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Current Management Current Management of Diabetesof Diabetes

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

Aim

• having information on assessing symptoms and signs.

• developing management plans for diabetes.

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ObjectivesAt the end of this session, the trainees should be

able to:-

– list diagnostic criteria for DM– describe how to differentiate Type I & II DM– explain symptoms and signs of diabetes– discuss the evidence for lifestyle changes– describe the indications, contraindications, and

side effects of antidiabetic agents

DM in Saudi ArabiaDM in Saudi Arabia

Lifestyle Changes :

Social & cultural changes

Prevalence :• Diabetes mellitus as a health problem in Saudi

Arabia• prevalence of DM is 23.7 % according to Dr. Al

Nozha study (SMJ 2004)– 1 / 4 of adults > 30 yr are diabetics.

– 36 Foot Amputation / day, at Riyadh.

D.M in Saudi Arabia cont…..D.M in Saudi Arabia cont…..

Cost & Impacts .• Psychological impact.• Family & Social impact .• Decreased Productivity .• Sick leaves.• Work Absence .• Economical Costs .

Etiologicclassification

of

diabetesmellitus

II- Type 2 diabetes.

III- Other specific types.

IV- Gestational diabetes mellitus.

I- Type 1 diabetes:

Etiologic Classification of Diabetes Etiologic Classification of Diabetes MellitusMellitus

Type 1:Type 1: -cell destruction with lack of insulin .-cell destruction with lack of insulin . has absolute insulin deficiencyhas absolute insulin deficiency predisposed to develop ketoacidosispredisposed to develop ketoacidosis insulin is required for survival.insulin is required for survival.

Etiologic Classification of Etiologic Classification of Diabetes MellitusDiabetes Mellitus

Type 2Type 2 has relative insulin deficiency combined with has relative insulin deficiency combined with

defects in insulin action.defects in insulin action. is the most common form of diabetes, is the most common form of diabetes,

accounting for 90–95% of the diseaseaccounting for 90–95% of the disease is most often found in overweight individuals.is most often found in overweight individuals.

Narayan K, Boyle J, Thompson T, Sorensen S, Williamson D (2003). "Lifetime risk for diabetes mellitus in the United States". JAMA 290 (14): 1884–90. doi:10.1001/jama.290.14.1884.

Risk Factors for Type 2 DM

• Modifiable– Overweight and obesity– Sedentary lifestyle– Previously identified

IGT and IFG– Metabolic syndrome– Diatery factors– Intrauterine

environment– Inflamation 10

• Non- Modifiable– Family history– Age– Gender– History of GDM– Polycystic ovary

syndrome (PCO)

• Classical symptoms– Unusual thirst (Polydipsia)– Frequent urination (Polyuria)– Unusual weight loss

• Other symptoms– Extreme fatigue or lack of energy– Unusually hungry– Moody & irritable– Blurred vision– Have recurrent infections– Wounds and bruises that are slow to heal– Get a lot of yeast infections– Have tingling or numbness in the hands and/or feet

• Patients may present with a variety of symptoms or even symptomless

Symptoms & Signs

Criteria to diagnosis diabetesCriteria to diagnosis diabetes

• FPG FPG >>126 mg/dl (7.0 mmol/l) 126 mg/dl (7.0 mmol/l) ( Fasting is defined as no caloric intake for at least 8 h)) OROR

• Symptoms of diabetes and a casual plasma Symptoms of diabetes and a casual plasma

glucose glucose > > 200 mg/dl200 mg/dl ( (11.1 mmol/l) 11.1 mmol/l) OROR

• 2-h plasma glucose 2-h plasma glucose >> 200 mg/dl (11.1 mmol/l) 200 mg/dl (11.1 mmol/l)

during an OGTT. during an OGTT. ( The test should be performed as described by the W H O (using a glucose load

containing the equivalent of 75g anhydrous glucose dissolved in water)).

Diagnosis of Diabetes :Plasma Glucose Cutoff Points

.

FBS 2- Hour BS on OGTT

categories mg/ dl mg/dl

NormalNormal < 100< 100 < 140< 140

IFGIFG >> 100 and < 126 100 and < 126 __

IGTIGT __ >> 140 and < 200 140 and < 200

DiabetesDiabetes >> 126 126 >> 200 200

* If without symptoms, there should be more than one measurement in

order to diagnose.

Diagnosis of gestational DM

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First visit evaluation

History taking and clinical assessmentHistory taking and clinical assessment

Physical examination Physical examination • Height and weight measurement .

• Blood pressure determination .

• Fundoscopic examination

• Oral examination

• Thyroid palpation

• Cardiac examination

First visit evaluation

Physical examination Physical examination Abdominal examination (e.g., for hepatomegaly) Evaluation of pulses by palpation Hand/finger examination Foot examination Skin examination Neurological examination Signs of diseases that can cause secondary diabetes

(e.g., hemochromatosis, pancreatic disease)

First visit evaluation

Laboratory evaluationLaboratory evaluation• HBA1c

• Fasting lipid profile

• Test for microalbuminuria

• Serum creatinine in adults .

• Thyroid-stimulating hormone (if indicated)

• Electrocardiogram in adults (if indicated)

• Urinalysis for ketones and protein

Management Goals

Annual visits and examinations should be done regularly

Eliminate symptoms and improve well-being Prevent and retard microvascular complications

optimize glycemic control target blood pressure levels

Reduce macrovascular events optimize glycemic control target blood pressure levels target lipid levels

Summary of recommendations for adults with Diabetes

Parameter Target Value

• HbA1c < 7%

• pre-prandial plasma glucose 70 - 130 mg/dL• post-prandial plasma glucose < 180 mg/dL • Blood pressure < 130/80 mmHg • LDL- cholesterol < 100 mg/dL (<2.6 mmol/l) • HDL- cholesterol > 40 mg/dL (1 mmol/l) for men

> 50 mg/dL (1.3 mmol/l) for wom.

• Triglycerides < 150 mg/dL (17 mmol/l)

ADA 2009

Goals should be individualized based on:

● duration of diabetes

● pregnancy status

● age

● co-morbid conditions

● hypoglycemia unawareness

● individual patient considerations

Key concepts in setting glycemic goals

Follow up

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Things to keep in mind during management of Diabetes

Type 2: Deterioration of beta cells over time Increasing prevalence with increasing risk factors,

e.g obesity Hyperglycemia affects morbidity, mortality and

resources Tight glycemic control with insulin may reduce

costly complications 30% to 40% of patients ultimately require insulin

Non-pharmacologic Therapy for DM Lifestyle therapeutic modifications Diet

Improved food choices Spacing meals Individualized carbohydrate content Moderate calorie restriction

Exercise

improve blood glucose control

reduce cardiovascular risk factors

contribute to weight loss.

improve well-being..

Nutritional recommendations for DM patients

• Protein to provide 10-20% of kcal/day

• Saturated fat to provide < 10% of kcal/day (< 7 % for those with

elevated LDL).

• Polyunsaturated fat to provide < 10 % of kcal.

• Remaining calories to be divided between carbohydrate &

monounsaturated fat, based on medical needs & personal

tolerance.

• Use of caloric sweeteners is acceptable.

Considerations in Pharmacologic Treatment of Diabetes

• Complications/tolerability• Frequency of hypoglycemia• Compliance/complexity of regimen• Cost

SulfonylureasDrug Dose Side effects

TolbutamideRestinon®

500-2000mgOd-Bid

Weight gainhypoglycemia

Glibenclamide

Daonil ® 5mg

15-20 mgOd-Bid

Weight gainHypoglycemia

GliclazideDiamicron ® 80mg

40-320mgOd-Bid

Weight gainhypoglycemia

GlipizideMinidiab ® 5mg

2.5-20mgOd

Weight gainhypoglycemia

GlimerpirideAmaryl ® 1,2,4

mg

1-8mgOd

Weight gainhypoglycemia

Drug Dose Side

effectsDrug class

Metformin Glocophage

® 500-850mg

1000-2550mgBid-Tid

Diarrhea Lactic

acidosis

BiguanidesBiguanides↓ hepatic glucose

production

Acrobose

Glucobay ® 50-100 mg

150-300 mgTid

Gas , Abdominal

pain, Diarrhea

αα ––Glucosidase Glucosidase inhibitorsinhibitors

↓ intestinal absorption

Rosiglitazone

Avandia ® 2,4,8 mg

4-8mgOd-Bid

Oedema,weight

gain,hepatic failure

TThiazolidinedionhiazolidinedioneses

↑ preipheral glucose disposal

Repaglinide Novonorm ® 0.5,1,2 mg

1.5-16mgTid-Qid

Weight gainhypoglycemia

Meglitinides Meglitinides ↑ pancreatic insulin

secretion