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DIABETES MELLITUS

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DIABETES MELLITUS Management – PowerPoint PPT presentation

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Title: DIABETES MELLITUS


1
DIABETES MELLITUS
  • Management

2
IMPORTANT POINTSIN 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, polydypsiablood 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
  • Rombergs test
  • FEET

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 lt23 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
  • lt30 of calories
  • lt7 saturated
  • lt200 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
Pioglitazon
Metformin
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 gt8
  • FBS gt 11.1
  • RBG gt 14.0
  • TYPE 1 DM
  • Insulin

21
TYPE 2 DM
  • Obese T2DM
  • Metformin
  • If intolerant give acarbose or TZD
  • HbA1C gt10 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 lt6.5

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)
  • FBGgt 7.0 mmol/L
  • HbA1cgt6.5
  • 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 2006367847

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 2006367847

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. 3070 Mixtard)
  • 1/3 of total dose in evening (1/2 long acting
    e.g. 5050 Mixtard)
  • Lancet 2006367847

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, gt35,
    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 lt2.6
  • TG lt1.7
  • HDL gt1.1
  • BP lt130/80
  • BP lt120/75 (with renal impairment or gross
    proteinuria)

37
COMPLICATIONS DIABETIC FOOT
38
COMPLICATIONS DIABETIC FOOT
39
COMPLICATIONS
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