DIABETES MELLITUS Management

IMPORTANT POINTS: IN HISTORY, EXAMINATION, INVESTIGATIONS AND TREATMENT –Control: good / poor? Treatment? –Complications –Cardiovascular risk factors

HISTORY: special points Introduction: ethnic group and age Presenting complaint –E.g. admitted for control of diabetes History of presenting complaint –Polyuria, polydypsia……blood 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

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 Romberg’s test FEET –Skin, bact / fungal infections, gangrene, pulses, neuropathy, ulcers, osteomyelitis,

INVESTIGATIONS Assess glycemic control Extent of complications Risk factors for CAD

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

PRINCIPLES OF TREATMENT Good glycemic control Prevent or treat complications Manage risk factors for CAD

PRINCIPLES OF TREATMENT TYPE 2 DM Good glycemic control Prevent or treat complications Manage risk factors for CAD

GLYCAEMIC CONTROL A healthy lifestyle OHD Insulin

HEALTHY LIFE STYLE Healthy eating Weight control Exercise Smoking and alcohol

HEALTHY LIFE STYLE Healthy diet Exercise Weight control: BMI <23 kg / m 2 Smoking and alcohol

DIET Carbohydrates –60% of calories –Low glycaemic foods preferred –Restrict refined sugars and high fiber –Non-nutrient sweeteners –Avoid alcohol Fats –<30% of calories –<7% saturated –<200 g of cholesterol –Avoid trans-fats Eat fish twice a week

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

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

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

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

DRUG THERAPY Asymptomatic Life-style modificationDrugs

DRUG THERAPY Asymptomatic Metformin Life-style modificationDrugs

DRUG THERAPY Asymptomatic Symptomatic High HbA 1C High FPG High RPG Life-style modificationDrugs

DRUG THERAPY TYPE 2 D M Asymptomatic Type 2 DM ? Metformin Symptomatic Type 2 DM HbA1c >8% FBS > 11.1 RBG > 14.0 TYPE 1 DM Insulin

TYPE 2 DM Obese T2DM: Metformin If intolerant give acarbose or TZD HbA1 C >10%: combination of metformin and gliclazide (sulphonyluria) Non-obese T2DM: Metformin or sulphonyluria (gliclazide)

GOALS OF GLYCEMIC CONTROL –FBS –Non-fasting –HbA1C<6.5%

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

ADD INSULIN If not reaching target after 3 months of optimum combination therapy (metformin, gliclazide, acarbose, pioglitazone) FBG> 7.0 mmol/L HbA 1c >6.5% Maximum doses of OHD

INSULIN Rapid-acting analogues Fast-acting insulin (short-acting) Intermediate-acting insulin Long-acting insulin Very long-acting analogues Lancet 2006;367:847

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 2006;367:847

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

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. 30:70 Mixtard) –1/3 of total dose in evening (1/2 long acting = e.g. 50;50 Mixtard) Lancet 2006;367:847

INSULIN PUMP

COMPLICATIONS OF TREATMENT Hypoglycaemia Hypoglycaemia unawareness

NEWER DRUGS IN TYPE 2 DM Exenatide –Stimulates insulin secretion –Glucagon-like-peptide –Given S.C

PREVENT COMPLICATIONS OF DIABETES

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

PREVENT COMPLICATIONS OF DIABETES Good glycaemic control Screen for complications Action to prevent specific complications

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, >35, 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

CONTROL HBP AND HYPERLIPIDAEMIA –LDL <2.6 –TG <1.7 –HDL >1.1 –BP<130/80 –BP<120/75 (with renal impairment or gross proteinuria)

COMPLICATIONS: DIABETIC FOOT

COMPLICATIONS