Management of diabetes mellitus (DM)

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• Management of diabetes mellitus (DM)
• WORKSHOP
• Dimitris Karanasios

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INTRODUCTION

• The Importance of DM Management in Primary Care
• The role of the GP / FM in everyday practice

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CONTENT

• Diagnosis and management of DM
• Major complications resulting from DM
• Strategies for a patient-centred care approach to
  achieving intensive glycemic control
• Patients empowerment through education about DM
  self-management

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Guidelines for DM management (ADA AACE/ACE
EASD IDF) and their differences
Despite the same objectives, these
guidelines are substantially different in
content. Czupryniak L. Guidelines for
the management of type 2 diabetes is ADA and
EASD consensus more clinically relevant than the
IDF recommendations? Diabetes Research and
Clinical Practice 2009 Dec 8 s22-s25
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Guidelines for DM management and their
differences
ADA/EASD guidelines offer practical
algorithms to help initiate and modify
pharmacological therapy for diabetes with
detailed descriptions of treatment options.
IDF document, however, concentrates on the role
of postprandial hyperglycemia and calls for a
lower HbA1c target value of 6.5 as opposed to
ADA/EASD guidelines advocating a value of 7.
Czupryniak L. Guidelines for the
management of type 2 diabetes is ADA and EASD
consensus more clinically relevant than the IDF
recommendations? Diabetes Research and Clinical
Practice 2009 Dec 8 s22-s25
6
Guidelines for DM management and their
differences
Careful analysis of the guidelines
contents suggests that an ADA/EASD consensus
might be more useful in everyday clinical
practice than IDF recommendations, which do not
offer a particular treatment algorithm.
Czupryniak L. Guidelines for the
management of type 2 diabetes is ADA and EASD
consensus more clinically relevant than the IDF
recommendations? Diabetes Research and Clinical
Practice 2009 Dec 8 s22-s25
7
Guidelines for DM management and their
differences
For example, having been developed by
endocrinologists, ACE/AACE guidelines set more
aggressive target A1C levels than the ADA/EASD
guidelines( 6.5 vs lt 7) they also stratify
patients into treatment-nave and treated groups.
In contrast, ADA/EASD guidelines are
unstratified and more general.
Robertson C. Translating Guidelines into Primary
Care of Patients With Type 2 Diabetes What's New
About ADA/EASD Guidelines and the ACE/AACE Road
Maps? Journal for Nurse Practitioners 2008 4(9)
661-671. 
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Major complications of DM

• Complications Macrovascular
• Atherosclerotic Heart Disease
• Myocardial Infarction
• Peripheral Vascular Disease
• Cerebrovascular Disease
• Renal Artery Stenosis
• Complications Microvascular
• Diabetic Retinopathy
• Diabetic Nephropathy
• Occurs in 40 of Type I Diabetes Mellitus
• Occurs in 20 of Type II Diabetes Mellitus
• Peripheral Neuropathy
• Autonomic Neuropathy
• Gastroparesis
• Impotence
• Family Practice Notebook, LLC, 2008

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Major complications of DM

• Major complications of DM are
• Cardiovascular Disease
• Diabetic Nephropathy
• Diabetic Retinopathy
• Family Practice Notebook, LLC, 2008

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CASE STUDY

• A 58-year-old man, referred by his cardiologist,
  is feeling very tired and fears that his heart
  disease has worsened. There are no indicators of
  a new coronary disease event.
• History
• Stopped smoking 10 years ago (40p/y)
• Drinks 1 glass of red wine per night
• Underwent angioplasty 10 months previously
• Current medication Statin, beta-blocker,
  aspirin, ACE inhibitor and a diuretic
• Physical examination
• BP 130/78 mmHg PULSE 88/min
• WEIGHT 120 kg BMI 38.3 kg/m2
• Examinations
• Fasting Glu 220 mg/dl, HbA1c 8.4
• TC 212 mg/Dl, LDL 124 mg/dL, HDL 24 mg/dL and TG
  320 mg/dL

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GROUP WORK - 3 GROUPS

• Design a plan for
• Diagnosis, additional examinations(using current
  diagnostic criteria)
• Lifestyle modifications Medication (using
  current guidelines treatment algorithms)
• Patient education / self-management (use current
  guidelines)

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GROUP PRESENTATIONS

• DM management plan group presentations
• Discussion

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SUMMARY

• Goals of the workshop
• Challenges in chronic disease management

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DM DIAGNOSTIC CRITERIA
CRITERIA FOR DIABETES DIAGNOSIS
1. A1C 6.5. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.
2. FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.
3. 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolved in water.
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl (11.1 mmol/l). Any of 4 but 1-3 should be confirmed by repeat testing. AMERICAN DIABETES ASSOCIATION Diabetes Care January 2010 vol. 33 no. Supplement 1 S62-S69
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THERAPEUTIC CHANGES TO ONES LIFESTYLE (TLC)
ATPIII

• Weight loss of 10 of BW in 6 months
• Lowering the daily calorie intake (500 kcal-1000
  kcal)
• Moderate exercise 30 min. daily
• Stress control, social and family support,
  smoking cessation
• Medication lowering lipid levels in case of an
  inability to reach target levels within 6 months
• http // www.nhlbi.nih.gov
• Copy for trainee

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Pharmacologic treatment of DM
Heine RJ, Diamant M, Mbanya J-C, Nathan DM.
Management of hyperglycaemia in type 2 diabetes
the end of recurrent failure?BMJ 2006 333
1200-1204
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Patient education in DM

• Recommendations
• People with diabetes should receive DSME
  according to national standards when their
  diabetes is diagnosed and as needed thereafter.
  (B)
• Self-management behaviour change is the key
  outcome of DSME and should be measured and
  monitored as part of care. (E)
• DSME should address psychosocial issues since
  emotional well-being is strongly associated with
  positive diabetes outcomes. (C)
• DSME should be reimbursed by third-party payers.
  (E)
• Standards of Medical Care in Diabetes2009.
• Diabetes Care 2009 Jan 32 S13S61. doi
  10.2337/dc09-S013.

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EMPOWERING PATIENTS WHAT PATIENTS SHOULD KNOW

• Reducing Risk
• What type 2 diabetes mellitus is (a) insulin
  deficiency and resistance (b) progression of the
  disease
• The long-term effect of high blood sugar,
  emphasizing the importance of lowering blood
  sugar levels in order to prevent complications
• What insulin is and why it is important
• How lifestyle modification affects long-term
  complications
• Healthy Eating and Activity
• How lifestyle (diet and exercise) modification
  affects blood sugar, i.e., foods that raise blood
  sugar and the impact of activity on blood sugar
• Monitoring
• The importance of rigorous management of blood
  sugar levelsachieving desired blood sugar levels
  
• The difference between fasting and postprandial
  sugar levels
• Taking Medications
• How various oral anti-diabetic agents affect
  blood sugar levels
• Postprandial medications
• When and why insulin should be administered
• Which insulin?
• Carolyn Robertson, Journal for Nurse
  Practitioners 2008 4(9) 661-671

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Indicators of DM control

• Treatment involves control of hyperglycemia
  to improve symptoms and prevent complications
  while minimizing hypoglycemic episodes.
• Goals for glycemic control are
• Blood glucose between 80 and 120 mg/dl during the
  day
• Blood glucose between 100 and 140 mg/dL at
  bedtime
• HbA1c levels lt 7
• Merck manuals online medical library