1. TREAT TO TARGET IN DIABETES: An Alternative pathway
ASSOC PROF DR AZIZ AL-SAFI ISMAIL
Universiti Sains Malaysia
Kubang Kerian, Kelantan.

2. Main cause of death in hospital
Malaysia Total populations 26 million Lifespan 69.6 yrs Male, 74.5 yrs Female
Main cause of death in hospital
Heart disease
Septicaemia
Stroke
Motor-vehicle accident
Cancer

3. 5 leading cause of death (% of all deaths)SEAMIC 99
REGIONAL
5 leading cause of death (% of all deaths)SEAMIC 99
country
year 1 2 3 4 5
Malay
1997 HD MN
CrVD
MVA
SEPTI
BRUN
1998
B,E,A DM
INDO
1996
PERIN
I,PNE TB
JPN
SUIC
PHIL
1995
HPT
SING
THAI
VIET

4. RISK FACTORS
Reversible Irreversible
Diabetes
Smoking age
HPT sex - male
Hypercholesterolemia family history
Obesity DM
Sedentary life Personality type

5. Top Ten Countries for Estimated Number of Adult
with Diabetes, 1995 and 2025
-Diabetes Care 1998

6. CHRONIC COMPLICATIONS
Atherosclerosis
Diabetic eye disease
Diabetic nephropathy
Diabetic neuropathy
Foot ulceration and amputation

9. Prevalence of Diabetic complications in Malaysia National Diabetes Care Seminar 1998

10. In ideal situation Prebreakfast blood glucose 3.5 – 5.3 mmol/l
HbA1c <6.5%
>50% on diet control
BMI <25 kg/m2
Blood pressure <130/85 mmHg
Total cholesterol <5.2 mmol/l
HDL-cholesterol >1.1 mmol/l
Triglycerides <1.7 mmol/l 4

11. In reality Mean HbA1c 9 - 10%, 70-83% HbA1c >7.5%
% on either biguanide or sulphonylurea
Mean BMI kg/m2, 57 – 63% >25 kg/m2
Mean Sys Blood pressure 148 mmHg
Mean Dia Blood pressure 91 mmHg
Mean Total cholesterol 6 mmol/l
HDL-cholesterol 0.97 mmol/l
Mean Triglycerides 1.9 mmol/l 4

12. Microvascular complications Macrovascular complications
Progressive nature of type 2 diabetes: insulin deficiency due to beta-cell failure
IGT
Diabetes
Average 6.5
years
Insulin resistance
Endogenous insulin
Postprandial plasma glucose
Fasting plasma glucose
Normal
insulin
Plasma levels
Normal
blood
glucose
Microvascular complications
Macrovascular complications
Modified from graphic developed by the International Diabetes Center

13. Better Control Equals Reduced Risk of Complications
EVERY 1%
reduction in HBA1C
REDUCED RISK* 1%
Deaths from diabetes
-21%
Heart attacks
-14%
Microvascular complications
-37%
Better Control Equals Reduced Risk of Complications
The UKPDS has proven beyond doubt that intensive glycaemic control is strongly associated with real clinical benefits for patients with type 2 diabetes.
Every 1% decrease in HbA1C was associated with clinically important reductions in the incidence of
diabetes-related death ( 21%)
myocardial infarction ( 14%)
microvascular complications ( 37%)
peripheral vascular disease ( 43%)
There is no lower limit beyond which reductions in HbA1C cease to be of benefit.
Taking diabetes-related death as an example, this means that:
a reduction in HbA1C of 2% delivers a 42% reduction in risk
a reduction in HbA1C of 3% delivers a 63% reduction in risk
and so on.
Therefore, the greater the reduction in HbA1C, the greater the protection against complications.
Stratton MI Adler AI, Neil AW, Matthews DR, Manley SE, Cull CA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:
Peripheral vascular disorders
-43%
UKPDS 35. BMJ 2000; 321:
*p<0.0001

14. Treat to Target in Diabetes
BMI < 25 kg/m2
BP < 130/80mmHg
HbA1C < 6.5%
Fasting blood sugar mmol/l
Random blood sugar < 8.0 mmol/l
LDL-Chol < 2.6mmol/l

15. Treatment of Diabetes Slide 16
The classical approach to treating type 2 diabetes can be described as stepped management
The first step is to encourage the patient to reduce hyperglycemia through a combination of diet and exercise followed by support with an oral anti-diabetic agent in monotherapy
If glycemic control continues to deteriorate, additional oral agents are added in a step-wise fashion followed by insulin where necessary

16. ORAL HYPOGLYCAEMIC AGENTS
Sulfonilurea (Dimicron,daonil,amaryl)
Biguanid ( Metformin/ glucophage)
Meglitinide ( NOVONORM, STARLIX)
Glitazone (Avandia )
Acarbose (Glucobay)
Januvia
Galvus/ Galvusmet

17. THE USE OF HERBS ESULIN IN CONTROLLING BLOOD GLUCOSE AND LIPIDS IN POORLY CONTROL TYPE 2 DIABETES MELLITUS PATIENTS

18. ACTIVE INGREDIENTS RADIX OPHIOPOGON JAPONICUS 100MG
RHIZOMA ANEMARRHENA ASPHODELOIDES 40MG
RADIX REHMANNIA PREPARATA 120MG
RADIX GLEHNIA LITTORALIS 80MG
RHIZOMA DIOSCOREA OPPOSITA 60MG

19. METHODOLOGY
INCLUSION CRITERIA: KNOWN TYPE 2 DIABETES, POORLY CONTROLLED, MONOTHERAPY
EXCLUSION CRITERIA: RENAL FAILURE, MALIGNANCY
DURATION OF TREATMENT: 12 WEEKS
TREATMENT: + ESULIN 2 CAPS 2-3X/DAY

20. PATIENTS CHARACTERISTICS
PARTICULARS
MALE
(%)
FEMALE
TOTAL
No. of Patients 19
63.33 11
36.67 30
Mean Age (Year)
55.42 -
57.82
56.30
Mean Duration (Year)
10.4
8.0
9.7
PATIENTS CHARACTERISTICS

21. Characteristics
Before Rx (V1)
After Rx (V4)
Difference
P-value
HbA1c (Mean)
10.81
10.37
(0.44)
NS 

22. HbA1c REDUCTION IN SELECTED PATIENTSNO
HBA1c Visit 1
HbA1c Visit 4
HbA1c Changes
REDUCTION (%) 1
14.50
14.20
0.30
2.1 2
8.60
8.40
0.20
2.3 3
8.80
8.50
3.4 4
11.40
10.80
0.60
5.3 5
12.10
0.70
5.8 6
6.30
5.90
0.40
6.3 7 8
13.30
1.20
8.3 9
10.70
9.70
1.00
9.3 10
13.50
12.20
1.30
9.6 11
9.20
8.20
10.9 12
10.50
12.4 13
18.50
16.20
2.30 14
6.70
5.80
0.90
13.4 15 16
9.00
7.70
14.4 17
9.60
1.40
14.6 18
11.10
1.90
17.1 19
9.50
7.80
1.70
17.9 20
14.90
12.00
2.90
19.5 21
13.20
10.40
2.80
21.2 22
9.90
2.10

23. Characteristics Before Rx (V1) After Rx (V4) Difference P-value
Body Mas Index (BMI) (Mean)
24.84
24.64
(0.20)
NS 
Systolic BP (Mean)
139
133.52
(5.88)
Dystolic BP (Mean) 78
79.21
1.28
Total Cholesterol (Mean)
6.07
6.21
0.14
Triglycerides (Mean)
2.15
2.38
0.23
Low Density Lipoprotein (LDL) (Mean)
3.63
3.67
0.04
High Density Lipoprotein (HDL) (Mean)
1.43
1.34
(0.09)
Creatinine (Mean)
127.30
143.57
16.27

24. THE EFFECT OF TREATMENT
No of Patients V1 V4
HbA1c < 6.5% 2 3
Low Density Lipoprotein ( LDL < 2.6 ) 5 6
Triglycerides < 1.7 13 9
Systolic BP < 130 11
Dystolic BP < 80 17 16 24

25. ADVERSE EVENTS – 14 (46.67%) Loose Stool – 10 Hot Flush – 1
Muscle ache – 2
Headache - 1

26. DISCUSSIONS
ANIMAL STUDIES: IMPROVE IN PANCREATIC TISSUE AND NUMBER OF BETA CELLS, INCREASE IN INSULIN RECEPTOR
INCREASE INSULIN SENSITIVITY
COMBINATION TREATMENT: WITH OHA AND INSULIN WILL GIVE BEST RESULTS

27. Treat to Target in Diabetes
BMI < 25 kg/m2
BP < 130/80mmHg
HbA1C < 6.5%
Fasting blood sugar mmol/l
Random blood sugar < 8.0 mmol/l
LDL-Chol < 2.6mmol/l

28. Thank you