2015-12-03 philippine academy of ophthalmologist: the changing landscape of diabetes

The Changing Landscape of Diabetes

Jeremy F. Robles, MD, FPCP, FPSEDMDirector, Philippine Society of Endocrinology, Diabetes & Metabolism

(PSEDM)Section of Endocrinology, Diabetes & Metabolism - Chong Hua Hospital (Cebu)

Department of Medicine, Cebu Institute of Medicine (CIM) - Cebu Velez General Hospital (CVGH)

Philippine Diabetes

• Prevalence: Global and National Statistics

• Diabetes Classification

• Diagnostic tests and Evaluations

• Treatment options and Comprehensive care

Global Prevalence of Diabetes

IDF Diabetes Atlas I Seventh edition 2015

IDF Diabetes Atlas I Seventh edition 2015

Western Pacific Region

Diabetes is among the leading causes of Mortality in the Philippines

WHO Western Pacific Country Health information Profiles 2011

8th National Nutrition Survey 2013

Diabetes Prevalence in the Philippines (2013)

Prevalence of diabetes significantly increased between 2008 & 2013. Urban poor have a higher prevalence Diabetes with increasing trend with increasing age and wealth.

1998 2003 2008 20130

1.5

3

4.5

6

43

55

Prev

alen

ce (%

)

8th National Nutrition Survey (FNRI)

• Type 1 diabetes mellitus (formerly IDDM or Juvenile diabetes mellitus): results from auto-immune beta-cell destruction, leading to absolute insulin deficiency. Typically but not exclusively in children.

• Type 2 diabetes mellitus (formerly NIDDM or adult-onset DM): results from a progressive insulin secretory defect on the background of insulin resistance

• Gestational diabetes mellitus (GDM): diabetes first diagnosed during pregnancy

• Secondary diabetes e.g., genetic defects in beta cell function or insulin action, diabetes of the exocrine pancreas (pancreatitis, cystic fibrosis), drug- or chemical-induced diabetes (such as from the treatment of AIDS, after organ transplantation, glucocorticoids), other endocrine diseases (Cushing’s syndrome, hyperthyroidism)

Diabetes Mellitus Classification

Jimeno, C. 2014 May 29. A Summary of the Philippines UNITE for Diabetes Clinical Practice Guidelines for the Diagnosis and Management of Diabetes (Part I: Screening and Diagnosis of DM). Journal of the ASEAN Federation of Endocrine Societies. [Online]

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Diabetes Mellitus Classification

Differentiating Type 1 vs Type 2 Diabetes Mellitus


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Characteristics Type 1 Diabetes Mellitus

Type 2 Diabetes Mellitus

Onset Acute & Asymptomatic Slow & Asymptomatic

Clinical Picture Weight loss, polyuria, polydipsia

If symptomatic, similar to T1 DM- weight loss, polyuria, polydipsia • Obese •Family history •PCOS

Ketosis Almost always present Usually absent

Therapy Insulin Lifestyle,oral anti-diabetic agents, insulin

Adapted from Alberti Diab Care, 2004.8 - ICA – islet cell antibodies; Anti-GAD – glutamic acid decarboxylase antibodies


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Summary of Recommendations for Screening & Diagnosis of Diabetes Mellitus

• All individuals should be evaluated annually for risk factors for type 2 diabetes & pre-diabetes. (Level 5, Grade D)

• Universal screening using laboratory tests is not recommended. (Level 5, Grade D)

• Repeat testing annually for Filipinos with Risk Factors if initial test are negative (Level 5, Grade D)

Diagnostic Examinations

Laboratories Normal Pre-diabetic Diabetic

FBS < 100 mg/dl 100-125 mg/dl >/= 126 mg/dl

75 OGTT < 140 mg/dl 140-199 mg/dl >/= 200 mg/dl

RBS < 140 mg/dl --- >/= 200 mg/dl

At the present time, we cannot recommend the routine use of the following tests for the diagnosis of diabetes: (Grade C, Level 3)

HBA1c (poor access and lack of standardization), Capillary Blood Glucose, Fructosamine


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Diabetes Care June 2012 vol. 35 no. 6 1364-1379

Antihyperglycemic therapy in type 2 diabetes: General Recommendations.

Initiation of Drug Therapy among Newly Diagnosed Type 2 Diabetes Patients

Newly Diagnosed T2DM

HbA1C < 9FBS < 250 mg/dl

Combination Therapy

HbA1C >/= 9FBS >/= 250 mg/dl

Insulin TherapyMonotherapy

Consider Combination

Tx

UNITE for Diabetes Philippine Clinical Practice Guidelines for the Diagnosis and Management of Diabetes 2015

Sequential Insulin Strategies in Type 2 Diabetes Mellitus


Non-Insulin Regimens

Basal Insulin+ 1 Rapid acting

InsulinPremix Insulin

Basal Insulin(Usually with oral

meds)

Basal Insulin+ >2 Rapid acting

Insulin

OPD Management of Diabetes


• Medical History & Physical Examination• Cardiovascular Risk Assessment• Foot Evaluation• Dental History and Oral Health• Thyroid Gland Evaluation• Eye Evaluation

• Comprehensive evaluation for retinopathy for T2DM by an ophthalmologist upon diagnosing diabetes. (Grade A, Level 1)

COMPLICATIONS AND CARDIOVASCULAR RISK FACTORS AMONG NEWLY-DIAGNOSED TYPE 2

DIABETICS IN MANILA

Phil. J. Internal Medicine, 47: 99-105, May-June, 2009

• N = 172 patients • Findings:

• 20% (n=34) with peripheral neuropathy• 42% (n=72) with proteinuria• 12% (n=20) with diabetic retinopathy

Mia C. Fojas, M.D., Frances Lina Lantion-Ang, M.D.,Cecilia A. Jimeno, M.D.,Darby Santiago, M.D., Milagros Arroyo, M.D., Aurora Laurel, Heustein Sy, M.D. and Jason See, M.D.

Diabetes Eye Health: Integrating Eye Health Care in Diabetes Management 2015

OPD Management of Diabetes


• Achieve glycemic targets within 6 months• Treat and control Hypertension and

Dyslipidemia• Integrate therapeutic Lifestyle Change:

• Medical Nutrition Therapy: Diet• Physical Activity

• Long term Diabetes Care Plan• Regular follow-up & monitoring• Vaccinations (Influenza & Pneumonia)

Key points• Increasing Prevalence of Diabetes (Globally &

Nationally)• Lifestyle: Rapid urbanization a significant

contributing factor but poor lifestyle habits are a main concern

• Local Guidelines: Streamlined approach for Diagnosis, Management & Follow-up for Diabetic Patients

• Comprehensive evaluation for Diabetes Complications

• Need for collaborative approach to management with various subspecialties of interest.

2015-12-03 philippine academy of ophthalmologist: the changing landscape of diabetes

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