management of diabetes

Management Of Diabetes

Presenters: Otaalo Brian Nalukenge Caroline

Outline

• Definition• Epidemiology • Classification• Clinical Features• Treatment

Diabetes Mellitus

DefinitionA chronic disorder of metabolism resulting from lack or reduced effectiveness of endogenous insulin, characterized by hyperglycemia.

Epidemiology

• >380 million people worldwide have DM• >90% have type 2 DM• In Uganda in 2014 (adults 20-79yr);- Approx 1.56 million pple have DM (est. 98,000 in yr 2000)- Prevalence of 4.4%- 693,200 cases were registered, 17,570 deaths- Cost per person with DM = $ 84.9 ( Ugshs=257,247)- Estimated undiagnosed DM= 520,500

Did you know?

Classification

• Type 1 DM• Type 2 DM• Gestational diabetes• Diabetes due to other causes

Type 1 DM

• Usually diagnosed in childhood but can occur at any age• Insulin deficiency from autoimmune destruction of pancreatic B cells• Concordance among identical twins approx 30%• >90% carry HLA DR3 +/- DR4• Environmental factors have a role in disease;-infection: mumps, cox sackie, CMV, EBV, rubella(in utero)-diet: bovine serum antigen (BSA)• Atleast 70-90% of pancreatic B cells destroyed • Latent Autoimmune Diabetes of Adults(LADA)

Type 1 cont…

• LADA• Latent Autoimmune Diabetes in Adults (LADA) is a form of type 1

DM which is diagnosed in individuals who are older than the usual age of onset of type 1 diabetes.

• Aka "Slow Onset Type 1" diabetes, and sometimes also Type 1.5• Often, patients with LADA are mistakenly thought to have type 2

dm, based on their age at the time of diagnosis.

Type 2 DM

• Common in adults > 40yrs • Teenagers are now also increasingly being diagnosed• Associated with obesity, lack of exercise, calorie & alcohol excess• Concordance in identical twins approx. 80%• Have B cell dysfunction and insulin resistance• Typically progresses from IGT or IFG• Maturity onset Diabetes of the Young (MODY)- Form of DM type 2

Gestational diabetes

• Diabetes occurring during pregnancy without prior hx of diabetes• Usually resolves after pregnancy• Occurrs in 4% of pregnancies• Risk : >25yrs, +ve family hx, obesity• Approx. 5-10% are found to have DM type 2 after pregnancy• Have 20-50% chance of developing type 2 DM in the next 5-10yrs

Clinical Features

• Polyuria, polydipsia & polyphagia• Weight loss• Fatigue • Dehydration • DKA• Eyes- Retinopathy/ cataract - ask for visual blurring or blindness. - check for visual acuity, do fundoscopy

Clinical features cont….

• Head : CN palsy• Cvs- hypertension,MI - take appropriate history, - take bp• GUT- nephropathy, erectile dysfunction, uti• MSS- peripheral neuropathy, slow wound healing, foot ulcers,

wasting, obesity• Skin- pigmentation, acathosis nigricans

Diagnosis of Diabetes Mellitus• Symptoms of diabetes or testing urine for glucose and

ketones.• random blood sugar(RBS) ≥ 11.1 mmol/L (200

mg/dL)• Fasting plasma sugar(FBS) ≥ 7.0 mmol/L (126 mg/dL)

NB: FBS is the most reliable & convenient test for identifying D.M in asymptomatic individuals.

• Random is defined as without regard to time since the last meal.

• Fasting is defined as no caloric intake for at least 8 h preceded by unrestricted carbohydrate diet for 3 days before the test.

Indications for Oral Glucose Tolerance test(OGTT)RBS: 7.8-11.0mmol/l (140-199 mg/dl)FBS: 6.1-7.0mmol/l (110-126 mg/dl)

• The OGTT should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

•

Normal glucose tolerance

Prediabetes Diabetes Mellitus

Fasting blood sugar

<5.6mmol/l (100mg/dl)

6.1-6.9 mmol/l (100-125mg/dl)

≥7.0mmol (126mg/dl)

2Hr Plasma glucose

<7.8mmol/l (140mg/dl)

7.8-11.1 mmol/l (140-199 mg/dl)

≥11.1 mmol/l (200 mg/dl)

Management of Diabetes

Approach to the Patient

• Proper history; DM risk factors, symptoms and complications.

• Physical Examination; weight or BMI, retinal examination, orthostatic blood pressure, foot examination, peripheral pulses, and insulin injection sites.

Investigations Urinalysis; glucose, protein, ketones. Blood glucose; RBS (4-7mmol/l is normal), FBS HBA 1C (normal; <6.5%) Blood lipids; total cholestrol, LDL, HDL, triglycerides. CBC LFTs RFTs

Treatment• The major components of the treatment of diabetes

are:

• Diet and ExerciseA

• Oral hypoglycaemic therapyB

• Insulin TherapyC

Basic Principles• Correct diagnosis is essential.

• lowering the blood glucose level but also correction of any associated CVD risk factors such as smoking,hyperlipidemias, and obesity

• Management of non-insulin-dependent diabetes mellitus (NIDDM) requires teamwork.

• Self-care is an essential strategy. People with diabetes should be encouraged and enabled to participate actively in managing and monitoring their condition.

• Good control is important

A. DietDiet is a basic part of management in every case.

Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition.

Dietary treatment should aim at:◦ensuring weight control◦providing nutritional requirements◦allowing good glycaemic control with blood

glucose levels as close to normal as possible◦correcting any associated blood lipid

abnormalities

A. Diet (cont.)• Dietary fat should provide 25-35% of total intake of

calories. Cholesterol consumption should be restricted and limited to 300 mg or less daily.

• Protein intake can range between 10-15% total energy (0.8-1 g/kg of desirable body weight). Requirements increase for children and during pregnancy

• Carbohydrates provide 50-60% of total caloric content of the diet. Carbohydrates should be low glycemic index and high in fibre.

Exercise• Physical activity promotes weight reduction and

improves insulin sensitivity, thus lowering blood glucose levels.

• Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness.

• People should, however, be educated about the potential risk of hypoglycaemia and how to avoid it.

B. Oral Anti-Diabetic Agents• There are currently four classes of oral anti-diabetic

agents:

i. Biguanidesii. Insulin Secretagogues – Sulphonylureasiii. Insulin Secretagogues – Non-sulphonylureasiv. α-glucosidase inhibitorsv. Thiazolidinediones (TZDs)

B.1 Oral Agent MonotherapyIf glycaemic control is not achieved (HbA1c > 6.5%

and/or; FPS > 7.0 mmol/L or; RPS >11.0mmol/L) with lifestyle modification within 1 –3 months, ORAL ANTI-DIABETIC AGENT should be initiated.

In the presence of marked hyperglycaemia in newly diagnosed symptomatic type 2 diabetes (HbA1c > 8%, FPS > 11.1 mmol/L, or RPS > 14 mmol/L), oral anti-diabetic agents can be considered at the outset together with lifestyle modification.

B.1 Oral Agent Monotherapy (cont.)As first line therapy:

Obese type 2 patients, consider use of metformin, acarbose or TZD.

Non-obese type 2 patients, consider the use of metformin or insulin secretagogues

Metformin is the drug of choice in overweight/obese patients. TZDs and acarbose are acceptable alternatives in those who are intolerant to metformin.

If monotherapy fails, a combination of TZDs, acarbose and metformin is recommended. If targets are still not achieved, insulin secretagogues may be added

B.3 Combination Oral Agents and Insulin If targets have not been reached after optimal dose of

combination therapy for 3 months, consider adding intermediate-acting/long-acting insulin (BIDS).

Combining insulin and the following oral anti-diabetic agents has been shown to be effective in people with type 2 diabetes:◦ Biguanide (metformin)◦ Insulin secretagogues (sulphonylureas)◦ Insulin sensitizers (TZDs)(the combination of a TZD plus insulin

is not an approved indication)◦ α-glucosidase inhibitor (acarbose)

Insulin dose can be increased until target FPS is achieved

Diabetes Management

Algorithm

Oral Hypoglycaemic Medications

General Guidelines for Use of Oral Anti-Diabetic Agent inDiabetes

• Oral anti-diabetic agent s are not recommended for diabetes in pregnancy

• Oral anti-diabetic agents are usually not the first line therapy in diabetes diagnosed during stress, such as infections. Insulin therapy is recommended for both the above

• When indicated, start with a minimal dose of oral anti-diabetic agent, while reemphasizing diet and physical activity.

C. Insulin TherapyShort-term use: Acute illness, surgery, stress and emergencies Pregnancy Breast-feeding Type 1 in marked hyperglycaemia

Long-term use: If targets have not been reached after optimal dose of

combination therapy or BIDS, consider change to multi-dose insulin therapy. When initiating this,insulin secretagogues should be stopped and insulin sensitisers e.g. Metformin or TZDs, can be continued.

Insulin regimensThe majority of patients will require more than one daily

injection if good glycaemic control is to be achieved. However, a once-daily injection of an intermediate acting preparation may be effectively used in some patients.

Twice-daily mixtures of short- and intermediate-acting insulin is a commonly used regimen.

In some cases, a mixture of short- and intermediate-acting insulin may be given in the morning. Further doses of short-acting insulin are given before lunch and the evening meal and an evening dose of intermediate-acting insulin is given at bedtime.

Other regimens based on the same principles may be used.

Monitoring of glycemic control• Self-monitoring of blood sugar by the patient.• Measurement of glycated hemoglobin(HB1AC)Rep. glycemic hx in previous 2-3 months; preceding

month contributes 50%1% rise in HB1AC translates in 2.0mmol/l (35mg/dl)

increase in mean glucose

Frequency; Good glycemic control; atleast twice a year. Poor glycemic control or when therapy is changed or

most pts with type 1 DM; every 3 months

Self-CarePatients should be educated to practice self-care.

This allows the patient to assume responsibility and control of his / her own diabetes management. Self-care should include:

◦ Blood glucose monitoring◦ Body weight monitoring◦ Foot-care◦ Personal hygiene◦ Healthy lifestyle/diet or physical activity◦ Identify targets for control◦ Stopping smoking

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