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Management of Type 2 Diabetes Mellitus: A New Paradigm Approach

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Title: Management of Type 2 Diabetes Mellitus: A New Paradigm Approach


1
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2
Management of Type 2Diabetes MellitusA New
Paradigm Approach
  • Dr. Chalermsak Suwichai
  • Phayao Hospital

3
Progression of Diabetes
  • Genetic susceptibility
  • Environmental factors
  • Nutrition
  • Obesity
  • Inactivity
  • Insulin resistance
  • HDL-C
  • Triglycerides
  • Atherosclerosis
  • Hypertension
  • PPG levels

Diagnosis of Diabetes
Appearance of Complications
Disability
Death
Ongoing Hyperglycemia
IGT
Blindness ESRD/Dialysis/Transplantation CHD Stroke
Amputation
Hyperglycemia
Retinopathy Nephropathy Neuropathy
4
Clinical Impact of Diabetes Mellitus
The leading cause of new cases of end-stage renal
disease(ESRD)
A 2- to 4-fold increase in cardiovascular risk
Diabetes
The leading cause of new cases of blindness in
working-age adults
The leading cause of nontraumatic
lower- extremity amputations
5
Management of Type 2 DM
  • 1. Non-pharmacologic
  • Dietary management
  • Active life style /
    Exercise
  • Weight reduction
    program

6
2. Pharmacologic Oral agents
Insulin
  • 3. Modifying other risk factors for
    atherosclerosis
  • Dyslipidemia ACEI/AIIRB
  • Antihypertensive agents Statins

  • Aspirin

  • Folate

7
Holistic Approach to The Managementof Diabetes
Mellitus
  • Early detection and prevention of diabetes
  • Intensive glycemic control
  • Intensive blood pressure control and lipid
    lowering
  • Early detection, prevention and treatment of
    diabetic complications
  • Diabetic education and self care management
  • Improving quality of life
  • Alternative Medicine for Diabetes

8
Diagnosis of Diabetes
1. FPG gt 126 mg/dL on 2 separate occasions
2. Random plasma glucose gt 200 mg/dL on 2
separate occasions symptoms (polyuria,
polydipsia, unexplained weight loss)
3. 2-hour plasma glucose gt 200 mg/dL during OGTT
in 2 separate occasions
9
Diagnosis of DiabetesPlasma Glucose Cutoff
Points
FPG
2-Hour PG on OGTT
Category
mg/dL
mmol/L
mmol/L
mg/dL
Normal
lt110
lt6.1
lt140
lt7.8
IFG
gt110lt126
gt6.1lt6.9
-
-
gt7.8lt11.1
IGT
-
-
gt140lt200
Diabetes
gt126
gt200
gt11.1
gt7.0
10
Risk Factors for Type 2 DM
  • Nonmodifiable
  • Genetic factors
  • Age
  • Ethnicity
  • Modifiable
  • Weight
  • Diet
  • Physical activity
  • Stress

11
Treatment Algorithm
Nonpharmacologic therapy
Very symptomatic Severe hyperglycemia Ketosis Late
ral autoimmune diabetes Pregnancy
Monotherapy Sulfonylureas/Benzoic acid
analogue Biguanide Alpha-glucosidase inhibitors Th
iazolidinediones Insulin
Insulin
Combination therapy
12
Medical Nutrition Therapyfor Type 2 Diabetes
  • Diet
  • - Improved food choices
  • - Spacing meals
  • - Individualized carbohydrate content
  • - Moderate calorie restriction
  • Exercise

13
Antihyperglycemic Agents for Type 2 DMThe Six
Classes
Class
Available Agents
a-Glucosidase inhibitor
Acarbose, miglitol
Thiazolidinedione
Pioglitazone, rosiglitazone
Biguanide
Metformin
Meglitinide
Repaglinide, nateglinide
Sulfonylurea
Glimepiride, glipizide, glyburide, and
first-generation sulfonylureas
Insulin
Many
14
Considerations in PharmacologicTreatment of
Type 2 Dibetes
  • Efficacy(HbA1c lowering capacity)
  • Mechanisms of action of drugs
  • Impact on weight gain
  • Complications/tolerability
  • Frequency of hypoglycemia
  • Compliance/complexity of regimen
  • Cost

15
Strategies for Insulin Therapy inElderly Patients
  • 1. Insulin therapy often considered a last resort
    in the elderly
  • 2. Therapeutic goals
  • Relieve symptoms
  • Prevent hypoglycemia
  • Prevent acute complication of hyperglycemia

16
  • 3. Way to facilitate insulin treatment
  • Simple dose schedules
  • Premixed preparations
  • Improved, more convenient delivery systems

17
Combination TherapyOral Agents Plus Insulin
  • 1. Rational
  • Combination of two agents with different
    mechanism of action
  • More convenient and maybe safer
  • 2. Sulfonylurea Insulin
  • BIDS therapy bedtime insulin/daytime
    sulfonylurea
  • Useful in patients early in course of disease

18
  • 3. Metformin Insulin
  • Improves Insulin sensitivity
  • 4. Alpha glucosidase inhibitor (acarbose)
    Insulin
  • Decrease postprandial glycemia
  • 5. Thiazolidnediones Insulin
  • Improve insulin resistance, improves insulin
    action in peripheral tissues
  • Reduces insulin requirement

19
ADA Treatment Guidelines
Normal Goal
Biochemical Index
Action Suggested
lt90
Preprandial glucose mg/dL
80-120
lt80 / gt 140
lt180
lt180
Postprandial glucose mg/dL
lt120
lt100 / gt160
Bedtime glucose mg/dL
lt120
100-140
HbA1c
lt8
lt7
lt6
Depending on assay norms
20
Hypertension and type 2 diabetes
  • Hypertension in diabetes increases risk for
  • 1. Coronary heart disease
  • 2. Atherosclerosis
  • 3. Retinopathy

21
  • 4. Diabetic nephropathy
  • Double microalbuminuria rates in hypertensive
    diabetes
  • Accelerated rated of decline in renal function
  • Microalbuminuria strong predictor of
    cardiovascular disease

22
ADA Clinical Practice Recommendation
  • Indication of initial treatment and goals for
    adult hypertensive
  • diabetic patients

BP Systolic Diastolic
Goal (mmHg.) lt130 lt80 Behavioral therapy
alone 130-139 80-89 (maximum 3 months
then add pharmacologic
treatment Behavioral therapy pharm gt 140 gt 90
23
Diabetes MicrovascularComplications
24
Atherosclerosis The Major cause ofdeath in
diabetes
25
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