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DIABETES MELLITUS

DIABETES MELLITUS. Management. IMPORTANT POINTS: IN HISTORY, EXAMINATION, INVESTIGATIONS AND TREATMENT. C ontrol: good / poor? Treatment? C omplications C ardiovascular risk factors. HISTORY: special points. Introduction: ethnic group and age Presenting complaint

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DIABETES MELLITUS

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  1. DIABETES MELLITUS Management

  2. IMPORTANT POINTS:IN HISTORY, EXAMINATION, INVESTIGATIONS AND TREATMENT • Control: good / poor? Treatment? • Complications • Cardiovascular risk factors

  3. HISTORY: special points • Introduction: ethnic group and age • Presenting complaint • E.g. admitted for control of diabetes • History of presenting complaint • Polyuria, polydypsia……blood glucose values, also indicates control, screening • Complications – systemic review esp. CVS, Neuro, Eye, Renal, Skin, • Drug history – What medication? Duration, Side effects? Compliance? • P/H/O complications esp. CVS, wound infections • F/H/O type 2 DM, IHD, CVA, HBP • Social history: smoking, diet, exercise, financial aspects

  4. EXAMINATION: special points • General examination • skin infections, edema, waist • CVS – • BP, postural hypotension, JVP, cardiomegaly • peripheral pulses, bruits • RS • Infections - TB • Abdomen • Fatty liver, ascites with nephrotic syndrome • CNS • Ophthalmoscopy and cranial nerves • Mononeuritis • Amyotrophy • Autonomic (postural hypotension) • Peripheral neuropathy • Muscle wasting • Early sensory signs: vibration sense, absent jerks • Romberg’s test • FEET • Skin, bact / fungal infections, gangrene, pulses, neuropathy, ulcers, osteomyelitis,

  5. INVESTIGATIONS • Assess glycemic control • Extent of complications • Risk factors for CAD

  6. INVESTIGATIONS • Assess glycemic control: blood glc levels, HbA1c, fructosamine • Extent of complications: ECG, A/B, Renal, CXR, ECHO, • Risk factors for CAD: BP, lipids, metabolic syndrome

  7. PRINCIPLES OF TREATMENT • Good glycemic control • Prevent or treat complications • Manage risk factors for CAD

  8. PRINCIPLES OF TREATMENTTYPE 2 DM • Good glycemic control • Prevent or treat complications • Manage risk factors for CAD

  9. GLYCAEMIC CONTROL • A healthy lifestyle • OHD • Insulin

  10. HEALTHY LIFE STYLE • Healthy eating • Weight control • Exercise • Smoking and alcohol

  11. HEALTHY LIFE STYLE • Healthy diet • Exercise • Weight control: BMI <23 kg / m2 • Smoking and alcohol

  12. DIET • Carbohydrates • 60% of calories • Low glycaemic foods preferred • Restrict refined sugars and high fiber • Non-nutrient sweeteners • Avoid alcohol • Fats • <30% of calories • <7% saturated • <200 g of cholesterol • Avoid trans-fats Eat fish twice a week

  13. EXERCISE • Control of blood sugar • Increases insulin sensitivity (danger of hypo) • Weight loss • Reduces body fat and maintains muscle bulk • Lowers blood pressure • Cardiovascular fitness

  14. DRUGS Decreased absorption Increased peripheral glc uptake Decreased hepatic glc output Stimulate insulin release

  15. OHD Decreased absorption Acarbose Increased peripheral glc uptake Decreased hepatic glc output Metformin Pioglitazon Stimulate insulin release Sulphonyluria, Repaglinide

  16. OHD • Biguanides: metformin • Sulphonyluria: glyclazide, glipizide • Thiozolidinediones: pioglitazone • Alpha glucosidase inhibitor: acarbose • Non-sulphonyluria secretagogues: repaglinide

  17. DRUG THERAPY Asymptomatic Life-style modification Drugs

  18. DRUG THERAPY Asymptomatic Metformin Life-style modification Drugs

  19. DRUG THERAPY Asymptomatic Symptomatic High HbA1C High FPG High RPG Life-style modification Drugs

  20. DRUG THERAPY TYPE 2 D M • Asymptomatic Type 2 DM ? Metformin • Symptomatic Type 2 DM • HbA1c >8% • FBS > 11.1 • RBG > 14.0 TYPE 1 DM • Insulin

  21. TYPE 2 DM Obese T2DM: • Metformin • If intolerant give acarbose or TZD • HbA1C>10%: combination of metformin and gliclazide (sulphonyluria) Non-obese T2DM: • Metformin or sulphonyluria (gliclazide)

  22. GOALS OF GLYCEMIC CONTROL • FBS 4.4-6.1 • Non-fasting 4.4-8.0 • HbA1C <6.5%

  23. Mono-therapy • Combination of metformin + gliclazide OR metformin + acarbose / TZDs (esp in obese) • Then add third drug • Add insulin

  24. ADD INSULIN • If not reaching target after 3 months of optimum combination therapy (metformin, gliclazide, acarbose, pioglitazone) • FBG> 7.0 mmol/L • HbA1c>6.5% • Maximum doses of OHD

  25. INSULIN • Rapid-acting analogues • Fast-acting insulin (short-acting) • Intermediate-acting insulin • Long-acting insulin • Very long-acting analogues • Lancet 2006;367:847

  26. INSULINS • Rapid-acting analogues: insulin lispro, Humalog (4-6 hours) • Fast-acting: soluble insulin, Actrapid, Humulin R (6-10 hours) • Intermediate-acting: (10-16 hours) • isophane; NPH, Humulin N • Humulin L (Lente insulin) • Long-acting insulin: Ultralente 24 hours • Very long-acting analogues: (24 hours) • Insulin glargine (Lantus) • Insulin detemir (Levemir) • Lancet 2006;367:847

  27. INSULIN REGIMES • Premixed (Mixtard) b.d. (30% soluble + 70% isophane) • Before meals rapid or short, with bedtime intermediate or long acting analog • Bedtime Long-acting or intermediate insulin, day time sulphonyluria + metformin

  28. INSULIN REGIMES • Basal-bolus (T1DM) • Insulin pumps (continuous subcutaneous) • Twice daily mixtard (Often for T2DM) • 2/3 of total dose in morning (2/3 long acting = e.g. 30:70 Mixtard) • 1/3 of total dose in evening (1/2 long acting = e.g. 50;50 Mixtard) • Lancet 2006;367:847

  29. INSULIN PUMP

  30. COMPLICATIONS OF TREATMENT • Hypoglycaemia • Hypoglycaemia unawareness

  31. NEWER DRUGS IN TYPE 2 DM • Exenatide • Stimulates insulin secretion • Glucagon-like-peptide • Given S.C

  32. PREVENT COMPLICATIONS OF DIABETES

  33. PREVENT COMPLICATIONS OF DIABETES • Nephropathy • Neuropathy • Retinopathy • Cardiovascular: IHD, CVA/TIA. PVD • Diabetic foot

  34. PREVENT COMPLICATIONS OF DIABETES • Good glycaemic control • Screen for complications • Action to prevent specific complications

  35. PREVENT COMPLICATIONS OF DIABETES • Good glycaemic control • Screen: regular BP, lipids, eye and renal check up • Action to prevent specific complications: • ACEI or ARBs in early renal involvement • Aspirin if IHD, or high risk of IHD (microalbuminuria, metabolic syndrome, >35, high-risk ethnic groups, family history) • Control hypertension (macrovascular, retinopathy and nephropathy) • Treat hyperlipidaemia (macrovascular and nephropathy) • Stop smoking (IHD, CVA, TIA, PVD) • Diabetic foot

  36. CONTROL HBP AND HYPERLIPIDAEMIA • LDL <2.6 • TG <1.7 • HDL >1.1 • BP <130/80 • BP <120/75 (with renal impairment or gross proteinuria)

  37. COMPLICATIONS: DIABETIC FOOT

  38. COMPLICATIONS: DIABETIC FOOT

  39. COMPLICATIONS

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