Current Management of Diabetes

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Current Management of Diabetes
Introduction to Primary Care a course of the
Center of Post Graduate Studies in FM
PO Box 27121 Riyadh 11417 Tel [phone] Fax
4970847
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Aim

• having information on assessing symptoms and
  signs.
• developing management plans for diabetes.

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Objectives

• At the end of this session, the trainees should
  be able to-
• list diagnostic criteria for DM
• describe how to differentiate Type I II DM
• explain symptoms and signs of diabetes
• discuss the evidence for lifestyle changes
• describe the indications, contraindications, and
  side effects of antidiabetic agents

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DM in Saudi Arabia

• Lifestyle Changes
• Social cultural changes
• Prevalence
• Diabetes mellitus as a health problem in Saudi
  Arabia
• prevalence of DM is 23.7 according to Dr. Al
  Nozha study (SMJ 2004)
• 1 / 4 of adults gt 30 yr are diabetics.
• 36 Foot Amputation / day, at Riyadh.

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D.M in Saudi Arabia cont..

• Cost Impacts .
• Psychological impact.
• Family Social impact .
• Decreased Productivity .
• Sick leaves.
• Work Absence .
• Economical Costs .

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Etiologic classification of diabetes mellitus
I- Type 1 diabetes
II- Type 2 diabetes.
III- Other specific types.
IV- Gestational diabetes mellitus.
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Etiologic Classification of Diabetes Mellitus

• Type 1
• b-cell destruction with lack of insulin .
• has absolute insulin deficiency
• predisposed to develop ketoacidosis
• insulin is required for survival.

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Etiologic Classification of Diabetes Mellitus

• Type 2
• has relative insulin deficiency combined with
  defects in insulin action.
• is the most common form of diabetes, accounting
  for 9095 of the disease
• is most often found in overweight individuals.

Narayan K, Boyle J, Thompson T, Sorensen S,
Williamson D (2003). "Lifetime risk for diabetes
mellitus in the United States". JAMA 290 (14)
188490. doi10.1001/jama.290.14.1884.
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Risk Factors for Type 2 DM

• Modifiable
• Overweight and obesity
• Sedentary lifestyle
• Previously identified IGT and IFG
• Metabolic syndrome
• Diatery factors
• Intrauterine environment
• Inflamation

• Non- Modifiable
• Family history
• Age
• Gender
• History of GDM
• Polycystic ovary syndrome (PCO)

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Symptoms Signs

• Classical symptoms
• Unusual thirst (Polydipsia)
• Frequent urination (Polyuria)
• Unusual weight loss
• Other symptoms
• Extreme fatigue or lack of energy
• Unusually hungry
• Moody irritable
• Blurred vision
• Have recurrent infections
• Wounds and bruises that are slow to heal
• Get a lot of yeast infections
• Have tingling or numbness in the hands and/or
  feet
• Patients may present with a variety of symptoms
  or even symptomless

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Criteria to diagnosis diabetes

• FPG gt126 mg/dl (7.0 mmol/l)
• ( Fasting is defined as no caloric intake for at
  least 8 h) OR
• Symptoms of diabetes and a casual plasma glucose
  gt 200 mg/dl (11.1 mmol/l) OR
• 2-h plasma glucose gt 200 mg/dl (11.1 mmol/l)
  during an OGTT.
• ( The test should be performed as described by
  the W H O (using a glucose load containing the
  equivalent of 75g anhydrous glucose dissolved in
  water)).

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Diagnosis of Diabetes Plasma Glucose Cutoff
Points
2- Hour BS on OGTT FBS
mg/dl mg/ dl categories
lt 140 lt 100 Normal
_ gt 100 and lt 126 IFG
gt 140 and lt 200 _ IGT
gt 200 gt 126 Diabetes
If without symptoms, there should be more than
one measurement in order to diagnose.
.
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Diagnosis of gestational DM
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First visit evaluation

• History taking and clinical assessment
• Physical examination
• Height and weight measurement .
• Blood pressure determination .
• Fundoscopic examination
• Oral examination
• Thyroid palpation
• Cardiac examination

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First visit evaluation

• Physical examination
• Abdominal examination (e.g., for hepatomegaly)
• Evaluation of pulses by palpation
• Hand/finger examination
• Foot examination
• Skin examination
• Neurological examination
• Signs of diseases that can cause secondary
  diabetes (e.g., hemochromatosis, pancreatic
  disease)

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First visit evaluation

• Laboratory evaluation
• HBA1c
• Fasting lipid profile
• Test for microalbuminuria
• Serum creatinine in adults .
• Thyroid-stimulating hormone (if indicated)
• Electrocardiogram in adults (if indicated)
• Urinalysis for ketones and protein

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Management Goals

• Annual visits and examinations should be done
  regularly
• Eliminate symptoms and improve well-being
• Prevent and retard microvascular complications
• optimize glycemic control
• target blood pressure levels
• Reduce macrovascular events
• optimize glycemic control
• target blood pressure levels
• target lipid levels

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Summary of recommendations for adults with
Diabetes

• Parameter Target Value
• HbA1c lt 7
• pre-prandial plasma glucose 70 - 130 mg/dL
• post-prandial plasma glucose lt 180 mg/dL
• Blood pressure lt 130/80
  mmHg
• LDL- cholesterol lt 100 mg/dL
  (lt2.6 mmol/l)
• HDL- cholesterol gt 40 mg/dL (1 mmol/l) for
  men gt 50 mg/dL (1.3 mmol/l) for wom.
• Triglycerides lt 150 mg/dL (17 mmol/l)

ADA 2009
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Key concepts in setting glycemic goals

• Goals should be individualized based on
• ? duration of diabetes
• ? pregnancy status
• ? age
• ? co-morbid conditions
• ? hypoglycemia unawareness
• ? individual patient considerations

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Follow up
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Things to keep in mind during management of
Diabetes

• Type 2 Deterioration of beta cells over time
• Increasing prevalence with increasing risk
  factors, e.g obesity
• Hyperglycemia affects morbidity, mortality and
  resources
• Tight glycemic control with insulin may reduce
  costly complications
• 30 to 40 of patients ultimately require insulin

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Non-pharmacologic Therapy for DM Lifestyle
therapeutic modifications

• Diet
• Improved food choices
• Spacing meals
• Individualized carbohydrate content
• Moderate calorie restriction
• Exercise
• improve blood glucose control
• reduce cardiovascular risk factors
• contribute to weight loss.
• improve well-being.

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Nutritional recommendations for DM patients

• Protein to provide 10-20 of kcal/day
• Saturated fat to provide lt 10 of kcal/day (lt 7
  for those with elevated LDL).
• Polyunsaturated fat to provide lt 10 of kcal.
• Remaining calories to be divided between
  carbohydrate monounsaturated fat, based on
  medical needs personal tolerance.
• Use of caloric sweeteners is acceptable.

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Considerations in Pharmacologic Treatment of
Diabetes

• Complications/tolerability
• Frequency of hypoglycemia
• Compliance/complexity of regimen
• Cost

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Sulfonylureas
Drug Dose Side effects
Tolbutamide Restinon 500-2000mg Od-Bid Weight gain hypoglycemia
Glibenclamide Daonil 5mg 15-20 mg Od-Bid Weight gain Hypoglycemia
Gliclazide Diamicron 80mg 40-320mg Od-Bid Weight gain hypoglycemia
Glipizide Minidiab 5mg 2.5-20mg Od Weight gain hypoglycemia
Glimerpiride Amaryl 1,2,4 mg 1-8mg Od Weight gain hypoglycemia
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Drug Dose Side effects Drug class
Metformin Glocophage 500-850mg 1000-2550mg Bid-Tid Diarrhea Lactic acidosis Biguanides ? hepatic glucose production
Acrobose Glucobay 50-100 mg 150-300 mg Tid Gas , Abdominal pain, Diarrhea a Glucosidase inhibitors ? intestinal absorption
Rosiglitazone Avandia 2,4,8 mg 4-8mg Od-Bid Oedema,weight gain,hepatic failure Thiazolidinediones ? preipheral glucose disposal
Repaglinide Novonorm 0.5,1,2 mg 1.5-16mg Tid-Qid Weight gain hypoglycemia Meglitinides ? pancreatic insulin secretion
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