Diabetes mellitus
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  • 1. Management of diabetes mellitus ((ADA Guidelines Dr. Faisal Al Hadad Consultant of Family Medicine & Occupational Health PSMMC
  • 2. Introduction  DM is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both  DM is a common health problem in Saudi Arabia  The overall prevalence of DM in adults in KSA is 23.7% according to Al Nozha et al (Saudi Med J 2004; Vol. 25 (11): 1603-1610)
  • 3. Criteria for the diagnosis of diabetes 1. Classic symptoms of diabetes and a casual plasma glucose ≥200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. 2. FPG≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h. 3. 2-h plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water. *Each (1, 2 and 3) must be confirmed on a subsequent day
  • 4. IFG/IGT  Recently, IFG and IGT have been officially termed “prediabetes.”  IFG and IGT are risk factors for future diabetes and CVD.  IFG = FPG 100-125 mg/dl (5.6-6.9 mmol/l) ● IGT = 2-h plasma glucose 140-199 mg/dl (7.8-11.0 mmol/l) * These criteria should be confirmed by repeat testing on a different day.
  • 5. Gestational DM Diagnostic criteria for the 100-g OGTT are as follows:      ≥95 mg/dl fasting ≥180 mg/dl at 1 h ≥155 mg/dl at 2 h ≥140 mg/dl at 3 h Two or more values must be met or exceeded for a positive diagnosis. OGTT should be done in the morning after an overnight fast of 8–14 h.
  • 6. Self-monitoring of blood glucose  SMBG should be carried out three or more times daily for patients using multiple insulin injections. ● For patients using less frequent insulin injections or oral agents or medical nutrition therapy alone, SMBG is useful in achieving glycemic goals. ● Instruct the patient in SMBG and routinely evaluate the patient’s technique and ability to use data to adjust therapy.
  • 7. Glycemic goals ● Perform the A1C test at least two times a year in patients who are meeting glycemic goals and quarterly in patients whose therapy has changed or who are not meeting glycemic goals. ● The A1C goal for patients in general is an A1C goal of <7%. ● The A1C goal for the individual patient is an A1C as close to normal (<6%) as possible without significant hypoglycemia. ● Less strict treatment goals (A1C <7%) may be appropriate for patients with a history of severe hypoglycemia, patients with limited life expectancies, very young children or older adults, and individuals with comorbid conditions.
  • 8. Management  Medical Nutrition Therapy (MNT)  Oral hypoglycemic agents  Insulin therapy  Prevention of diabetes complications (e.g. aspirin, statin, ACEI or ARB)
  • 9. Medical Nutrition Therapy  Weight loss is recommended for all overweight or obese individuals who have diabetes.  Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss.  Low-fat diets  Low-carbohydrate diets
  • 10. Sulfonylureas Drug Dose Tolbutamide ® Restinon 500-2000mg OD-BID Glibenclamide mg 15-20 OD-BID Daonil ® 5mg Gliclazide Diamicron ® 80mg 40-320mg OD-BID Glipizide Minidiab ® 5mg 2.5-20mg OD Glimerpiride Amaryl ® 1,2,4 mg 1-8mg OD Side effects Weight gain hypoglycemia
  • 11. Drug Dose Side effects Drug class Metformin ® Glocophage 500-850mg 1000-2550mg BID-TID Dyspepsia, diarrhea, lactic acidosis Biguanides mg 150-300 TID Gas, abdominal pain, diarrhea α –Glucosidase inhibitors 4-8mg OD-BID Oedema, weight gain, hepatic failure 1.5-16mg TID-QID Weight gain hypoglycemia Acrobose ® Glucobay mg 50-100 Rosiglitazone Avandia ® 2,4,8 mg Repaglinide Novonorm ® 0.5,1,2 mg Thiazolidinediones Meglitinides
  • 12. HTN and DM  BP should be measured at every routine diabetes visit. Patients found to have systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg should have BP confirmed on a separate day.  Patients with a systolic BP of 130–139 mmHg or a diastolic BP of 80–89 mmHg should be given lifestyle and behavioral therapy alone for a maximum of 3 months and then, if targets are not achieved, in addition, be treated with ACEI or ARB.  Patients with hypertension (systolic BP ≥140 or diastolic BP ≥90 mmHg) should receive drug therapy (ACEI/ARB± thiazide diuretic) in addition to lifestyle and behavioral therapy.
  • 13. Dyslipidemia and DM ● In adult patients, test for lipid disorders at least annually.  In adults with low-risk lipid values (LDL<100 mg/dl, HDL >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years. ● Lifestyle modification (reduction of fat and cholesterol intake, weight loss and increased physical activity) has been shown to improve the lipid profile in patients with diabetes.
  • 14. Dyslipidemia and DM In individuals without overt CVD ● The primary goal is an LDL <100 mg/dl (2.6 mmol/l). ● > 40 years, statin therapy is recommended. ● < 40 years but at increased risk of CVD who do not achieve lipid goals with lifestyle modifications alone, the addition of statin therapy is appropriate. In individuals with overt CVD ● All patients should be treated with a statin. ● A lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option.
  • 15. Dyslipidemia and DM  Lower TG to<150 mg/dl (1.7 mmol/l).  Raise HDL cholesterol to >40 mg/dl (1.0 mmol/l) in men and >50 mg/dl (1.25 mmol/l) in women. ● Combination therapy using statins and other lipid-lowering agents may be necessary to achieve lipid targets. ● Statin therapy is contraindicated in pregnancy.
  • 16. Antiplatelet agents  As a secondary prevention strategy in those with diabetes with a history of CVD.  As a primary prevention strategy in those with diabetes and at increased CV risk (> 40 years of age or additional risk factors)  Combination therapy using other antiplatelet agents such as clopidrogel in addition to aspirin should be used in patients with severe and progressive CVD.
  • 17. Diabetic Nephropathy ● To reduce the risk and/or slow the progression of nephropathy, optimize glucose control and BP control. ● Perform an annual test for the presence of microalbuminuria in type 1 diabetic patients with diabetes duration of ≥5 years and in all type 2 diabetic patients, starting at diagnosis and during pregnancy.  In the treatment of both micro- and macroalbuminuria, either ACEI or ARBs should be used except during pregnancy.
  • 18. Diabetic Nephropathy  Serum creatinine should be measured at least annually for the estimation of GFR in all adults with diabetes regardless of the degree of urine albumin excretion  Consider referral to a physician experienced in the care of diabetic renal disease when the estimated GFR has fallen to <60 ml/min per 1.73 m2. ● Reduction of protein intake is recommended
  • 19. Diabetic retinopathy  Optimal glycemic and BP control can substantially reduce the risk and progression of Diabetic retinopathy .  Annual comprehensive eye examination by an ophthalmologist is recommended in type 1 diabetic patients with diabetes duration of ≥5 years and in all type 2 diabetic patients. ● Women who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and should be counseled on the risk of development and/or progression of diabetic retinopathy.
  • 20. Diabetic neuropathy ● All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests. ● Once the diagnosis of DPN is established, special foot care is appropriate for insensate feet to decrease the risk of amputation. ● Simple inspection of insensate feet should be performed at 3to 6-month intervals. An abnormality should trigger referral for special footwear, preventive specialist, or podiatric care.
  • 21. Thank you