response to usual dosage of insulin is observed in instances in which the resistance is due to enhanced destruction at the subcutaneous injection site.

The treatment of type 2 diabetes and impaired glucose tolerance (IGT)—conditions that are strongly associated with insulin resistance and significant cardiovascular morbidity and mortality—should aim at restoring the normal relationship between insulin sensitivity and secretion.

For diabetes, this involves pharmacotherapy, which includes stimulation of insulin secretion (sulfonylureas, meglitinides, incretin mimetics) and insulin sensitivity (metformin, thiazolidinediones), as well as treatment intended to support the signals that mediate the islet adaptation (incretin mimetics).[51, 52]

Pramlintide (an amylin analogue) acts as an amylinomimetic agent by modulating gastric emptying, preventing postprandial increases in plasma glucagon, and promoting satiety, leading to decreased caloric intake and potential weight loss. Antiobesity drugs, such as orlistat, may reduce insulin resistance and related cardiovascular risk factors through weight reduction and other mechanisms.[62, 63, 64, 65, 66] In most patients, the administration of insulin is also crucial in the treatment of diabetes.

Most experts recommend early preventive strategies in children, especially lifestyle changes such as diet and increased level of physical activity, whereas pharmacotherapy is reserved for selected cases.[31]

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Biguanides

Class Summary

Biguanides are insulin sensitizers useful in type 2 diabetes and related insulin resistance. They reduce hepatic glucose output and peripheral resistance to insulin action and lower plasma insulin levels.

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Metformin (Glucophage, Glucophage XR)

 

Metformin reduces hepatic glucose output, decreases intestinal absorption of glucose, and increases glucose uptake in the peripheral tissues (muscle and adipocytes). It is a major drug used in obese patients who have type 2 diabetes. It enhances weight reduction and improves lipid profile and vascular integrity. Individualize metformin treatment with monotherapy, or administer it in combination with insulin or sulfonylureas.

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Thiazolidinediones

Class Summary

Thiazolidinediones are insulin-sensitizing drugs that increase the disposal of glucose in peripheral tissues and act by activating a specific nuclear receptor, the peroxisome proliferator-activated receptor gamma (PPAR-gamma). Thiazolidinediones have a major effect in the stimulation of glucose uptake, skeletal muscle, and adipose tissue. They lower plasma insulin levels and are used to treat type 2 diabetes associated with insulin resistance. They appear to benefit patients with PCOS. Thiazolidinediones include rosiglitazone and pioglitazone.[51, 53]

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Pioglitazone (Actos)

 

Pioglitazone may be used in monotherapy and in combination with metformin, insulin, or sulfonylureas. It improves target cell response to insulin without increasing insulin secretion from pancreas. It decreases hepatic glucose output and increases insulin-dependent glucose use in skeletal muscle and, possibly, in liver and adipose tissue.

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Rosiglitazone (Avandia)

 

Rosiglitazone is an insulin sensitizer with a major effect in stimulating glucose uptake in skeletal muscle and adipose tissue. It lowers plasma insulin levels. Rosiglitazone is used for treatment of type 2 diabetes associated with insulin resistance and may benefit polycystic ovary syndrome (PCOS) patients. It may be used as monotherapy or in combination with metformin.

Rosiglitazone is highly selective and a potent agonist for PPAR-gamma. The activation of PPAR-gamma receptors regulates insulin-responsive gene transcription involved in glucose production, transport, and utilization, thereby lowering blood glucose concentrations and reducing hyperinsulinemia. Potent PPAR-gamma agonists have been shown to increase the incidence of edema. A large-scale, phase III trial (RECORD) is currently underway that is specifically designed to study cardiovascular outcomes of rosiglitazone.

On May 21, 2007, following the online publication of a meta-analysis, the US Food and Drug Administration (FDA) issued an alert to patients and health care professionals warning that rosiglitazone can potentially increase the risk for myocardial infarction and heart-related deaths.

As of September 2010, the FDA is requiring a restricted access program to be developed for rosiglitazone under a risk evaluation and mitigation strategy (REMS). Patients currently taking rosiglitazone and benefiting from the drug will be able to continue if they choose to do so. Rosiglitazone will only be available to new patients if they are unable to achieve glucose control on other medications and are unable to take pioglitazone, the only other thiazolidinedione.

For more information, see FDA's Safety Alert on Avandia. The meta-analysis, entitled Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes, can be viewed online. Additionally, responses to the controversy—including the articles Rosiglitazone increases MI and CV death in meta-analysis and The rosiglitazone aftermath: legitimate concerns or hype? —can be viewed at the Heartwire news site (the heart.org), from WebMD.

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Glucocorticoids

Class Summary

Glucocorticoids are immunosuppressants used for the treatment of immune insulin resistance due to anti-insulin antibodies.

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Prednisone

 

Prednisone is an immunosuppressant used for the treatment of autoimmune disorders. It may decrease inflammation by suppressing key steps of the immune reaction process.

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Antidiabetic Agents, Insulin

Class Summary

Insulin is given to overcome insulin resistance, but large quantities are often required.

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Insulin (Humulin, Novolin, Humalog)

 

Insulin stimulates proper utilization of glucose by the cells and reduces blood sugar levels. Various preparations are currently available. There are rapid-acting, intermediate acting, and long-acting formulations. Insulin mixes are also available that provide a rapid onset and an intermediate duration of action.

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Lipase Inhibitors

Class Summary

Lipase inhibitors inhibit nutrient absorption. Lipase inhibitors such as orlistat may reduce insulin resistance and related cardiovascular risk factors through weight reduction and other mechanisms.

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Orlistat (Xenical, Alli)

 

Orlistat is a gastrointestinal lipase inhibitor that induces weight loss by inhibiting nutrient absorption. Its effectiveness in producing weight loss does not depend on systemic absorption. May reduce absorption of some fat-soluble vitamins (A, D, E, K) and beta-carotene. Administer a daily oral multivitamin supplement containing fat-soluble vitamins 2 hours before meals or 1 hour after meals. Rare cases of severe liver injury have been reported with use so caution should be taken when administering orlistat.

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Contributor Information and Disclosures
Author

Samuel T Olatunbosun, MD, FACP  Endocrinology Department, Wilford Hall Medical Center, 59th Medical Wing, Lackland Air Force Base

Samuel T Olatunbosun, MD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, and American Diabetes Association

Disclosure: Nothing to disclose.

Coauthor(s)

Samuel Dagogo-Jack, MD, MBBS, MSc, FRCP  Professor of Medicine, Program Director, Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center

Samuel Dagogo-Jack, MD, MBBS, MSc, FRCP is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, and Royal College of Physicians

Disclosure: Eli Lilly None Speaking and teaching; GlaxoSmithKline None Speaking and teaching; Merck None Speaking and teaching

Specialty Editor Board

David S Schade, MD  Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Don S Schalch, MD  Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

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