Management of diabetes

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Management of diabetes

• Dr.Thongchai Pratipanawatr MD.

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Atherosclerosis in Diabetes

• 80 of all diabetic mortality
• 75 from coronary atherosclerosis
• 25 from cerebral or peripheral vascular disease
• gt75 of all hospitalizations for diabetic
  complications

National Diabetes Data Group. Diabetes in
America. 2nd ed. NIH1995.
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Framingham Study DM and CHD Mortality20-Year
Follow-up
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17
DM Non-DM
Annual CHD Deaths per 1000 Persons
8
4
Men
Women
Kannel WB, McGee DL. JAMA 19792412035-2038.
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Influence of Multiple Risk Factors on CVD Death
Rates in Diabetic and Nondiabetic Men MRFIT
Screenees
No diabetes
Diabetes
Age-adjusted CVD death rate per 10,000
person-years
None
One only
All three
Two only
Serum cholesterol gt200 mg/dl, smoking, SBP gt120
mmHg Stamler J et al. Diabetes Care
199316434-444
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Targets

• Glycemic control Hb A1clt7
• Hypertension control BPlt130/80mmHg
• Dyslipidemia LDLlt100 mg/dl
• HDLgt40mg/dl(male)
• HDLgt40mg/dl(female)
• Aspirin ASA 75-300mg/day

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Glycemic control
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Hb A1c 1 decrease complication by37
microvascular14 macrovascular
Glycemic control and complications
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Glycemic management
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Glycemic management

• Diet control
• Weight reduction
• Exercise
• Anti-diabetic medication

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Glycemic control

• A1C lt7
• Prepandial glucose 90-130
• Post pandial lt180

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Glycemic control

• SMBG should be carried out three or more time
  daily for pt using multiple insulin injection.
• Hb A1c
• At least 2 time a year
• Quarterly
• Therapy has been changed or
• Poor control

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Type 1 or type 2 DM
Type 1 Type 2
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??????? ??? ????
DKA ???? ???
?? ???????? ????????
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• Type 2

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????????????????????? 2 - ??????????????????????
?????????? - ??????????????????????
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Oral hypoglycemic agents
Action Side effect
Sulphonylurea Insulin secretion Hypoglycemia
Metformin Insulin sensitizer N/V diarrhea
TZD Insulin sensitizer Obesity
Acrabose Decrease GI absorption Diarrhea, ?????
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• Sulfonylureas or Metformin
• If fail
• Combined Sulfonylureas and Metformin

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• Combined Sulfonylureas and Metformin
• If fail
• Add Thiazolidenediones
• Add bed time insulin
• Change to Mix-splite insulin

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• Type 1

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Banting and BestUniversity of Toronto , 1921
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• ?????????????? 1
• Multiple insulin injection ( 4 injections/ day )
• Continuous insulin infusion pump
• ?????????????? 2
• Mix and split ( 2 injections/ day )
• or
• Oral hypoglycemic agent bedtime insulin

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(No Transcript)
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????????????????????? 1 ???? ???????????????????
???????
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Multiple injection ???????? 4 ?????
A c t r a p i d / I n s u l a t a r d
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????????????????? multiple injection

• ??????????? 4 ?????????????
• ???????????? 40 ?????/??? ??? Actrapid 10 ?????
  ?????????? ???? ?????? ???? Insulatard /
  Ultratard 10 ????? ?????????? ???????

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????????????????????? 2 - ??????????????????????
?????????? - ??????????????????????
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Mix and Split ????? 2 ?????
M i x t a r d 30
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????????????????? mix and split

• ??????? 2 ?????
• ???? 2/3 ???? 1/3
• ??????????????????????
• ???? 30/70 ???? 50/50 , 30/70

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????????????????????? Bedtime insulin

• ??????????? Sulfonylurea ???? Metformin ???????
  Intermediate acting insulin ?????????? ???????

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??????????????? Insulin

• 3-7 days Absorbtion ,Food , Activities ,
  Stress , Response
• Start 2 times / day
• Multiple injection 1-2 unit 40-50 mg

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Hypertension control
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Even decrease per 10 mmHg-13 for
microvascular-12 for MI-19 for CVA
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Screening

• Every visit
• If 130/80 mmHg, should be confirmed on a
  separated day.
• Goal gt130/80 mmHg

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Treatment

• 130-139/80-89 mmHg, non pharmaco for 3 months
  before med
• 140/90 mmHg start medication
• Initial drugs ACE, ARB, B-blocker, diuretic and
  CCB
• ACE or ARB if fail add HCTZ
• ACE or ARB monitor renal and K

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What is BP optimal target?
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HOT trial Mortality and Blood pressure target in
diabetes
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What is BP optimal target?

• Answer BPlt130/80 mmHg

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???????????????????????????? ?

• ACE inhibitor
• If fail
• Add Thiazide diuretic

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???????????????????????????? ?

• ACE inhibitor Thiazide diuretic
• If fail
• Add B-blocker or Ca blocker

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???????????????????????????? ?

• ???????????? ACE inhibitor ???? ??
• Thiazide diuretic
• or
• A II blocker

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Dyslipidemia
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Lipid targets

• LDL lt 100 mg/dl
• HDL gt 40 mg/dl (male)
• gt 40 mg/dl (female)
• TG lt 200 mg/dl

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Lipid targets

• LDL lt 100 mg/dl
• HDL gt 40 mg/dl (male)
• gt 40 mg/dl (female)
• TG lt 200 mg/dl

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• Statin Lower LDL
• Fibrate Lower triglyceride and increase HDL
  trial

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Management of dyslipidemia
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Risk Similar in Patients With Type 2 Diabetes and
No Prior MI vs Nondiabetic Subjects With Prior MI
100
80
60
Survival()
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Nondiabetic subjects without prior MI
(n1,304)Diabetic subjects without prior MI
(n890)Nondiabetic subjects with prior MI
(n69)Diabetic subjects with prior MI (n169)
20
0
0
1
2
3
4
5
6
7
8
Year
Haffner SM et al. N Engl J Med. 1998339229-234.
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Management of dyslipidemia

• Diet control
• Weight reduction
• Exercise
• Improve glycemic control
• Lipid lowering medication

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Screening

• Annually
• More ofter if need
• LDL lt 100 HDLgt 40 TG lt150 may be repeated every 2
  years

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Treatment LDL

• Without CVD
• Agelt40 LDL lt100 mg/dl
• Agegt40
• Cholesterol 135 Start Statin
• Aim 30-40 reduction and LDLlt100
• With CVD
• Cholesterol 135 Start Statin
• Aim 30-40 reduction and LDLlt70

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Other dyslipidemia

• TG gt400 mg/dl Fibrate
• HDLlt40 mg/dl
• Primary prevention no medication
• secondary prevention Fibrate

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Anti-platelet agents
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ASA(75-162 mg/day)

• A secondary prevention
• A primary prevention
• Agegt40 year or
• Additional risk factor
• F Hx, HT, smoking, dyslipidemia or albuminurea
• Not recommended for agelt21, no data for agelt30.

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Screening
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Screening

• Urine microalbumin
• Indirect opthalmoscope
• Sensation test
• Monofilament 10 gm
• Vibration
• Lipid
• EKG

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Diabetic nephropathy
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Screening

• Annual test for
• Type 1 duration more than 5 years
• Type 2 ALL
• Plan for or during pregnancy

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Treatment

• Type 1 with HT ACE
• Type 2 with HT
• Microalbuminurea ACE or ARB
• Macroalb or renal insuff ARB
• Protein restriction 0.8 mg/kg/day

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Treatment

• Unable to tolerate (and pregnancy) to ACE or ARB
  consider the use of non-DCCB, B-blocker, or
  diuretic for HT
• DCCB not effective

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Diabetic retinopathy
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Screening

• Annual test for
• Type 1 duration more than 5 years
• Type 2 ALL
• Plan for or during pregnancy

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Treatment

• Refer to ophthalmologists
• Macular edema
• Severe PDR
• PDR

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Take Home Massage

• Glycemic control Hb A1clt7
• Hypertension control BPlt130/80mmHg
• Dyslipidemia LDLlt100 mg/dl
• HDLgt40mg/dl(male)
• HDLgt50mg/dl(female)
• Aspirin ASA 75-162mg/day

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Thank you