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Mandatory Examinations

Family H/o DM H/o IHD. Angina, IC H/o Smoking H/o Hypoglycemia Exam for all pulses B.P recording Foot exam - Trophic PNP and ANP Fungal Infect., Pruritus. Mandatory Examinations. Fasting and PP BG Hb A1c on Dx & six monthly Lipid profile, Lp(a), hs-CRP CHD Risk factors MAU - ACR

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Mandatory Examinations

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  1. Family H/o DM H/o IHD. Angina, IC H/o Smoking H/o Hypoglycemia Exam for all pulses B.P recording Foot exam - Trophic PNP and ANP Fungal Infect., Pruritus Mandatory Examinations • Fasting and PP BG • Hb A1c on Dx & six monthly • Lipid profile, Lp(a), hs-CRP • CHD Risk factors • MAU - ACR • ECG for LVH, IHD • Echo for LVD, LVH • Stress test in equivocal cases • Fundus exam for DR www.drsarma.in

  2. Diagnosis – O-GTT 75g of oral glucose – 2 hrs. after DM IGT Normal DM IFG Normal FPG 200 mg% 140 mg% 126 mg% 100 mg% PPG • FBG > 126 & PPBG > 200 - same day • RBG > 200 mg % on 2 occasions or www.drsarma.in

  3. Diagnosis - Practical Points 1. Do not label one a diabetic by glycosuria alone For, one may have renal glycosuria 2. Benedict’s less accurate; shows any reducing substance. Glucose oxidase test strips confirm glucosuria 3. Do not neglect urine test for acetone 4. Never base Dx on a single blood sugar test 5. O-GTT (2 sample) is the gold standard for Dx. of DM 6. HbA1c – Not for Dx. Follow up once in 3 to 6 months 7. Majority of diabetics are not symptomatic – so screen One may present first time with complications – too late www.drsarma.in

  4. Correlation of MPG - HbA1c Mean Plasma Glucose = (35.6 x HbA1c %) – 77.3 HbA1c = (MPG mg% + 77.3) / 35.6 Diabetes Care Vol.26 (S), P33, 2003 www.drsarma.in

  5. Blood Sample – Practical Points • The whole blood glucose is 15% higher • We need to estimate plasma glucose • Na F is to be used as the anti-coagulant • Centrifuge and separate plasma within 1 hour • For HbA1c – we need EDTA added blood – • HbA1c measurement – No fasting is required • C-Peptide or Serum Insulin – Only on fasting • Shouldn’t add any anti-coagulant for C peptide www.drsarma.in

  6. Stages of T2DM Insulin Resistance IR Stage 1 Insulin Deficiency • Insulin Resistance • Hyper Insulinemia • Normal Glucose Tolerance Stage 2 • Insulin Resistance • Declining Insulin levels • Abnormal Glucose Tolerance IR + ID Stage 3 • Insulin Resistance • Very low Insulin levels • Hyperglycemia round the clock ID www.drsarma.in

  7. What is new in Rx. of T2DM • The step-care therapy is not advocated now. • Choice of OAD/Insulin to be individualized • Glycemic targets must be achieved quickly • Multiple therapies may be needed • A1c is the target now - within 6 months • Diet alone is not the option now - difficulties • Even prediabetes needs Rx. aggressively • Total metabolic control – notglycemia alone • Combination of OAD + Insulin, early insulin • Avoid hypoglycemia by proper drug choice www.drsarma.in

  8. Stage Based Management www.drsarma.in

  9. Today’s Treatment Goals Keeping HbA1c and FBG, PPBG with in limits • Exercise – Diet – Weight reduction • OHAs and Insulin Correction of all metabolic abnormalities • Normalizing lipids,BP Goal < 130/80 • Reducing Obesity and Waist Circumference Prevention and Rx. of complications • Macrovascular, 2. Microvascular, 3. Metabolic Special emphasis on Prevention of CHD www.drsarma.in

  10. Complications of T2DM • Metabolic Complications • IR; Obesity, Lipids – ↑TG, ↓HDL, ↑ sLDL • Thrombogenic ( ↑PAI-1, ↑ fibrinogen) profile • Micro-vascular Complications • Diabetic Retinopathy (DR) • Diabetic Kidney Disease (DKD) – Nephropathy • Diabetic Neuropathy – DPN, DAN • Macro-vascular Complication • Coronary Artery Disease (CAD) • Stroke, CVD, TIA, HT • Peripheral Vascular Disease (PVD) www.drsarma.in

  11. Ticking Clock of T2DM • Micro-vascular Complications • At the onset of hyperglycemia • Control of hyperglycemia essential • The A1c target of less than 7 must (A) • Macro-vascular Complication • At the onset of insulin resistance • Blood pressure goal of 130/80 (B) • Control of lipid abnormalities (C) www.drsarma.in

  12. How to Identify IR ? www.drsarma.in

  13. Diet, Exercise, TLC Weight reduction, Waist reduction Metformin – unmasks Insulin receptors Insulin sensitizers – TZDs - PPARγ Abolition of Glucotoxicity Control of hypertension Control of Metabolic abnormalities ID IR How to treat Insulin Resistance ? www.drsarma.in

  14. Drugs that sensitize the body to insulin and/or control HGO Drugs that stimulate the pancreas to make more insulin Drugs that slow the absorption of starches TZD – Glitazones And Metformin Sulfonylureas and Meglitinides -Glucosidase Inhibitors – Acarbose, Miglitol, Voglibose Major Classes of Medications www.drsarma.in

  15. Metformin, TZD, (-GI add on) Insulin SU Meglitinide Lifestyle 350 Post Meal Glucose 300 250 Fasting Glucose Glucose 200 150 100 50 250 200 Insulin Resistance Relative Function 150 100 Insulin Level At risk for Diabetes Beta cell failure 50 0 -10 -5 0 5 10 15 20 25 30 Years of Diabetes Timeline for Utilization of Therapies www.drsarma.in © International Diabetes Center. From Kendall D, Bergenstal R.

  16. Efficacy of Monotherapy - OADs DeFronzo Annals of Internal Medicine 1999;131:281-303, Nathan N Engl J Med 2002; 347:1342-1349 www.drsarma.in

  17. Summary of all effects of Rx. Diabetes Spectrum Vol. 5, # 3, 103-108 www.drsarma.in

  18. Basis of Treatment Decisions Dx. of T 2 DM (2 readings) Test Hb A1c % Acute/ DKA Hb A1c < 9.0 % Early Insulin +/- OAD Hb A1c > 9.0 % No IR Features IR Features + DM 5 yr / 5+ yrs LIFE STYLE RF N / Abn. CHF +/- LFT N /↑ SU aller. lipid HT N FBG, ↑ PPBG ↑FBG, PPBG N ↑FBG, ↑ PPBG OAD = BG, SU, TZD, RG, AGI, OAD + In. + Amy + Ex www.drsarma.in

  19. HbA1c < 7 HbA1c < 7% HbA1c < 7 HbA1c < 7 Treatment Algorithm NEJM 355; 2478 23 December 7, 2006 Dx. of T 2 DM (2 readings) HbA1c < 9% HbA1c > 9% TLC + Metformin 3 mon. I+OAD Y No Add Basal Insulin Add SU 3 M Add TZD 3 M No Y No Y No Y ↑ Insulin + OAD Add TZD Basal Insulin Add SU www.drsarma.in

  20. Insulin Preparations www.drsarma.in

  21. Three Types of Profiles Annals of Internal Medicine Volume 145 • Number 2, July 2006 www.drsarma.in

  22. How to prevention Complications of Diabetes ? • Weight reduction, Exercise • Strict control hyperglycemia • Achieving lipid profile targets • Smoking cessation • Rx. of Hypertension with ACEi/ ARB • Low dose Aspirin therapy • Statin therapy for all T2DM • ACEi or ARB for all with MAU • Early detection and evaluation www.drsarma.in

  23. Take Home – A B C D E • A A1c – target of < 7%; Better 6% Aspirin for all DM ACEi or ARB for all DM • B Blood Pressure target of 130/80 Blood Glucose monitoring • C Cholesterol LDL <100, Statin for all DM • D Diet modifications, Do not smoke • E Exercise 45’ every day, Education on DM Equivalent to having CAD is DM www.drsarma.in

  24. www.drsarma.in

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