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OVERVIEW OF DIABETES MELLITUS (TYPE 2)

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Title: OVERVIEW OF DIABETES MELLITUS (TYPE 2)


1
OVERVIEW OF DIABETES MELLITUS (TYPE 2)
  • Bhushan Ghoorbin

2
St Vincent Declaration (WHO 1989)
  • 1. Reduce new blindness due to diabetes by one
    third or more
  • 2. Reduce the number of people entering end-stage
    diabetic renal failure by at least one third
  • 3. Reduce the rate of limb amputation for
    diabetes gangrene by a half
  • 4. Cut morbidity and mortality from coronary
    heart disease in the diabetic by vigorous
    programmes of risk factor reduction
  • 5. Achieve pregnancy outcome in diabetic women
    that approximates to that of non-diabetic women

3
St Vincent Declaration
  • 2 Reduce the numbers of people entering end-stage
    diabetic renal failure by at least one third

4
St Vincent Declaration
  • 3 Reduce the rate of limb amputation for diabetic
    gangrene by half

5
St Vincent Declaration
  • 4 Cut morbidity and mortality from coronary heart
    disease in the diabetic by vigorous programmes of
    risk factor reduction

6
St Vincent Declaration
  • 5. Achieve pregnancy outcome in diabetic women
    that approximates to that of non-diabetic women

7
Prevalence
  • Total population 3
  • gt60 yrs 6
  • South Asian (40-75 yrs) 20 30
  • gt 1.2 million in UK 85 90 type2
  • 3 million by 2010
  • 1 million undiagnosed (WHO)

8
The Problem - UK
  • 2001 5 total NHS resourses
  • 10 inpatient resourses
  • Blood kit 90
    million
  • Oral hypoglycaemic 64 million
  • (20 increase on 2000)

9
Local Issues
  • Population MSW 82 white
  • 18 ethnic
    minority
  • Projected 2011 gt2 increase on 1999
  • Ethnic minority distribution
  • Wandsworth 22
  • Merton 21
  • Sutton 8
  • Diabetes mellitus prevalence 2.75

10
Classification and Terminology
  • IDDM and NIDDM no longer used
  • Type1 destruction of pancreatic B cells
  • autoimmune
  • Type2 Insulin resistance insulin
  • not working properly /
    insensitivity
  • of tissues to the actions of
    insulin

11
Diagnostic criteria (WHO 2000)
  • Fasting plasma glucose gt7mmol / L
  • Random plasma glucose gt11.1
  • 2 hrs plasma glucose (GTT) gt11.1
  • Impaired fasting glucose gt6.1 lt7.0
  • Impaired glucose tolerance gt7.8 lt11.1

12
New diagnostic criteria
  • With no symptoms requires 2 abnormal test
    results on two different days
  • If diabetes is suspected in a child refer
    IMMEDIATELY to hospital diabetes team

13
Impaired fasting glucose
  • FBG gt6.1 but lt7.0 mmol / L
  • Risk category for future diabetes
  • - increased hepatic glucose production
  • - impaired insulin secretion
  • Lifestyle advice and annual surveillance

14
Impaired Glucose Tolerance
  • FBG lt7.0 mmol / L
  • OGTT 2 hrs gt7.8 but lt11.1 mmol / L
  • - Insulin resistance
  • Prevalence 7 17
  • 6 10 times developing diabetes
  • Increased cardiovascular problems
  • OGTT Gold standard 75 gms glucose load
  • Lifestyle advice and annual surveillance

15
Risk factors The serious seven
  • 1. Lifestyle weight , exercise , smoking
  • 2. Hyperglycaemia
  • 3. Hypertension
  • 4. Dyslipidaemia
  • 5. Microalbuminuria
  • 6. Retinopathy
  • 7. foot problems

16
Type2 DM characteristics at onset
  • 100 hyperglycaemic and elevated FFAs
  • 80 are obese
  • 80 have fasting hyperinsulinaemia
  • 50 are hypertensive
  • 50 have dyslipidaemia
  • 30 have macrovascular complications
  • 15 have retinopathy
  • 15 have neuropathy
  • 5 have nephropathy

17
Oral agents
  • Traditional therapies
  • Metformin
  • Sulphonyl ureas
  • Acarbose
  • Newer therapies
  • Glitazones eg
  • rosiglitazone
  • pioglitazone
  • Prandial regulators
  • Repaglinide
  • Nateglinide

18
Treatment of Obese Type2 DM
  • STEP1 - DIET
  • Lifestyle modification diet and exercises to
    reduce CVS risk factors
  • .. BUT progressive

19
Treatment of Obese Type 2 DM
  • STEP 2 - Metformin
  • Improves Insulin resistance
  • No risk of hypos
  • Improves mortality
  • No weight gain
  • Cheap
  • Aspirin / ACE-I / B- blockers /Statins

20
Treatment of Obese Type 2 DM
  • STEP 3 MF SU
  • Patient not adequately controlled on MF / unable
    to tolerate dose
  • eg Glimepiride - once daily (min weight
    gain)

21
Treatment of Obese Type 2 DM
  • STEP 4 MF new drug
  • Consider glitazone to improve insulin resistance
  • Consider prandial regulator to improve PPG peaks

22
GLITAZONES
  • ROSIGLITAZONE
  • 4mg daily
  • Not monotherapy
  • Only after trial of MFSU
  • PIOGLITAZONE
  • 30mg daily
  • Not monotherapy
  • Only after trial of MFSU

23
GLITAZONES other benefits
  • Lipid subfractions
  • HDL2,HDL3 up
  • Small dense LDL particles become larger and less
    atherogenic
  • FFA level falls
  • Urinary albumin
  • 26 decrease with rosiglitazone at 12 m
  • Blood pressure
  • Falls by 3.5 / 2.7
  • Clotting factors
  • CRP fall

24
GLITAZONES - questions
  • Good evidence that addition to MF or SU better
    than MF or SU alone
  • Triple therapy?
  • Monotherapy?
  • Insulin?

25
GLITAZONES NICE recommendations
  • Only use in combination with MF or SU
  • Where BG remains high despite adequate trial of
    MT SU

26
GLITAZONES delayed onset
  • Max effect may take weeks months
  • May see BG deteriorate initially as SU /MF stopped

27
Prandial regulators
  • Meglitines repaglinide Novonorm
  • Phenylalanine derivative nateglinide starlix
  • Low risk of hypoglycaemia
  • Increase Insulin secretion within 15 mins of meal
  • Stimulate early phase Insulin response to food

28
Prandial regulators
  • With SU NO
  • Ineffective after SU depletes beta cells of
    Insulin
  • With MF YES
  • With Glitazones Unlicensed
  • Limited data on 75 yrs

29
DO NOT
  • Insulin Glitazone
  • SU Prandial regulator
  • Glitazone Prandial regulator
  • SU SU

30
Non- obese Type2 DM
  • STEP2 SU
  • eg gliclazide bd
  • or glimepiride if compliance poor
  • STEP 3 -5 as for obese

31
Non-obese Type2 DM
  • May be slow onset Type1
  • More likely to require Insulin eventually
    especially if ve islet cell antibodies or ve
    GAD antibodies

32
Insulins
  • Rapid acting analogues
  • Insulin lispro - Humalog
  • Insulin aspart Novorapid
  • Long acting analogues
  • Insulin glargine
    Lantus
  • Insulin detemir -
    Levemir

33
Decisions
  • Obese vs thin
  • Ketones
  • Metformin tolerance
  • Risk of hypos
  • Renal function
  • Cardiac function
  • Patient choice
  • Evidence

34
  • Thank you
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