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Update in Diabetes Mellitus

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Update in Diabetes Mellitus Chaicharn Deerochanawong M.D. Professor of Medicine Diabetes and Endocrinology Unit Department of Medicine, Rangsit Medical School – PowerPoint PPT presentation

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Title: Update in Diabetes Mellitus


1
Update in Diabetes Mellitus
  • Chaicharn Deerochanawong M.D.
  • Professor of Medicine
  • Diabetes and Endocrinology Unit
  • Department of Medicine, Rangsit Medical School
  • Rajavithi Hospital, Ministry of Public Health

2
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

3
National Health Examination Survey 2008-9
N 31,640 age gt 15 years old
Prevalence of DM 6.9
4
Prevalence of diabetes in Thai population
aged gt 15 years from 1991-2009

Data from the National
Health Examination Survey
Thailand Health Profle in http//www.moph.go.th/o
ps/thp/index.php?optioncom
5
Percentage of undiagnosed diabetes, diagnosed but
untreated diabetes, and controlled diabetes among
Thai adults in 2004 and 2009
Women
Men
2004
2004
2009
2009
2,439
1,824
1,177
895
Number
66.5
23.4
51.4
47.3
Undiagnosed DM
Diabetes Care, 2011 34 1980-1985
6
Percentage of undiagnosed diabetes, diagnosed but
untreated diabetes, and controlled diabetes among
Thai adults in 2004 and 2009
Women
Men
2009
2004
2009
2004
1,177
2,439
895
1,824
Number
23.4
51.4
47.3
66.5
Undiagnosed DM
1.9
1.7
5.6
2.6
Diagnosed but not treated
40.8
31.2
29.7
23.2
Treated but not controlled
31.9
15.8
17.5
7.7
Treated and controlled
Diabetes Care, 2011 34 1980-1985
7
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

8
Diagnosis of Diabetes
  • Symptoms of diabetes plus casual plasma
  • glucose concentration 200 mg/dl
  • Fasting plasma glucose 126 mg/dl (Fasting
  • is defined as no caloric intake for at least 8
    hr)
  • 2 hour plasma glucose 200 mg/dl during an
  • OGTT
  • A1c gt 6.5 ( lab NGSP certified standardized
    to DCCT assay )
  • ( In the absence of symptoms of hyperglycemia,
    these criteria should
    be confirmed on another day)

9
Prospective Pima Indian Population Study
10
???????????? FPG, 2hPG ??? HbA1c ??? Sensitivity,
Specificity ??? Positive Predictive Values
????????????????????? Moderate NPDR
Cut-Point Cut-Point Sensitivity () Specificity () Positive Predictive Value ()
FPG (mg/dL) 100 108 117 126 135 92.0 86.0 82.0 76.0 73.0 52.0 72.0 81.3 86.7 89.8 2.3 3.7 5.2 6.6 8.2
2hPG (mg/dL) 180 189 198 200 207 216 90.1 88.7 87.6 87.2 84.3 82.8 72.1 75.1 77.5 77.7 79.8 81.7 4.0 4.3 4.7 4.8 5.1 5.4
HbA1C () 5.5 6.0 6.5 7.0 7.5 97.7 93.2 87.1 77.7 68.6 39.4 72.2 85.6 90.6 93.1 2.5 5.0 8.7 11.5 13.5
11
?????????????????????????? HbA1c ????????? 3
???????????? FPG ???????????? HbA1c lt 6.5
??????? overlap ????????????? 3 ?????
??????????????????????? FPG ??????????????????????
? HbA1c ??????? 6.5
12
Should We Use A1c for Diagnosis in Thailand?
  • Method of assay and lab no standardization?
  • Abnormal Hb?
  • Conditions that effect RBC turnover?
  • Fe deficiency anemia?
  • Cost?
  • If any answers above are yes
  • We should not use A1c for the diagnosis DM
  • Remember prevalence of diabetes with cutpoint
    A1c of 6.5 are usually less than using FPG and
    OGTT

13
Categories of increased risk for diabetes
  • FPG 100-125 mg/dL
  • 2-h PG on the 75-g OGTT 140-199 mg/dL
  • A1C 5.7-6.4

14
?????????????????????????? HbA1c ????????? 3
???????????? FPG ????????????
HbA1c lt 6.5 ??????? overlap ????????????? 3
????? ??????????????????????? FPG
???????????????????? HbA1c ??????? 5.7
15
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

16
Monitoring of Glycemic Control
  • SMBG
  • CGM
  • HbA1c or A1C

17
Optimal use of SMBG
  • Requires proper interpretation of data
  • Patients should be taught how to use the data to
    adjust MNT, exercise or pharmacological therapy
    to achieve specific goals
  • Health professionals should evaluate at regular
    intervals the patients ability to use SMBG data
    to guide treatment

18
Who need SMBG ?
  • All type 1 diabetic patients
  • Type 2 diabetic patients who treated with insulin
  • Gestational diabetes
  • Type 2 diabetes who treated with OHA and have
    problem with hypoglycemia

Question the clinical utility and
cost-effectiveness of routine SMBG in non-insulin
treated patients
19
CGM ( Continuous Glucose Monitoring )
20
CGM
  • CGM in conjuction with intensive insuln regimens
    can be a useful tool to lower A1C in selected
    adults age gt 25 years with type 1 diabetes
  • CGM may be a supplemental tool to SMBG in those
    with hypoglycemia unawareness and/or frequent
    hypoglycmic episodes

21
A1C
  • Perform A1C test at least two times a year in
    patients who are meeting treatment goals
  • Perform A1C test quarterly in patients whose
    therapy has changed or who are not meeting
    glycemic goals
  • Limitation of A1C
  • - condition that affect erythrocyte turnover,
    - does not measure glycemic variability or
    hypoglycemia

22
All the curves will give same HbA1c
300
150
100
50
23
Correlation of A1Cwith Average plasma glucose
  • HbA1c() Mean Plasma Glucose (mg/dL)
  • 6 126
  • 7 154
  • 8 183
  • 9 212
  • 10 240
  • 11 269
  • 12 298

24
Glycemic Goals in Diabetes
  •  Patient-Centered  means that It is important
    to individualize
  • Treatment targets and
  • Treatment regimens
  • according to patients needs

25
A1c 7.5 or 8
A1c lt 6.5 or 7
1.
2.
3.
4.
5.
6.
7.
26
Benefit and Risk of
Tight Glycemic Control
GOAL A1C lt 6.5
GOAL A1C lt 7.0-7.5 or gt
Hypoglycemia
Microvascular complications
  • Newly diagnosed
  • Long life expectancy
  • Young kids
  • Very elderly
  • Advanced complications

27
Goals of Glycemic Control
  • ADA
    IDF
  • HbA1c (4.0-6.0) lt 7.0 lt 6.5
  • FPG (preprandial) 70-130 70-110
  • Postprandial lt 180 lt 160

28
Treatment of Diabetes
  • Type 2
  • Activity
  • Healthy food
  • /- Tablets
  • /- Insulin
  • Type 1
  • Insulin
  • Healthy food

29
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30
CONCERNING COSTS
31
Concerning Hypoglycemia
32
Concerning Weight gain
33
Three drugs combination was recommended before
going to complex insulin strategy
34
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37
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

38
A Paradigm Shift for Prevention of Diabetes
Sattar N. Diabetologia 201356686-95
39
Goal of BP Recommendations forPatients with
Diabetes
Year
Diastolic BP
Systolic BP
Organization
lt80
lt130
2003
JNC 7 ( USA )
lt140 (130)
lt80
NICE ( UK )
2009
lt140 (130)
ADA ( USA )
lt80
2012-3
lt140
2013
ESH ( Europe)
lt85
lt90
lt140
2013
JNC 8 ( USA )
40
Treatment Decisions LDL Cholesterol in Adults
with Diabetes
Target LDL lt 70 LDL lt 100 LDL lt 100
  • Risk Profile
  • Diabetes Known CVD
  • Diabetes High Risk
  • Diabetes - Lower Risk
  • Initiate Drug Rx
  • Statin for all
  • Statin for all
  • Statin if LDL gt100

High Risk DM age gt 40 1 risk factor
type 1 DM with microalbuminuria
41
Sattar N. Diabetologia 201356686-95
42
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

43
JPAD Trial
44
Primary End Point Total Atherosclerotic Events
According to the Treatment Groups
10
8
Log-Rank Test, P 0.16 HR (95 CI) 0.80
(0.581.10)
6

4
Aspirin Group
Nonaspirin Group
2
0
Years
0
1
2
3
4
5
45
Subgroup Analysis
Events, No./Total No.
Favors No Aspirin
Favors Aspirin
Age, y Aspirin Group Nonaspirin Group Hazard Ratio (95 CI) Hazard Ratio (95 CI)
65 45/719 59/644 0.68 (0.460.99) 0.68 (0.460.99)
lt65 23/543 27/633 1.0 (0.571.70) 1.0 (0.571.70)

Gender Gender Gender Gender Gender
Male 40/706 51/681 0.74 (0.491.12) 0.74 (0.491.12)
Female 28/556 35/596 0.88 (0.531.44) 0.88 (0.531.44)

Hypertensive Status Hypertensive Status Hypertensive Status Hypertensive Status Hypertensive Status
Hypertensive 49/742 55/731 0.88 (0.601.30) 0.88 (0.601.30)
Normotensive 19/520 31/546 0.64 (0.361.13) 0.64 (0.361.13)

Lipid Status Lipid Status Lipid Status Lipid Status Lipid Status
Dyslipidemia 38/680 43/665 0.88 (0.571.37) 0.88 (0.571.37)
Normolipidemia 30/582 43/612 0.71 (0.451.14) 0.71 (0.451.14)

Smoking Smoking Smoking Smoking Smoking
Current or past smoker 36/565 42/494 0.73 (0.471.14) 0.73 (0.471.14)
Nonsmoker 32/697 44/783 0.83 (0.531.31) 0.83 (0.531.31)
0.3
Hazard Ratio (95 CI)
46
JPAD Conclusions
  • JPAD was the largest primary prevention trial of
    aspirin in type 2 diabetes
  • Although the effect of low-dose aspirin was not
    statistically significant for the primary end
    point, the trial suggests that low-dose aspirin
    might reduce total events in older patients.

47
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49
ADA Recommendation 2013Aspirin for Primary
Prevention in DM
  • Use aspirin therapy ( 75-162 mg/day ) as a
    primary prevention strategy in those with type 1
    or 2 diabetes who are gt 50 yrs (men) or gt 60 yrs
    (woman) and have an additional risk factors ( FH
    of CVD, HT, smoking, dyslipidemia, albuminuria )
    (C)
  • Not recommend aspirin for primary prevention in
    men lt 50 yrs or women lt 60 yrs without other
    major risk factors. For patients in these
    age-groups with multiple other risk factors, need
    clinical judgement

Diabetes Care 201334(suppl 1)S32
50
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

51
Annual Screening for Complications is important
  • Nephropathy serum creatinine, urine protein if
    negative do urine microalbumin ( spot morning
    urine albumin/creatinine 30-300 mg Alb/g Cr )
  • Retinopathy dilated retina exam every 1-2 year
  • Neuropathy comprehensive, monofilament
  • Foot ulcer identify high risk
  • Coronary artery disease symptoms, EKG???
  • Cerebrovascular disease symptoms, carotid bruit

52
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

53
DSME ( Diabetes Self- Management Education )
  • Complications of diabetes
  • Goals of therapy
  • Hyperglycemia and Hypoglycemia
  • Medical nutritional therapy
  • Exercise
  • How to use OHA, insulin?
  • Sick day care
  • Foot care

54
DSME ( Diabetes Self- Management Education )
  • People with diabetes should receive DSME when
    their diabetes is diagnosed and as needed
    thereafter
  • Effective self-management and quality of life are
    the key outcomes of DSME and should be measured
    and monitoring as part of care
  • Because DSME can result in cost savings and
    improved outcomes, DSME should be reimbursed by
    third-party payers

55
Topics
  • Epidemiology of diabetes in Thailand
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

56
Pathophysiology of Type 2 Diabetes The Ominous
Octet
Glucose production
Incretineffect
Glucoseuptake
Insulinsecretion
Poor Glucose Homeostasis
Glucagon secretion
Lipolysis
Neurotransmitter dysfunction
Glucose reabsorption
  • Multiple drugs in combination may be required to
    improve glucose homeostasis
  • Treatment should target underlying pathophysiology

DeFronzo RA. Diabetes. 200958773-795.
57
Selective SGLT2 Inhibitors
  • Dapagliflozin
  • Canagliflozin
  • Remogliflozin
  • Sergliflozin

58
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59
SGLT2 Inhibitors Rationale
  • Inhibit glucose reabsorption in the renal
    proximal tuble
  • The resultant glucosuria leads to a decline in
    plasma glucose and reversal of glucotoxicity
  • Even in the most refractory to treatment diabetic
    patients will respond

60
SGLT2 Inhibtion is a Novel Approach to the
Treatment of Type 2 Diabetes
  • Dapagliflozin and Canagliflozin provide proof of
    concept of the efficacy of SGLT2 inhibition in
    reducing both fasting and postprandial plasma
    glucose concentrations in T2DM
  • Genetic mutations leading to renal glucosuria
    have documented the long term safety of SGLT2
    inhibition in man

61
Advantage and Risk of SGLT2 Inhibitors
  • Can use in any stage of diabetes regardless of
    background therapy
  • Do not cause weight gain
  • Slightly decrease blood pressure
  • Increase genital and urinary tract infections
  • Risk for volume depletion in elderly
  • No efficacy in patients with GFR lt 45 ml/min

62
Conclusions
  • Diagnosis of diabetes
  • Glycemic goals and therapy
  • BP, lipid goals
  • Antiplatelet therapy
  • Annual screening of complications
  • Diabetic education
  • New drugs in diabetes mellitus

Individualized Therapy for Diabetes Management
63
Thank you for your attention
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