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

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0.5

1.0

1.5

2.0

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3.5

1940 1960 1980 1996 2004 2005 2010

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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

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Neurop

RELA

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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

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(%

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%)

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2020

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55

0000 11 22 33 44 55 66

YearsYears

PP=0.16=0.16

StandardStandard

IntensiveIntensive

ACCORD: All-Cause ACCORD: All-Cause MortalityMortality

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%)

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(%

)

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2020

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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

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CV

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Pts

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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.