นพ. เฉลิมศักดิ์ สุวิชัย โรงพยาบาล พะเยา

Management of Type 2 Diabetes Mellitus: A New Paradigm Approach Dr. Chalermsak Suwichai Phayao Hospital

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 IGT Ongoing Hyperglycemia HyperglycemiaRetinopathy Nephropathy Neuropathy Blindness ESRD/Dialysis/Transplantation CHD Stroke Amputation

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 The leading cause of new cases of blindness in working-age adults The leading cause of nontraumatic lower- extremity amputations Diabetes

Management of Type 2 DM 1. Non- pharmacologic Dietary management Active life style / Exercise Weight reduction program

3. Modifying other risk factors for atherosclerosis: Dyslipidemia ACEI/AIIRB Antihypertensive agents Statins Aspirin Folate 2. Pharmacologic Oral agents Insulin

Holistic Approach to The Management of 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

Diagnosis of Diabetes : 1. FPG > 126 mg/dL on 2 separate occasions 2. Random plasma glucose > 200 mg/dL on 2 separate occasions + symptoms (polyuria, polydipsia, unexplained weight loss) 3. 2-hour plasma glucose > 200 mg/dL during OGTT in 2 separate occasions

Diagnosis of Diabetes: Plasma Glucose Cutoff Points Cate gory FPG 2-Hour PG on OGTT mg/d L mmol /L mg/d L mmol /L Nor mal <110<6.1 <140 <7.8 IFG >110&<1 26 >6.1&< IGT - - Diab etes >126 >7.0 >200>11.1 >140&<20 0 >7.8&<11.1

Risk Factors for Type 2 DM Nonmodifi able Genetic factors Age Ethnicity Modifiable Weight Diet Physical activity Stress

Treatment Algorithm Nonpharmacologic therapy Monotherapy Sulfonylureas/Benzoic acid analogue Biguanide Alpha-glucosidase inhibitors Thiazolidinediones Insulin Combination therapy Very symptomatic Severe hyperglycemia Ketosis Lateral autoimmune diabetes Pregnancy Insulin

Medical Nutrition Therapy for Type 2 Diabetes Diet - Improved food choices - Spacing meals - Individualized carbohydrate content - Moderate calorie restriction Exercise

Antihyperglycemic Agents for Type 2 DM: The Six Classes ClassAvailable Agents a-Glucosidase inhibitor Acarbose, miglitol ThiazolidinedionePioglitazone, rosiglitazone Biguanide Metformin Meglitinide Repaglinide, nateglinide* SulfonylureaGlimepiride, glipizide, glyburide, and first-generation sulfonylureas Insulin Many

Considerations in Pharmacologic Treatment of Type 2 Dibetes Efficacy(HbA 1c lowering capacity) Mechanisms of action of drugs Impact on weight gain Complications/tolerability Frequency of hypoglycemia Compliance/complexity of regimen Cost

Strategies for Insulin Therapy in Elderly Patients 1. Insulin therapy often considered a last resort in the elderly 2. Therapeutic goals: Relieve symptoms Prevent hypoglycemia Prevent acute complication of hyperglycemia

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

Combination Therapy: Oral 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

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

ADA Treatment Guidelines Biochemical Index Normal Goal <90 Action Suggested 160 Preprandial glucose mg/dL Postprandial glucose mg/dL Bedtime glucose mg/dL HbA 1c <120 <6%* < <7% <8% 140 <180 *Depending on assay norms

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

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

ADA Clinical Practice Recommendation: Indication of initial treatment and goals for adult hypertensive diabetic patients BP Systolic Diastolic Goal (mmHg.)<130 <80 Behavioral therapy alone (maximum 3 months then add pharmacologic treatment Behavioral therapy + pharm> 140 > 90

Diabetes Microvascular Complications

Atherosclerosis: The Major cause of death in diabetes