Management of Type 2 Diabetes Mellitus: A New Paradigm Approach

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Management of Type 2Diabetes MellitusA New
Paradigm Approach

• Dr. Chalermsak Suwichai
• Phayao Hospital

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Progression of Diabetes

• Genetic susceptibility
• Environmental factors
• Nutrition
• Obesity
• Inactivity
• Insulin resistance
• HDL-C
• Triglycerides
• Atherosclerosis
• Hypertension
• PPG levels

Diagnosis of Diabetes
Appearance of Complications
Disability
Death
Ongoing Hyperglycemia
IGT
Blindness ESRD/Dialysis/Transplantation CHD Stroke
Amputation
Hyperglycemia
Retinopathy Nephropathy Neuropathy
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Clinical Impact of Diabetes Mellitus
The leading cause of new cases of end-stage renal
disease(ESRD)
A 2- to 4-fold increase in cardiovascular risk
Diabetes
The leading cause of new cases of blindness in
working-age adults
The leading cause of nontraumatic
lower- extremity amputations
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Management of Type 2 DM

• 1. Non-pharmacologic
• Dietary management
• Active life style /
  Exercise
• Weight reduction
  program

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2. Pharmacologic Oral agents
Insulin

• 3. Modifying other risk factors for
  atherosclerosis
• Dyslipidemia ACEI/AIIRB
• Antihypertensive agents Statins
• 
  Aspirin
• 
  Folate

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Holistic Approach to The Managementof Diabetes
Mellitus

• Early detection and prevention of diabetes
• Intensive glycemic control
• Intensive blood pressure control and lipid
  lowering
• Early detection, prevention and treatment of
  diabetic complications
• Diabetic education and self care management
• Improving quality of life
• Alternative Medicine for Diabetes

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Diagnosis of Diabetes
1. FPG gt 126 mg/dL on 2 separate occasions
2. Random plasma glucose gt 200 mg/dL on 2
separate occasions symptoms (polyuria,
polydipsia, unexplained weight loss)
3. 2-hour plasma glucose gt 200 mg/dL during OGTT
in 2 separate occasions
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Diagnosis of DiabetesPlasma Glucose Cutoff
Points
FPG
2-Hour PG on OGTT
Category
mg/dL
mmol/L
mmol/L
mg/dL
Normal
lt110
lt6.1
lt140
lt7.8
IFG
gt110lt126
gt6.1lt6.9
-
-
gt7.8lt11.1
IGT
-
-
gt140lt200
Diabetes
gt126
gt200
gt11.1
gt7.0
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Risk Factors for Type 2 DM

• Nonmodifiable
• Genetic factors
• Age
• Ethnicity

• Modifiable
• Weight
• Diet
• Physical activity
• Stress

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Treatment Algorithm
Nonpharmacologic therapy
Very symptomatic Severe hyperglycemia Ketosis Late
ral autoimmune diabetes Pregnancy
Monotherapy Sulfonylureas/Benzoic acid
analogue Biguanide Alpha-glucosidase inhibitors Th
iazolidinediones Insulin
Insulin
Combination therapy
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Medical Nutrition Therapyfor Type 2 Diabetes

• Diet
• - Improved food choices
• - Spacing meals
• - Individualized carbohydrate content
• - Moderate calorie restriction
• Exercise

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Antihyperglycemic Agents for Type 2 DMThe Six
Classes
Class
Available Agents
a-Glucosidase inhibitor
Acarbose, miglitol
Thiazolidinedione
Pioglitazone, rosiglitazone
Biguanide
Metformin
Meglitinide
Repaglinide, nateglinide
Sulfonylurea
Glimepiride, glipizide, glyburide, and
first-generation sulfonylureas
Insulin
Many
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Considerations in PharmacologicTreatment of
Type 2 Dibetes

• Efficacy(HbA1c lowering capacity)
• Mechanisms of action of drugs
• Impact on weight gain
• Complications/tolerability
• Frequency of hypoglycemia
• Compliance/complexity of regimen
• Cost

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Strategies for Insulin Therapy inElderly Patients

• 1. Insulin therapy often considered a last resort
  in the elderly
• 2. Therapeutic goals
• Relieve symptoms
• Prevent hypoglycemia
• Prevent acute complication of hyperglycemia

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• 3. Way to facilitate insulin treatment
• Simple dose schedules
• Premixed preparations
• Improved, more convenient delivery systems

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Combination TherapyOral Agents Plus Insulin

• 1. Rational
• Combination of two agents with different
  mechanism of action
• More convenient and maybe safer
• 2. Sulfonylurea Insulin
• BIDS therapy bedtime insulin/daytime
  sulfonylurea
• Useful in patients early in course of disease

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• 3. Metformin Insulin
• Improves Insulin sensitivity
• 4. Alpha glucosidase inhibitor (acarbose)
  Insulin
• Decrease postprandial glycemia
• 5. Thiazolidnediones Insulin
• Improve insulin resistance, improves insulin
  action in peripheral tissues
• Reduces insulin requirement

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ADA Treatment Guidelines
Normal Goal
Biochemical Index
Action Suggested
lt90
Preprandial glucose mg/dL
80-120
lt80 / gt 140
lt180
lt180
Postprandial glucose mg/dL
lt120
lt100 / gt160
Bedtime glucose mg/dL
lt120
100-140
HbA1c
lt8
lt7
lt6
Depending on assay norms
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Hypertension and type 2 diabetes

• Hypertension in diabetes increases risk for
• 1. Coronary heart disease
• 2. Atherosclerosis
• 3. Retinopathy

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• 4. Diabetic nephropathy
• Double microalbuminuria rates in hypertensive
  diabetes
• Accelerated rated of decline in renal function
• Microalbuminuria strong predictor of
  cardiovascular disease

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ADA Clinical Practice Recommendation

• Indication of initial treatment and goals for
  adult hypertensive
• diabetic patients

BP Systolic Diastolic
Goal (mmHg.) lt130 lt80 Behavioral therapy
alone 130-139 80-89 (maximum 3 months
then add pharmacologic
treatment Behavioral therapy pharm gt 140 gt 90
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Diabetes MicrovascularComplications
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Atherosclerosis The Major cause ofdeath in
diabetes
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