What the GP Should Know about Diabetes Mellitus

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What the GP Should Know about Diabetes Mellitus
Dr. Muhieddin Omar
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Definition of Diabetes

• It is a group of metabolic diseases characterized
  by hyperglycemia resulting from defects of
  insulin secretion and/or increased cellular
  resistance to insulin.
• Chronic hyperglycemia and other metabolic
  disturbances of DM lead to long-term tissue and
  organ damage as well as dysfunction.

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Type 2 diabetesthe modern epidemic

• Type 2 diabetes is a major clinical and public
  health problem.
• It is estimated that in the year 2000, 171
  million people worldwide had type 2 diabetes
• In Palestine, the prevalence of diabetes between
  9 13 of the population.

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Diabetes in the UK is increasing
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.
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How we Diagnose Diabetes?
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Criteria for the diagnosis of DM

1. Symptoms of diabetes plus random plasma glucose
   concentration gt200 mg/dL.
2. Fasting plasma glucose gt126 mg/dL. (Fasting for
   at least 8 h.)

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Criteria for the diagnosis of DM

1. Two-hour plasma glucose gt200 mg/dL during an OGTT
   (75 g).
2. HbA1c gt 6.5 (ADA in 2010)

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Diagnosing Diabetes Using A1C

• Diabetes diagnosed when A1C 6.5
• Confirm with a repeat A1C test
• Not necessary to confirm in symptomatic persons
  with PG gt200 mg/dL
• If A1C testing not possible, use previous tests
• Can not be used during pregnancy because of
  changes in red cell turnover

July 2009, International Committee, American
Diabetes Association International Diabetes
Federation
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Diagnosing Diabetes Using A1C

• A1C 6.0 should receive preventive interventions
  (pre-diabetes)
• A1C reliable measure of chronic glucose levels
  values vary less than FPG and testing more
  convenient for patients (can be done any time of
  day)

July 2009, International Committee, American
Diabetes Association International Diabetes
Federation
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Who should be screened for diabetes

• All individuals gt45 years
• Consider testing at a younger age or more
  frequently for high-risk individuals

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HIGH-RISK Individuals

• Obese
• Having a first-degree relative with DM
• High-risk ethnic population

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HIGH-RISK Individuals

• Delivered a baby weighing gt4 kg or gestational DM
• Hypertensive (gt140/90 mmHg)
• Having HDL-C lt35 mg/dL and/or a Triglyceride gt250
  mg/dL
• IGT or IFG on previous testing

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Can we prevent or delay the onset of Diabetes and
its complications?
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Who should start the prevention
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Metformin in some patients
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The Plate Method
Fruit
Dairy
Vegetables
Breads Grains Starchy Veggies
Meats Proteins
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Management of Diabetes
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Type 2 Diabetes A Progressive Disease
Onset Diabetes Beginning of Insulin Deficiency
Pre-diabetes Insulin Resistance
Diabetes insulin Deficiency
Medical Nutrition Therapy Alone orwith
Medications
Medical Nutrition Therapy Medications Insulin
LifestyleInterventions
Meds
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Goals for Glycemic Control
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Stepwise Management of Type 2 Diabetes
Insulin oral agents
Oral combination
Oral monotherapy
Diet exercise
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Non-insulin agents in the management of type 2
diabetes
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Insulin in the Management of Type 2 Diabetes
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Combination between Insulin and other
antihyperglycemics
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Conclusions

• Many, if not most, patients with type 2 diabetes
  will eventually require insulin.
• Insulin should be offered to patients as a safe
  and effective treatment option, not as a
  punishment.
• Treatment is initiated with a single bedtime
  injection of basal insulin

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Take Home Message . . .

• When Oral Agents Fail, Add Basal Insulin While
  Continuing Orals
• Titrate Basal Insulin Rapidly To Normalize FBS
• When FBS Normal But A1C Elevated, Add Mealtime
  Bolus Insulin One Meal At A Time Withdraw
  Sulfonylurea when All Meals Covered
• Dont Forget The ABCs

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Thank You
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Recent Updates in Diabetes Mellitus
Dr. Muhieddin Omar
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How to follow up your diabetic patient?
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Assessment guidelines

• EVERY VISIT
• Blood pressure
• Weight
• Visual foot examination
• QUARTERLY
• Hemoglobin A1C
• BIANNUAL
• Dental examination

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Assessment guidelines

• ANNUALLY
• Albumin/creatinine ratio (unless proteinuria is
  documented)
• Pedal pulses and neurologic examination
• Eye examination (by ophthalmologist)
• Blood lipids

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Correlation of A1C with Average Glucose
Mean plasma glucose
A1C () mg/dl
6 126
7 154
8 183
9 212
10 240
11 269
12 298
Diabetes Care 32(Suppl 1)S19, 2009
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Micro and Macro Vascular Complications of Diabetes
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Relative Risk of Progression of Diabetic
Complications
RELATIVE RISK
Mean A1C
DCCT Research Group, N Engl J Med 1993,
329977-986.
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Glycemic Control

• Each 1 reduction in mean HbA1c was associated
  with reduction
• 21 for deaths related to diabetes
• 14 for myocardial infarction
• 37 for microvascular complications
• Stratton IM, Adler AI, Neil HA, et alBMJ 2000
  Aug 12321(7258)405-12

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How to prevent the microvascular complications?
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Diabetic Nephropathy

• Optimize glucose control
• Optimize blood pressure control
• Limit protein intake
• Test for microalbuminuria
• Measure serum creatinine annually
• Treat with either ACE inhibitors or ARBs

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Hypertension

• BP should be measured at every routine diabetes
  visit.
• Patients with diabetes should be treated to a SBP
  lt130/80 mmHg.
• Multiple drug therapy is generally required to
  achieve targets.

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Hypertension

• Initial drug therapy for raised BP should be with
  ACE inhibitors or ARBs
• All patients with diabetes should be treated with
  ACE inhibitor.

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Monitoring Lipid Levels

• In adults, test for lipid disorders at least
  annually.
• Lifestyle modification including reduction of
  saturated fat and cholesterol intake.

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Monitoring Lipid Levels

• For those over the age of 40 years, statin
  therapy to achieve an LDL reduction of 3040
  regardless of baseline LDL levels.
• Lower LDL cholesterol to lt100 mg/dL
• Lower triglycerides to lt150 mg/dL
• Raise HDL cholesterol to gt40 mg/dL.

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The Action to Control CardiOvascular Risk in
Diabetes
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STUDY HYPOTHESIS A therapeutic strategy that
targets HbA1c lt 6.0 reduces the rate of CVD
events more than a strategy that targets HbA1c
7.0 to 7.9
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ACCORD

• 257 Deaths In Intensive Arm
• 203 Deaths In Conventional Arm
• Not Due To Hypoglycemia
• Not Due To Medication

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ACCORD Primary Outcome
The ACCORD Study Group. N Engl J Med.
20083582545-2559.
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ACCORD All-Cause Mortality
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ADVANCEAction In Diabetes And Vascular
DiseasePreterax And Diamicron MR Controlled
Evaluation

• 11,140 Patients, Age 66, With Type 2 DM, And
  High CV Risk
• Intensive (A1c 6.4) vs Conventional (A1c 7)
• No Excess Mortality In Intensive Group

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ADVANCE All-Cause Mortality
P0.28
Advance Collaborative Group. New Engl. J. Med.
20083582572.
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ADVANCE Macrovascular Events
P0.32
Pts With A CV Event
Advance Collaborative Group. New Engl. J. Med.
20083582572.
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A1c As Close to Normal Without HypoglycemiaAnd
Goals Need to Be Individualized!
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Conclusions

• The overall effect of glycemic target on
  macrovascular events, if any, is small.
• Extremely tight glycemic control in very high
  risk patients is not benign.
• Lipid and BP control, smoking cessation and
  anti-platelet therapy remain most important for
  reducing CVD risk.

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