DIABETES MELLITUS

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DIABETES MELLITUS

• Management

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IMPORTANT POINTSIN HISTORY, EXAMINATION,
INVESTIGATIONS AND TREATMENT

• Control good / poor? Treatment?
• Complications
• Cardiovascular risk factors

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HISTORY special points

• Introduction ethnic group and age
• Presenting complaint
• E.g. admitted for control of diabetes
• History of presenting complaint
• Polyuria, polydypsiablood glucose values, also
  indicates control, screening
• Complications systemic review esp. CVS, Neuro,
  Eye, Renal, Skin,
• Drug history What medication? Duration, Side
  effects? Compliance?
• P/H/O complications esp. CVS, wound infections
• F/H/O type 2 DM, IHD, CVA, HBP
• Social history smoking, diet, exercise,
  financial aspects

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EXAMINATION special points

• General examination
• skin infections, edema, waist
• CVS
• BP, postural hypotension, JVP, cardiomegaly
• peripheral pulses, bruits
• RS
• Infections - TB
• Abdomen
• Fatty liver, ascites with nephrotic syndrome
• CNS
• Ophthalmoscopy and cranial nerves
• Mononeuritis
• Amyotrophy
• Autonomic (postural hypotension)
• Peripheral neuropathy
• Muscle wasting
• Early sensory signs vibration sense, absent
  jerks
• Rombergs test
• FEET

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INVESTIGATIONS

• Assess glycemic control
• Extent of complications
• Risk factors for CAD

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INVESTIGATIONS

• Assess glycemic control blood glc levels, HbA1c,
  fructosamine
• Extent of complications ECG, A/B, Renal, CXR,
  ECHO,
• Risk factors for CAD BP, lipids, metabolic
  syndrome

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PRINCIPLES OF TREATMENT

• Good glycemic control
• Prevent or treat complications
• Manage risk factors for CAD

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PRINCIPLES OF TREATMENTTYPE 2 DM

• Good glycemic control
• Prevent or treat complications
• Manage risk factors for CAD

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GLYCAEMIC CONTROL

• A healthy lifestyle
• OHD
• Insulin

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HEALTHY LIFE STYLE

• Healthy eating
• Weight control
• Exercise
• Smoking and alcohol

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HEALTHY LIFE STYLE

• Healthy diet
• Exercise
• Weight control BMI lt23 kg / m2
• Smoking and alcohol

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DIET

• Carbohydrates
• 60 of calories
• Low glycaemic foods preferred
• Restrict refined sugars and high fiber
• Non-nutrient sweeteners
• Avoid alcohol
• Fats
• lt30 of calories
• lt7 saturated
• lt200 g of cholesterol
• Avoid trans-fats
• Eat fish twice a week

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EXERCISE

• Control of blood sugar
• Increases insulin sensitivity (danger of hypo)
• Weight loss
• Reduces body fat and maintains muscle bulk
• Lowers blood pressure
• Cardiovascular fitness

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DRUGS

Decreased absorption
Increased peripheral glc uptake
Decreased hepatic glc output
Stimulate insulin release
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OHD

Decreased absorption
Acarbose
Increased peripheral glc uptake
Decreased hepatic glc output
Pioglitazon
Metformin
Stimulate insulin release
Sulphonyluria, Repaglinide
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OHD

• Biguanides metformin
• Sulphonyluria glyclazide, glipizide
• Thiozolidinediones pioglitazone
• Alpha glucosidase inhibitor acarbose
• Non-sulphonyluria secretagogues repaglinide

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DRUG THERAPY

• Asymptomatic
• Life-style modification Drugs

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DRUG THERAPY

• Asymptomatic
• Metformin
• Life-style modification Drugs

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DRUG THERAPY

• Asymptomatic Symptomatic
• High HbA1C
• High FPG
• High RPG
• Life-style modification Drugs

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DRUG THERAPY

• TYPE 2 D M
• Asymptomatic Type 2 DM ? Metformin
• Symptomatic Type 2 DM
• HbA1c gt8
• FBS gt 11.1
• RBG gt 14.0
• TYPE 1 DM
• Insulin

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TYPE 2 DM

• Obese T2DM
• Metformin
• If intolerant give acarbose or TZD
• HbA1C gt10 combination of metformin and
  gliclazide (sulphonyluria)
• Non-obese T2DM
• Metformin or sulphonyluria (gliclazide)

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GOALS OF GLYCEMIC CONTROL

• FBS 4.4-6.1
• Non-fasting 4.4-8.0
• HbA1C lt6.5

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• Mono-therapy
• Combination of metformin gliclazide
• OR metformin acarbose / TZDs (esp in obese)
• Then add third drug
• Add insulin

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ADD INSULIN

• If not reaching target after 3 months of optimum
  combination therapy (metformin, gliclazide,
  acarbose, pioglitazone)
• FBGgt 7.0 mmol/L
• HbA1cgt6.5
• Maximum doses of OHD

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INSULIN

• Rapid-acting analogues
• Fast-acting insulin (short-acting)
• Intermediate-acting insulin
• Long-acting insulin
• Very long-acting analogues
• Lancet 2006367847

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INSULINS

• Rapid-acting analogues insulin lispro, Humalog
  (4-6 hours)
• Fast-acting soluble insulin, Actrapid, Humulin R
  (6-10 hours)
• Intermediate-acting (10-16 hours)
• isophane NPH, Humulin N
• Humulin L (Lente insulin)
• Long-acting insulin Ultralente 24 hours
• Very long-acting analogues (24 hours)
• Insulin glargine (Lantus)
• Insulin detemir (Levemir)
• Lancet 2006367847

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INSULIN REGIMES

• Premixed (Mixtard) b.d.
• (30 soluble 70 isophane)
• Before meals rapid or short, with bedtime
  intermediate or long acting analog
• Bedtime Long-acting or intermediate insulin, day
  time sulphonyluria metformin

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INSULIN REGIMES

• Basal-bolus (T1DM)
• Insulin pumps (continuous subcutaneous)
• Twice daily mixtard (Often for T2DM)
• 2/3 of total dose in morning (2/3 long acting
  e.g. 3070 Mixtard)
• 1/3 of total dose in evening (1/2 long acting
  e.g. 5050 Mixtard)
• Lancet 2006367847

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INSULIN PUMP
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COMPLICATIONS OF TREATMENT

• Hypoglycaemia
• Hypoglycaemia unawareness

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NEWER DRUGS IN TYPE 2 DM

• Exenatide
• Stimulates insulin secretion
• Glucagon-like-peptide
• Given S.C

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PREVENT COMPLICATIONS OF DIABETES
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PREVENT COMPLICATIONS OF DIABETES

• Nephropathy
• Neuropathy
• Retinopathy
• Cardiovascular IHD, CVA/TIA. PVD
• Diabetic foot

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PREVENT COMPLICATIONS OF DIABETES

• Good glycaemic control
• Screen for complications
• Action to prevent specific complications

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PREVENT COMPLICATIONS OF DIABETES

• Good glycaemic control
• Screen regular BP, lipids, eye and renal check
  up
• Action to prevent specific complications
• ACEI or ARBs in early renal involvement
• Aspirin if IHD, or high risk of IHD
  (microalbuminuria, metabolic syndrome, gt35,
  high-risk ethnic groups, family history)
• Control hypertension (macrovascular, retinopathy
  and nephropathy)
• Treat hyperlipidaemia (macrovascular and
  nephropathy)
• Stop smoking (IHD, CVA, TIA, PVD)
• Diabetic foot

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CONTROL HBP AND HYPERLIPIDAEMIA

• LDL lt2.6
• TG lt1.7
• HDL gt1.1
• BP lt130/80
• BP lt120/75 (with renal impairment or gross
  proteinuria)

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COMPLICATIONS DIABETIC FOOT
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COMPLICATIONS DIABETIC FOOT
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COMPLICATIONS