Management of a New Diabetes Patient

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This is a presentation describing the management principles of a newly diagnosed diabetic patient, including, diet therapy, medical treatment and exercise

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Management of a New Diabetes Patient

  1. 1. Dr. S. Aswini Kumar. MD<br />Professor of Medicine<br />Medical College Hospital<br />Thiruvananthapuram<br />1<br />Management of Newly<br />Detected Diabetes<br />
  2. 2. Learning Objectives <br />Importance<br />Diagnosis<br />Diet<br />Exercise<br />OHAs<br />Insulin<br />What is new<br />Summarize<br />2<br />
  3. 3. importance<br />3<br />
  4. 4. Diabetes Mellitus<br />Pancreatic insulin deficiency state<br />Poor cells of the body crying for more insulin<br />4<br />
  5. 5. The Role of Insulin<br />Insulin is the key that opens the door of the cell<br />Without insulin glucose can not enter the cells<br />5<br />
  6. 6. Types of Diabetes<br />6<br />IDDM<br />&lt;10%<br />&gt;90%<br />NIDDM<br />
  7. 7. Type 2 Diabetes<br />It’s a Nightmare!<br /> Chronic <br />Kidney Disease<br />Peripheral <br />Occlusive <br />Vascular <br />Disease<br />Autonomic<br />Neuropathy <br />Stroke<br />Sudden<br />Blindness<br />Heart Attack<br />Peripheral <br />Neuropathy <br />7<br />Aswini Kumar. MD<br />7<br />Microvascular and Macrovascular Complications of Diabetes<br />
  8. 8. Why control diabetes?<br />Tight control of DM and maintaining blood sugar values within normal range has proved to prevent long term micro-vascular and macro-vascular complications of diabetes<br />8<br />
  9. 9. Symptoms of diabetes<br />Polyuria<br />Polydypsia<br />Polyphagia<br />Weight loss in spite of adequate food<br />Tingling and numbness in extremities<br />Generalized pruritus<br />Pruritus vulva, Balanoposthitis<br />Impotency, loss of libido <br />Premature cataract<br />9<br />
  10. 10. Diagnosis of Diabetes<br />MUST <br />be based on blood glucose estimation<br />NOT <br />urine glucose testing<br />Fasting venous glucose &gt; 126mg% (Normal 70-110)<br />2Hr PP venous glucose &gt; 200mg% (Normal 110-140)<br />RBS value not diagnostic<br />To be confirmed on repeat testing with FBS PPBS<br />In presence of symptoms of DM - diagnostic<br />GTT is not needed in a confirmed diabetic<br />10<br />
  11. 11. Monitoring Glycemic Control<br />Urine sugar testing<br />Widely used. Depends on renal threshold<br />Of value if threshold is normal & stable<br />What if the urine sugar is absent?<br />What if the urine sugar is high?<br />Blood sugar estimation:<br />Gives prevailing blood glucose<br />Does not assess the overall control<br />Periodic check up necessary- monthly<br />Diet and medicines should be continued on the day<br />11<br />
  12. 12. Self Monitoring of Blood Glucose<br />SMBG using test strips<br />AcucheckActiva<br />Use within a month<br />Costs 30 rupees per strip<br />Accuracy question<br />Indications:<br />Wide fluctuations<br />Proneness for ketosis<br />Need for tight control - pregnancy<br />Acute illness: peri-operative period<br />12<br />
  13. 13. Hb A1c<br />Excellent test to judge overall glycemic control<br />Gives idea of average blood sugar <br />Over a period of previous 120 days<br />Because RBC Life Span is 121 days<br />Ideally done every 3-4 months<br />Normal &lt; 6.5 Good &lt;7.0 Fair &lt;8.0 Poor&lt;9.0 Bad &gt;10<br />Disadvantages:<br />Costly – Rs. 250 per test <br />Falsely high values – Renal failure<br />Falsely low values – RBC life span<br />13<br />
  14. 14. What are the goals?<br />ADA and ACE/ AACE differ from each other<br />ADA Goals<br />FBS - 70-130 <br />PPBS - &lt;180<br />HbA1c - &lt;7.0<br />ACE/AACE Goals<br />FBS - &lt;110<br />PPBS - &lt;140<br />HbA1c - ≤6.5<br />14<br />
  15. 15. diet<br />15<br />
  16. 16. Medical Nutrition Therapy<br /> Dietprescription<br /> Main stay of treatment<br />Shall be individualized,<br /> realistic<br /> flexible &<br /> suitable to patients life style<br /> preferably Indian diet<br />Patient educatedand at regular <br /> intervals compliance judged<br />16<br />
  17. 17. Weight Management<br />17<br /><ul><li>Record height - Record weight - Calculate BMI
  18. 18. Read against ready made charts – To get BMI
  19. 19. Healthy value 20-25
  20. 20. Above 25 – Overweight
  21. 21. Above 30 – Obese</li></ul>.<br />
  22. 22. Diet Control<br />Principle less food – <br />Better insulin action<br />No sugars sweets tubers <br />Otherwise eat normal food<br />18<br />
  23. 23. Which Food To Avoid<br />19<br />
  24. 24. Avoid all fried foods<br />20<br />
  25. 25. What for Breakfast?<br />2 idli or 2 Dosa or ½ Puttu No Appam or Poori masala<br />Western Style Breakfast Tea, Milk and Eggs<br />21<br />
  26. 26. What is for lunch?<br />Ordinary Indian meals It is the ideal choice<br />Fish 2-3 pieces everyday Chicken once a week<br />22<br />
  27. 27. Which Fruit To Eat?<br />23<br />
  28. 28. What for Evening and Dinner?<br />3 Arrow root biscuits Tea with out sugar<br />Green Salad 2 Chappathi + Veg Kuruma<br />24<br />
  29. 29. exercise<br />25<br />
  30. 30. 26<br />
  31. 31. 27<br />
  32. 32. 28<br />
  33. 33. Caloric equivalents:<br />29<br />
  34. 34. Exercise<br />Regular Exercise<br />Daily at least 5 days/wk <br />Isotonic Exercise - Yes<br />Isometric - No<br />30<br />
  35. 35. What prevents one from Walking<br />Traffic, heavy rain or dogs on the street<br />Choose Vellayambalam Museum or Gandhi Park<br />31<br />
  36. 36. Precautions<br />Correct foot wear<br />Comfortable loose clothes<br />Close inspection of feet every day<br />Carry snacks as protection from hypoglycemia<br />How it should be:<br />Patient should be able to carry out a normal conversation while exercising without getting breathless<br />32<br />
  37. 37. Physique Exercise Treadmill<br />33<br />
  38. 38. DruG treatment<br />34<br />
  39. 39. 35<br />Causes of Hyperglycemia in DM<br />1 Intestine: glucose absorption<br />2 Muscle and adipose tissue:decreased glucose uptake<br />5 Insulin resistance<br />Blood glucose<br />4 Liver: increased hepaticglucose output<br />5 Insulinresistance<br />3 Pancreas: impaired insulin <br />secretion<br />
  40. 40. Biguanides<br />Mode Of Action:<br />Decreases hepatic glucose production<br />Increases peripheral glucose uptake<br />Increases insulin sensitivity<br />No effect on insulin release<br />Does not cause hypoglycemia<br />First line choice in DM2 – <br />Ideal in over weight<br />Metformin 250 to 1500mg <br />Phenformin no longer used<br />36<br />
  41. 41. Sulphonylureas<br />Stimulates Pancreatic B cells to produce MORE<br />Second line choice after Metformin <br />First line in lean diabetics<br />Most effective in Type 2 DM of recent onset<br />Glibenglamide 2.5 to 10mg<br />Glipizide2.5 to 10mg<br />Glipride 1 to 4mg <br />Glyclazide 40 to160mg<br />37<br />
  42. 42. Thiazolidinediones<br />Add on druguseful for reducing PPBS<br />Reduce insulin resistance by binding to PPAR receptor<br />Facilitates insulin’s effect on GLUT-4<br />Promote adipocyte differentiation<br />Enhance fatty acid storage<br />Pioglitazone 15-30mg OD <br />Rosiglitazone 2-4mg OD<br />Modest weight gain <br />Fluid retention, edema <br />SGPT screening is advisable<br />38<br />
  43. 43.  Glucosidase Inhibitors<br />For Big Eaters who can’t stop eating<br />MOA: inhibition of pancreatic alpha amylase in the gut lumen which hydrolyses complex starches to oligosaccharides.<br />Delay absorption, when taken with meals <br />Thus reduces PPBS<br />Do not influence insulin secretion<br />Do not affect glucose utilization<br />Acarbose 25-50mg BID <br />Voglibose 0.2 -0.3mg BID<br />39<br />
  44. 44. Role of Incretins in Glucose Homoeostasis<br />Blood glucose in fasting and postprandial states<br />Glucose production by liver<br />Ingestion of food<br />Glucose-dependent Insulin from β cells<br />(GLP-1 and GIP)<br />Glucose uptake by muscles<br />Release of gut hormones — incretins*<br />Pancreas<br />GI tract<br />β cells<br />α cells<br />Active<br />GLP-1 & GIP<br />Glucose dependent<br /> Glucagon fromα cells<br />(GLP-1)<br />DPP-4 enzyme<br />InactiveGIP<br />InactiveGLP-1<br />*Incretins are also released throughout the day at basal levels.<br />40<br />
  45. 45. DPP-4 Inhibitors<br />New class of oral agents<br />Increase endogenous GLP-1 activity<br />Promote insulin secretion<br />Preferential effect on PPBS<br />FDA approved first molecule<br />Sitagliptin – For use with diet and exercise<br />Or with metformin or thiozolidinediones<br />41<br />
  46. 46. Sitagliptin in clinical practice<br />Dose: 100mg orally once daily<br />Reduced dose<br />Creatinine clearance 30-50ml/min – 50mg/day<br />Creatinine clearance &lt;30ml/min – 25mg /day<br />RFT done initially and repeated there after<br />42<br />
  47. 47. Oral Hypoglycemic Agents<br />43<br />
  48. 48. 44<br />
  49. 49. 45<br />Intensifying of Oral Therapies<br />metformin &/or glitazone<br />sulfonylurea/repaglinide<br />+<br />&/or glucosidase inh<br />sulfonylurea/repaglinide<br />+<br />and/or glucosidase inhibitors<br />metformin and/or glitazone<br />FPG &lt; 120 mg/dl A1C &lt; 6.5%<br />FPG &gt; 120 mg/dl A1C &gt;6.5%<br />Continue<br />Add Insulin<br />
  50. 50. Insulin<br />46<br />
  51. 51. 47<br />
  52. 52. 48<br />
  53. 53. 49<br />Insulin secretion<br />Years from <br />diagnosis<br />0<br />10<br />5<br />15<br />-10<br />-5<br />Onset<br />Diagnosis<br />Insulin resistance<br />Postprandial glucose<br />Fasting glucose<br />Microvascular complications<br />Macrovascular complications<br />Pre-diabetes<br />Type 2 diabetes<br />
  54. 54. 50<br />
  55. 55. 51<br />Hyperglycaemia<br />(glucose toxicity)<br />Insulin resistance<br />b-cell<br />(genetic background)<br />“lipotoxicity”<br />elevated FFA,TG<br />Protein<br />glycation<br />Amyloid<br />deposition<br />
  56. 56. 52<br />
  57. 57. 53<br />
  58. 58. Insulin analogues<br />54<br />
  59. 59. 55<br />Short acting <br />Insulin Lispro and aspart<br />Long acting <br />Insulin Glargine and Detemir<br />Full biological activity<br />Less tendency for self aggregation<br />
  60. 60. 56<br />
  61. 61. 57<br />Peak Time = 40-50 min<br />Peak Time = 80-120 min<br /> InsulinAspart or<br />Lispro<br />Subcutaneous Tissue<br />CapillaryMembrane<br />RegularHuman <br />Insulin<br />
  62. 62. C14 fatty acid chain (Myristicacid)<br />Phe<br />Gly<br />Phe<br />Arg<br />Glu<br />Tyr<br />Thr<br />Gly<br />Pro<br />Cys<br />Lys<br />Val<br />Thr<br />Lys<br />Cys<br />Asn<br />A21<br />B29<br />Leu<br />Tyr<br />Gly<br />A1<br />Asn<br />Tyr<br />Ile<br />Glu<br />Leu<br />Val<br />Leu<br />Ala<br />Glu<br />Glu<br />Gln<br />Gln<br />Tyr<br />Val<br />Cys<br />Leu<br />Leu<br />Cys<br />Ser<br />Ser<br />Thr<br />Cys<br />Ile<br />His<br />Ser<br />Gly<br />Cys<br />Leu<br />Gln<br />His<br />Asn<br />Val<br />Phe<br />B1<br />58<br />
  63. 63. 59<br />
  64. 64. 60<br />
  65. 65. Guidelines<br />61<br />
  66. 66. 62<br />Metformin<br />Sulfonylureas<br />TZDs <br />Other oral agents <br />Insulin<br />Lifestyle only<br />60%<br />45%<br />15%<br />6%<br />12%<br />15%<br />Patients currently taking medication (%)<br />
  67. 67. 63<br />A1C &lt; 9%<br />A1C ≥ 9%<br />Initiate insulin<br />2 oral agents<br />1 oral agent<br />If not at target<br />If not at target<br />If not at target<br /> Add an oral agent <br />ORInitiate insulin alone or in combination with an oral agent <br />Intensify insulin ORadd an oral agent<br />Add insulin ORan oral agent<br />Timely adjustments of chosen therapy shall made to attain target A1C within 6 to 12 months.<br />Adapted from the CDA 2003 Clinical Practice Guidelines.<br />
  68. 68. 64<br />
  69. 69. What is new<br />65<br />
  70. 70. 66<br />
  71. 71. 67<br />75<br />Basal <br />exogenous insulin is essential for regulating glycogen breakdown, gluconeogenesis lipolysis and ketogenesis<br />For normal glucose utilization and storage<br />Breakfast<br />Lunch<br />Dinner<br />50<br />Plasma insulin (µU/ml) <br />25<br />4:00<br />8:00<br />12:00<br />16:00<br />20:00 <br />24:00<br />4:00<br />Time<br />
  72. 72. 68<br />Impressive benefits<br />Breakfast<br />Lunch<br />Dinner<br />Aspart Aspart Aspart<br />or<br />or<br />or<br />Personal financial cost<br />Lispro Lispro Lispro<br />Plasma insulin<br />Detemir or Glargine<br />4:00<br />16:00<br />20:00 <br />24:00<br />4:00<br />12:00<br />8:00<br />8:00<br />Time<br />
  73. 73. 69<br />
  74. 74. 70<br />
  75. 75. 71<br />
  76. 76. 72<br />
  77. 77. 73<br />
  78. 78. Thank You <br />For The <br />Patient Listening<br />74<br />

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