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2. 2 By: Prof. Richard Nabhan Senior Consultant Physician Cardiologist & Diabetologist MRCP (UK), FRCP (London)

3. 3 List Target Glucose, BP & Lipid levels in patients with Type II DM Review recommended schedule of monitoring Recognize importance of achieving Target levels Discuss Treatment Strategies for Glucose, BP & Lipids.

4. 4 IdealOptimalSuboptimalInadequate Glycated Hb (% of upper limit)4% - 6%< 7%7% - 8.4% > 8.4% Fasting or Premeal Glucose (mmol/L) 3.8 – 6.14 – 77.1 - 10  10 Glucose Level 1-2 h after meal (mmol/L) 4.4 - 75 - 1111.1 - 14> 14

5. 5 Target Levels of LIPIDS in Type II DM Recommendations: Consider Diabetic Patients as: VERY HIGH RISK GROUP Target Levels: LDLTC/HDL ratioTG < 130 mg/dL< 430 – 150 mg/dL

6. 6 Evolution of Guidelines for HTN Control in DM 1997 Patients with DM < 130/85 mmHg Patients with Proteinuria < 125/75 mmHg 1998 Patients with DM < 130/85 mmHg 1999 Patients with DM < 130/80 mmHg

7. 7 When to Monitor? Every 2 – 4 months, Monitor: - BP - Glycated Hb On Annual Basis, Monitor: - Lipids (total chol, HDL, LDL & TG) - Microalbumin levels in Urine. Monitor Rest/Exercise ECG according to the case.

8. 8 With Glucose Control Risk Reduction for Secondary Complications 12%for any diabetes-related endpointp = 0.029 25%for microvascular endpointsp = 0.0099 16%for myocardial infarctionp = 0.052 24%for cataract extractionp = 0.046 21%for retinopathy at 12 yearsp = 0.015 33%for microalbulinuria at 12 yearsp = 0.000054

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17. 17 Metabolic Abnormalities in Diabetes: Lipid Problem Prevalence of elevated TC in general population: 44% 1 Hyperlipidemia = increased CHD risk in patients with diabetes 2 Coexistence of dyslipidemia, hyperuricemia, hypertension and glucose intolerance associated with 95% prevalence of insulin resistance 3 1.Maclean et al. Can J Cardio 1999: 434-444 2.Pyorala et al. Diabetes Care 1997 Apr;20(4):614-620 3.Bonara et al. Diabetes 1998; 47:1643-1649

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38. 38 Thiazolidinediones: Safety Considerations Edema – small number of patients CHF – rare, need to watch for signs of fluid retention Anemia – relates the hemodilution from fluid retention May cause ovulation to resume in anovulatory women Recently CAD

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42. 42 Hypertension in Diabetes: Pharmacological Agents Recommended first-line agents: Ace inhibitors ARBS Alpha-blockers CCB’s In elderly: low dose diuretics, beta-blockers

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