what the gp should know about diabetes mellitus dr. muhieddin omar
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What the GP Should Know What the GP Should Know aboutabout
Diabetes MellitusDiabetes Mellitus
Dr. Muhieddin Omar
Definition of DiabetesDefinition of Diabetes It is a group of It is a group of metabolic diseasesmetabolic diseases
characterized by hyperglycemia characterized by hyperglycemia resulting from defects of resulting from defects of insulin insulin
secretion and/or increased cellular secretion and/or increased cellular resistance to insulinresistance to insulin. .
Chronic hyperglycemiaChronic hyperglycemia and other and other metabolic disturbances of DM lead to metabolic disturbances of DM lead to
long-term tissue and organ damage as long-term tissue and organ damage as well as dysfunction.well as dysfunction.
Type 2 diabetes is a major clinical and public Type 2 diabetes is a major clinical and public
health problem. health problem.
It is estimated that in the year 2000, 171 It is estimated that in the year 2000, 171 million people worldwide had type 2 diabetesmillion people worldwide had type 2 diabetes
In PalestineIn Palestine, the prevalence of diabetes , the prevalence of diabetes between 9 – 13% of the population.between 9 – 13% of the population.
Type 2 diabetesType 2 diabetesthe modern epidemicthe modern epidemic
Diabetes in the UK is Diabetes in the UK is increasingincreasing
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1940 1960 1980 1996 2004 2005 2010
Mill
ions
of p
eopl
e
with
dia
bete
s
Adapted from: 1. Diabetes UK. Diabetes in the UK 2004. Diabetes UK, London, 2004.2. Diabetes UK. State of the Nation 2005. Diabetes UK, London, 2005.
How we How we
Diagnose Diabetes?Diagnose Diabetes?
Criteria for the diagnosis of Criteria for the diagnosis of DMDM
1.1. Symptoms of diabetes plus Symptoms of diabetes plus
random plasma glucoserandom plasma glucose
concentration >200 mg/dL.concentration >200 mg/dL.
2.2. Fasting plasma glucoseFasting plasma glucose >126 >126
mg/dL. (Fasting for at least 8 h.)mg/dL. (Fasting for at least 8 h.)
Criteria for the diagnosis of Criteria for the diagnosis of DMDM
3.3. Two-hour plasma glucoseTwo-hour plasma glucose >200 >200
mg/dL during an mg/dL during an OGTTOGTT (75 g). (75 g).
4.4. HbA1c > 6.5%HbA1c > 6.5% (ADA in 2010)(ADA in 2010)
Diagnosing Diabetes Using A1CDiagnosing Diabetes Using A1C
Diabetes diagnosed when A1C ≥6.5%Diabetes diagnosed when A1C ≥6.5%
Confirm with a repeat A1C test
Not necessary to confirm in symptomatic
persons with PG >200 mg/dL
If A1C testing not possible, use previous If A1C testing not possible, use previous
teststests
Can not be used during pregnancyCan not be used during pregnancy
because of changes in red cell turnoverbecause of changes in red cell turnover
July 2009, International Committee, American Diabetes Association & International Diabetes Federation
Diagnosing Diabetes Using A1CDiagnosing Diabetes Using A1C
A1C ≥6.0% should receive preventive A1C ≥6.0% should receive preventive
interventions (pre-diabetes)interventions (pre-diabetes)
A1C: reliable measure of chronic glucose A1C: reliable measure of chronic glucose
levels; values vary less than FPG and testing levels; values vary less than FPG and testing
more convenient for patients (can be done more convenient for patients (can be done
any time of day)any time of day)July 2009, International Committee, American Diabetes Association & International Diabetes Federation
Who should be screened for Who should be screened for diabetesdiabetes
All individuals >45 yearsAll individuals >45 years
Consider testing at a younger age Consider testing at a younger age
or more frequently for high-risk or more frequently for high-risk
individualsindividuals
HIGH-RISKHIGH-RISK Individuals Individuals
ObeseObese
Having a Having a first-degree relativefirst-degree relative with DMwith DM
High-risk High-risk ethnic populationethnic population
HIGH-RISKHIGH-RISK Individuals Individuals
Delivered a Delivered a baby weighing >4 kgbaby weighing >4 kg or or
gestational DMgestational DM
HypertensiveHypertensive (>140/90 mmHg) (>140/90 mmHg)
Having Having HDL-C <35HDL-C <35 mg/dL and/or a mg/dL and/or a
Triglyceride >250Triglyceride >250 mg/dL mg/dL
IGTIGT or or IFGIFG on previous testing on previous testing
Can we prevent or delay the Can we prevent or delay the
onset of Diabetes and its onset of Diabetes and its
complications?complications?
Who should start the Who should start the preventionprevention
Metformin [in some patients]
The Plate MethodThe Plate Method
Fruit FruitVegetablesVegetables
BreadsGrains StarchyVeggies
BreadsGrains StarchyVeggies
MeatsProteinsMeatsProteins
DairyDairy
Management of
Diabetes
Type 2 Diabetes: Type 2 Diabetes: A Progressive DiseaseA Progressive Disease
LifestyleInterventions
Medical Nutrition Therapy
Alone
orwith Medications
Medical Nutrition Therapy
Medications
Insulin
Meds
Goals for Glycemic ControlGoals for Glycemic Control
Stepwise Management Stepwise Management of Type 2 Diabetesof Type 2 Diabetes
Insulin ± oral agents
Oral combination
Oral monotherapy
Diet & exercise
Non-insulin agents in Non-insulin agents in
the management of type the management of type
2 diabetes2 diabetes
InsulinInsulin in the Management of in the Management of
Type 2 DiabetesType 2 Diabetes
Combination between Combination between
InsulinInsulin and other and other
antihyperglycemicsantihyperglycemics
ConclusionsConclusions Many, if not most, patients with type 2 Many, if not most, patients with type 2
diabetes will eventually require insulin.diabetes will eventually require insulin.
Insulin should be offered to patients as a safe Insulin should be offered to patients as a safe
and effective treatment option, not as a and effective treatment option, not as a
punishment.punishment.
Treatment is initiated with a Treatment is initiated with a single bedtime single bedtime
injection of basal insulininjection of basal insulin
Take Home Take Home Message . . .Message . . .
When Oral Agents Fail, Add Basal Insulin When Oral Agents Fail, Add Basal Insulin While Continuing OralsWhile Continuing Orals
Titrate Basal Insulin Titrate Basal Insulin RapidlyRapidly To Normalize To Normalize FBSFBS
When FBS Normal But A1C Elevated, Add When FBS Normal But A1C Elevated, Add Mealtime Bolus Insulin One Meal At A Mealtime Bolus Insulin One Meal At A
Time Time & Withdraw Sulfonylurea when & Withdraw Sulfonylurea when All Meals CoveredAll Meals Covered
Don’t Forget The ABC’s Don’t Forget The ABC’s
Thank YouThank You
Recent Updates inRecent Updates in
Diabetes MellitusDiabetes Mellitus
Dr. Muhieddin Omar
How to follow up your How to follow up your
diabetic patient?diabetic patient?
Assessment guidelinesAssessment guidelines
EVERY VISITEVERY VISITBlood pressureBlood pressure
WeightWeight
Visual foot examinationVisual foot examination
QUARTERLYQUARTERLYHemoglobin A1CHemoglobin A1C
BIANNUALBIANNUALDental examinationDental examination
Assessment guidelinesAssessment guidelines
ANNUALLYANNUALLY
Albumin/creatinine ratioAlbumin/creatinine ratio (unless (unless
proteinuria is documented)proteinuria is documented)
Pedal Pedal pulsespulses and and neurologicneurologic examination examination
EyeEye examination (by ophthalmologist) examination (by ophthalmologist)
Blood Blood lipidslipids
Correlation of A1C with Average Correlation of A1C with Average GlucoseGlucose
Mean plasma glucoseMean plasma glucose
A1C (%)A1C (%)mg/dlmg/dl
66126126
77154154
88183183
99212212
1010240240
1111269269
1212298298
Diabetes Care 32(Suppl 1):S19, 2009
Micro and Macro Vascular Micro and Macro Vascular
Complications of DiabetesComplications of Diabetes
Relative Risk of Progression of Relative Risk of Progression of Diabetic Complications Diabetic Complications
DCCT Research Group, N Engl J Med 1993, 329:977-986.
1
3
5
7
9
11
13
15
6 7 8 9 10 11 12
Retinop
Neph
Neurop
RELA
TIV
E
RIS
K
Mean A1C
Glycemic ControlGlycemic Control
Each 1% reduction in mean HbA1c Each 1% reduction in mean HbA1c
was associated with reduction:was associated with reduction:
21% for deaths related to diabetes 21% for deaths related to diabetes
14% for myocardial infarction 14% for myocardial infarction
37% for microvascular complications 37% for microvascular complications
Stratton IM, Adler AI, Neil HA, et alStratton IM, Adler AI, Neil HA, et alBMJBMJ 2000 Aug 12;321(7258):405-12 2000 Aug 12;321(7258):405-12
How to prevent the How to prevent the
microvascular microvascular
complications?complications?
Diabetic NephropathyDiabetic Nephropathy
Optimize glucose controlOptimize glucose control
Optimize blood pressure controlOptimize blood pressure control
Limit protein intake Limit protein intake
Test for microalbuminuria Test for microalbuminuria
Measure serum creatinine annually Measure serum creatinine annually
Treat with either ACE inhibitors or ARBsTreat with either ACE inhibitors or ARBs
HypertensionHypertension
BP should be measured at every routine BP should be measured at every routine
diabetes visit.diabetes visit.
Patients with diabetes should be treated Patients with diabetes should be treated
to a SBP <130/80 mmHg. to a SBP <130/80 mmHg.
Multiple drug therapy is generally Multiple drug therapy is generally
required to achieve targets.required to achieve targets.
HypertensionHypertension
Initial drug therapy for raised BP should Initial drug therapy for raised BP should
be with be with ACE inhibitors or ARBsACE inhibitors or ARBs
All patients with diabetes should be All patients with diabetes should be
treated with treated with ACE inhibitorACE inhibitor..
Monitoring Lipid LevelsMonitoring Lipid Levels
In adults, test for lipid disorders at least In adults, test for lipid disorders at least
annually. annually.
Lifestyle modificationLifestyle modification including including
reduction of saturated fat and reduction of saturated fat and
cholesterol intake.cholesterol intake.
Monitoring Lipid LevelsMonitoring Lipid Levels
For those over the age of 40 years, For those over the age of 40 years, statinstatin
therapy to achieve an therapy to achieve an LDL reduction of 30–LDL reduction of 30–
40% regardless of baseline LDL levels40% regardless of baseline LDL levels..
Lower Lower LDL cholesterolLDL cholesterol to <100 mg/dL to <100 mg/dL
Lower Lower triglyceridestriglycerides to <150 mg/dL to <150 mg/dL
Raise Raise HDL cholesterolHDL cholesterol to >40 mg/dL. to >40 mg/dL.
The The AAction to ction to CControl ontrol
CCardiardiOOvascular vascular RRisk in isk in
DDiabetesiabetes
STUDY HYPOTHESIS:STUDY HYPOTHESIS:
A therapeutic strategy that targets HbA1c < 6.0%
reduces the rate of CVD events more than a
strategy that targets HbA1c 7.0% to 7.9%
ACCORDACCORD
257 Deaths257 Deaths In Intensive Arm In Intensive Arm
203 Deaths203 Deaths In Conventional Arm In Conventional Arm
Not Due To HypoglycemiaNot Due To Hypoglycemia
Not Due To MedicationNot Due To Medication
The ACCORD Study Group. N Engl J Med. 2008;358:2545-2559.The ACCORD Study Group. N Engl J Med. 2008;358:2545-2559.
ACCORD: Primary OutcomeACCORD: Primary Outcome
2525
Pat
ien
ts W
ith
Eve
nts
(%
)P
atie
nts
Wit
h E
ven
ts (
%)
1515
2020
1010
55
0000 11 22 33 44 55 66
YearsYears
PP=0.16=0.16
StandardStandard
IntensiveIntensive
ACCORD: All-Cause ACCORD: All-Cause MortalityMortality
2525P
atie
nts
Wit
h E
ven
ts (
%)
Pat
ien
ts W
ith
Eve
nts
(%
)
1515
2020
1010
55
0000 11 22 33 44 55 66
YearsYears
The ACCORD Study GroupThe ACCORD Study Group. N Engl J Med. N Engl J Med. 2008;358:2545-2559.. 2008;358:2545-2559.
PP=0.04=0.04
StandardStandard
IntensiveIntensive
ADVANCEADVANCEAction In Diabetes And Vascular Disease:Action In Diabetes And Vascular Disease:
Preterax And Diamicron MR Controlled Preterax And Diamicron MR Controlled EvaluationEvaluation
11,140 Patients, Age ~66, With Type 2 11,140 Patients, Age ~66, With Type 2 DM, And High CV RiskDM, And High CV Risk
Intensive (Intensive (A1c 6.4%A1c 6.4%) vs Conventional ) vs Conventional ((A1c 7%A1c 7%))
NoNo Excess Mortality In Intensive GroupExcess Mortality In Intensive Group
P=0.28
Advance Collaborative Group. New Engl. J. Med. 2008;358:2572.
ADVANCE: All-Cause MortalityADVANCE: All-Cause Mortality
P=0.32
Advance Collaborative Group. New Engl. J. Med. 2008;358:2572.Advance Collaborative Group. New Engl. J. Med. 2008;358:2572.
ADVANCE: Macrovascular EventsADVANCE: Macrovascular Events
Pts
Wit
h A
CV
Eve
nt
Pts
Wit
h A
CV
Eve
nt
A1c As Close to Normal A1c As Close to Normal
Without HypoglycemiaWithout Hypoglycemia
And Goals Need to Be And Goals Need to Be
Individualized!Individualized!
ConclusionsConclusionsThe overall effect of glycemic target on The overall effect of glycemic target on
macrovascular eventsmacrovascular events, if any, is , if any, is small.small.
Extremely tight glycemic control in very Extremely tight glycemic control in very high risk patients is not benign.high risk patients is not benign.
Lipid and BP control, smoking Lipid and BP control, smoking cessation cessation and anti-platelet and anti-platelet
therapy remain most therapy remain most important important for reducing CVD risk.for reducing CVD risk.