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What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
What is new in Diabetes
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What is new in Diabetes

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  • Reference: Report of a WHO Consultation: Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes mellitus. Available at http://whqlibdoc.who.int/hq/1999/WHO_NCD_NCS_99.2.pdf . Accessed 4 December, 2004.
  • In 1998, the World Health Organization predicted that by 2025, diabetes cases in adults would have more than doubled globally from 1997 figures. Dietary and other lifestyle factors were predicted to cause an increase from 143 million in 1997 to 300 million. 1 Around 90% of these cases will be due to type 2 diabetes. 2 King et al. 3 estimated the prevalence of diabetes and the number of individuals with diabetes who are > 20 years of age in all countries of the world for three points in time (1995, 2000 and 2025). The major portion of the numerical increase in diabetes is predicted to occur in developing countries. There will be a 42% increase, from 51 to 72 million, in developed countries and a 170% increase, from 84 to 228 million, in developing countries. 3 More recently, the WHO has updated these figures, giving a total worldwide prevalence of diabetes as 177 million in 2000, and a prediction that this will rise to 370 million in 2030. 4 1. World Health Organization. The World Health Report: Life in the 21st century, a vision for all. Geneva: WHO, 1998. 2. World Health Organization. The World Health Report: Conquering suffering, enriching humanity. Geneva: WHO, 1997. 3. King H, et al . Diabetes Care 1997; 21 :1414–1431. 4 . http://www.who.int/diabetes/facts/world_figures/en/
  • In 1998, the World Health Organization predicted that by 2025, diabetes cases in adults would have more than doubled globally from 1997 figures. Dietary and other lifestyle factors were predicted to cause an increase from 143 million in 1997 to 300 million. 1 Around 90% of these cases will be due to type 2 diabetes. 2 King et al. 3 estimated the prevalence of diabetes and the number of individuals with diabetes who are > 20 years of age in all countries of the world for three points in time (1995, 2000 and 2025). The major portion of the numerical increase in diabetes is predicted to occur in developing countries. There will be a 42% increase, from 51 to 72 million, in developed countries and a 170% increase, from 84 to 228 million, in developing countries. 3 More recently, the WHO has updated these figures, giving a total worldwide prevalence of diabetes as 177 million in 2000, and a prediction that this will rise to 370 million in 2030. 4 1. World Health Organization. The World Health Report: Life in the 21st century, a vision for all. Geneva: WHO, 1998. 2. World Health Organization. The World Health Report: Conquering suffering, enriching humanity. Geneva: WHO, 1997. 3. King H, et al . Diabetes Care 1997; 21 :1414–1431. 4 . http://www.who.int/diabetes/facts/world_figures/en/
  • Transcript

    • 1. What is new in DM? Nagwa Eid Sobhy Head of FM Department Cairo University
    • 2. World Health Organization’s (WHO) definition of diabetes mellitus• A metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both
    • 3. Global Perspective• Diabetes is the 4th or 5th leading cause of death in most developed countries• Epidemic in developing countries
    • 4. Worldwide prevalence of diabetes in 2000Number of persons < 5,000 5,000–74,000 75,000–349,000 350,000–1,499,000 1,500,000–4,999,000 > 5,000,000 No data available World Health Organization, 2003 http://www.who.int/diabetes/facts/world_figures/en/ (accessed September 2004).
    • 5. Worldwide prevalence of diabetes in 2030 (projected)Number of persons < 5,000 5,000–74,000 75,000–349,000 350,000–1,499,000 1,500,000–4,999,000 > 5,000,000 No data available Total cases > 370 million adults World Health Organization, 2003 http://www.who.int/diabetes/facts/world_figures/en/ (accessed September 2004).
    • 6. Classification of diabetes mellitus• Type I DM• Type 2 DM:90%• gestational diabetes• Others
    • 7. Other types of diabetes mellitus• Gestational diabetes (GDM)• Maturity Onset Diabetes of the Young (MODY)• Latent Autoimmune Diabetes of Adulthood (LADA)• Secondary to other conditions. Ex: exocrine pancreas disease, endocrinopathies, infections• Drug-induced (ex: corticosteroids) hyperglycemia
    • 8. LADA - Latent Autoimmune Diabetes of Adulthood• These patients have immune markers of type 1 but do not require insulin initially• usually progress to require insulin therapy• Also called slowly progressing type 1 or type 1.5• Sometimes mistakenly diagnosed as type 2
    • 9. MODY – Mature Onset Diabetes of the Young• Genetic defects of β cell function which results in diabetes at an early age• Characterised by impaired insulin secretion without insulin resistance• The term MODY should not be used to describe the increasingly occurring type 2 in children and adolescents
    • 10. Drug or chemical induced DM:• Nicotinic acid• Glucocorticoids• Thyroid hormone• Alpha-adrenergic agonists• Beta- adrenergic agonists• Thiazides
    • 11. Current criteria for the diagnosis of diabetes1. A1C 6.5%2. FPG126 mg/dl: Fasting is defined as no caloric intake for at least 8 h.3. 2-h plasma glucose 200 mg/dl: using 75 g anhydrous glucose dissolved in water.4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis: a random plasma glucose 200 mg/dlN.B.: 1,2 &3 test must be repeated in another day
    • 12. Primary prevention of diabetesAmong individuals at high risk for developing type 2 diabetes, structured programs emphasizing lifestyle changes including:• moderate weight loss (7% body weight)• regular physical activity (150 min/week)• dietary strategies including reduced calories, reduced intake of dietary fat & ↑dietary fiber (14 g fiber/1,000 kcal) and foods whole grains (one- half of grain intake)
    • 13. Primary Prevention of DM● In addition to lifestyle counseling, metformin may be considered in those who are at very high risk for developing diabetes:Combined IFG and IGT plus other risk factors such as: A1C 6%, hypertension, low HDL cholesterol, elevated triglycerides, or family history of diabetes in a first-degree relativeObese and under 60 years of age.
    • 14. Testing for type 2 diabetes in asymptomatic childrenOverweight:• BMI 85th percentile for age and sex• weight for height 85th percentile• weight 120% of ideal for heightPlus any two of the following risk factors:
    • 15. Testing for type 2 diabetes in asymptomatic childrenPlus any two of the following risk factors:● Family history of type 2 diabetes in first- or second-degree relative● Race/ethnicity● Signs of insulin resistance or conditions associated with insulin● Maternal history of diabetes or GDM during the child’s gestation
    • 16. Testing for type 2 diabetes in asymptomatic children● Race/ethnicity:Native AmericanAfrican AmericanLatinoAsian AmericanPacific Islander
    • 17. Testing for type 2 diabetes in asymptomatic children● Conditions associated with insulin resistance:Acanthosis nigricansHypertensionDyslipidemiaPolycystic ovary syndromeSmall for gestational age birthweight
    • 18. Testing for type 2 diabetes in asymptomatic childrenAge of initiation:Age 10 years or at onset of puberty, if puberty occurs at a younger ageFrequency:Every 3 years
    • 19. To Meet Care Objectives1. Routinely prescribe regular exercise and moderate weight loss for all overweight adults.2. Identify all patients with diabetes in the practice by testing those aged 40+ q3years.3. Maintain an office registry.4. Use a flow sheet for each patient with diabetes.5. Use a recall system for regular visits.6. Review patient records to ensure care objectives are being met.7. Prearrange testing performed regularly, e.g., A1C q3months.
    • 20. Lifestyle modification-Engaging in regular physical activity- Healthy eating habits- Achieving and maintaining a healthy weight- Stopping smoking
    • 21. Physical activity● People with diabetes should be advised to perform at least 150 min/week of moderate- intensity aerobic physical activity (50–70% of maximum heart rate).● In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week.
    • 22. The benefits of physical activity include:• reduction of blood glucose levels• reduction of blood pressure levels• reduction of cholesterol levels• reduction of cardiovascular risks for heart attack and stroke• reduction of stress• improved muscle tone, including heart muscle• improved bone strength• improved flexibility• improved blood circulation• induce weight loss.
    • 23. Medical nutrition therapy• Individuals who have pre-diabetes or diabetes should receive individualized medical nutrition therapy (MNT) as needed to achieve treatment goals• MNT can result in cost-savings and improved outcomes
    • 24. Energy balance, overweight and obesity● In overweight and obese insulin resistant individuals, modest weight loss has been shown to reduce insulin resistance.● For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short-term (up to 1 year).● Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss.
    • 25. Energy balance, overweight and obesity● For patients on low-carbohydrate diets, monitor:• lipid profiles• renal function• protein intake (in those with nephropathy)• adjust hypoglycemic therapy as needed.
    • 26. Dietary fat intake in diabetes● Saturated fat intake should be 7% of total calories.
    • 27. Carbohydrate intake in diabetes● For individuals with diabetes, the use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone.
    • 28. Other nutrition recommendations● Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the Food and Drug Administration.● Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety.
    • 29. Other nutrition recommendations● Benefit from chromium supplementation in people with diabetes or obesity has not been conclusively demonstrated and, therefore, cannot be recommended.● Individualized meal planning should include optimization of food choices to meet recommended dietary allowances (RDAs)/dietary reference intakes (DRIs) for all micronutrients.
    • 30. Bariatric surgery● Bariatric surgery should be considered for adults with BMI 35 kg/m2 and type 2 diabetes, especially if the diabetes or associated co morbidities are difficult to control with lifestyle and pharmacologic therapy.● Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and medical monitoring.
    • 31. Bariatric surgery● Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI of 30–35 kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI < 35 kg/m2 outside of a research protocol.
    • 32. Diabetes self-management education● People with diabetes should receive diabetes self-management education (DSME) according to national standards when their diabetes is diagnosed and as needed thereafter.● Effective self-management and quality of life are the key outcomes of DSME and should be measured and monitored as part of care.● DSME should address psychosocial issues, since emotional well-being is associated with positive diabetes outcomes.
    • 33. Smoking cessation● Advise all patients not to smoke.● Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care
    • 34. Immunization● Annually provide an influenza vaccine to all diabetic patients 6 months of age.● Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥ 2 years of age.A one-time revaccination is recommended for individuals > 64 years of age previously immunized when they were < 65 years of age if the vaccine was administered > 5 years ago.
    • 35.  Other indications for repeat pneumococcal polysaccharide vaccination Include:nephrotic syndromechronic renal diseaseother immuno-compromised states, such as after transplantation.
    • 36. Insulin
    • 37. analogsLispro Humalog/Eli LillyAspart Novolog/Novo NordiskGlulisine Apidra/sanofi-aventisLong-acting analogsGlargine Lantus/sanofi-aventisDetemir Levemir/Novo NordiskPremixed analogs75% neutral protamine lispro, 25% lispro75/25 Humalog/Eli Lilly50% neutral protamine lispro, 50% lispro50/50 Humalog/Eli Lilly70% protamine aspart, 30% aspart 70/30 Novolog/Novo Nordisk
    • 38. Potential strategy for insulin initiation andadvancement:1. Start 10 units NPH, glargine or detemir at bedtime2. Continue metformin. Stop all other antihyperglycemic medications.3. Have patient check daily FBG4. Increase insulin doses5. If A1C meets goal (usually <7%), continue with single daily injection of insulin6. If A1C is above goal, and FBG has been > 100–120 mg/dL for at least 2 months, →
    • 39. 6. If A1C is above goal, and FBG has been > 100–120 mg/dL for at least 2 months:a.patient check BG before breakfast, lunch,dinner, and bedtimeb.Initiate 1–3 additional insulin injections per day,according to the following:• if pre-lunch BG is above 180 mg/dL, add pre-breakfast insulin aspart, lispro or glulisine• if pre-dinner BG is above 180 mg/dL, add pre-lunch insulin aspart, lispro or glulisine• if pre-bedtime BG is above 180 mg/dL, add pre-dinner insulin aspart, lispro or glulisine
    • 40. Oral Hypoglycemic
    • 41. Class Primary mechanism of actionBiguanides Decrease glucose production (liver)Sulfonylureas Increase insulin secretion (pancreas)Glinides Increase insulin secretion (pancreas)Thiazolidinediones Increase glucose uptake (muscle, fat)α-Glucosidase Delay carbohydrate absorption (gut)inhibitorsGliptins Prolong effects of GLP-1 (↑ insulin, ↓glucagon)GLP-1 analogs Similar effects as GLP-1 (↑insulin, ↓glucagon, ↑satiety, delays gastric emptying)Amylin analogs Similar effects as amylin ( glucagon, satiety, delays gastric emptying)
    • 42. Effectiveness of agents on A1C levels Approximate A1C reduction (%)Biguanides (metformin ) 0.9–2.5Sulfonylureas (glipizide, glyburide, 1.1–3.0glimiperide, others)Glinides (repaglinide, nateglindide) 1.0–1.5Thiazolidinediones (pioglitazone, 1.5–1.6rosiglitazone)α-Glucosidase inhibitors (acarbose, 0.6–1.3miglitol)Gliptins (sitagliptin) 0.8GLP-1 analogs (exenetide) 0.8–0.9Amylin analogs (pramlintide) 0.4–0.6
    • 43. Rosiglitazone
    • 44. Appetite suppressant
    • 45. Glucose monitoring● Self-monitoring of blood glucose (SMBG) should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy.● For patients using less frequent insulin injections, noninsulin therapies, SMBG may be useful as a guide to the success of therapy.● To achieve postprandial glucose targets, postprandial SMBG may be appropriate.
    • 46. Continuous glucose monitoring (CGM)CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes.
    • 47. A1C• Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control).● Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals.● Use of point-of-care testing for A1C allows for timely decisions on therapy changes, when needed.
    • 48. • a glycosylated hemoglobin (A1C) value <7% is often set as a target for treatment, which is consistent with the American Diabetes Association (ADA) goals for patients with diabetes.• Although this goal may seem aggressive and is difficult for many patients to reach, this value is substantially higher than that for patients without diabetes, whose A1C range is typically 4% to 6%.
    • 49. Psychosocial assessment and care● Assessment of psychological and social situation should be included as an ongoing part of the medical management of diabetes.● Psychosocial screening and follow-up should include, but is not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes- related quality of life, resources (financial, social, and emotional), and psychiatric history.
    • 50. ● Screen for psychosocial problems such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self-management is poor.● Co-existing depression and other psychiatric conditions are common in patients with diabetes and treatment of these conditions may improve diabetes outcomes.
    • 51. Hypertension/blood pressure controlScreening and diagnosis● Blood pressure should be measured at every routine diabetes visit.• Patients found to have systolic blood pressure 130 mmHg or diastolic blood pressure 80 mmHg should have blood pressure confirmed on a separate day.• Repeat systolic blood pressure 130 mmHg or diastolic blood pressure 80 mmHg confirms a diagnosis of hypertension.
    • 52. Hypertension/blood pressure controlGoals● Patients with diabetes should be treatedto a systolic blood pressure 130mmHg.● Patients with diabetes should be treatedto a diastolic blood pressure 80mmHg.
    • 53. Hypertension/blood pressure controlTreatment● Patients with a systolic blood pressure of 130–139 mmHg or a diastolic blood pressure of 80– 89mmHgmay be given lifestyle therapy alone for a maximum of 3 months, then be treated with addition of pharmacological agents.● Patients with systolic blood pressure 140 or diastolic blood pressure 90 mmHg at diagnosis or follow-up should receive pharmacologic therapy in addition to lifestyle therapy.
    • 54. Hypertension/blood pressure controlTreatment● Lifestyle therapy for hypertension consists of:• weight loss if overweight,• DASH style dietary pattern including reducing sodium and increasing potassium intake• moderation of alcohol intake• increased physical activity.
    • 55. Hypertension/blood pressure control● Pharmacologic therapy for patients with diabetes and hypertension should be with a regimen that includes either an ACE inhibitor or ARBs.If one class is not tolerated, the other should be substituted.If needed to achieve blood pressure targets, a thiazide diuretic should be added to those with an estimated glomerular filtration rate (GFR) ≥ 30 ml/min per 1.73 m2 and a loop diuretic for those with an estimated GFR < 30 ml/min per 1.73 m2.
    • 56. Hypertension/blood pressure control● Multiple drug therapy is generally required to achieve blood pressure targets.● If ACE inhibitors, ARBs, or diuretics are used, kidney function and serum potassium levels should be closely monitored.● In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110–129/65–79 mmHg are suggested in the interest of long term maternal health and minimizing impaired fetal growth. ACE inhibitors and ARBs are contraindicated during pregnancy.
    • 57. Dyslipidemia/lipid managementScreening:● In most adult patients, measure fasting lipid profile at least annually.In adults with low-risk lipid values (LDL cholesterol 100 mg/dl, HDL cholesterol 50 mg/dl, and triglycerides 150 mg/dl), lipid assessments may be repeated every 2 years.
    • 58. Vascular Protection• Anti-platelet therapy – low dose ASA• ACE inhibitors are indicated for any of:- Age 55 or over- Hypertension- Confirmed albuminuria• Optimize BP to less than or equal to 130/80. If lifestyle modification is not sufficient, choose: thiazide diuretic, ACEI/ARB, cardioselective B-blockers.• Optimize glycemic control• Calculate 10 year coronary heart disease (CHD) risk• Treat dyslipidemia
    • 59. ● Consider aspirin therapy (75–162 mg/ day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk 10%).This includes most men 50 years of age or women 60 years of age who have at least one additional major risk factor: family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria.
    • 60. ● There is not sufficient evidence to recommend aspirin for primary prevention in lower risk individuals:such as men 50 years of age or women 60 years of age without other major risk factors. In patients in these age-groups with multiple other risk factors, clinical judgment is required.
    • 61. ● For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used.● Combination therapy with ASA (75– 162 mg/day) and clopidogrel (75 mg/ day) is reasonable for up to a year after an acute coronary syndrome.
    • 62. Treatment recommendations and goals● Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients:● with overt CVD.● without CVD who are over the age of 40 years and have one or more otherCVD risk factors.● Statin therapy is contraindicated in pregnancy.
    • 63. Treatment recommendations and goals● For lower risk patients than the above (e.g., without overt CVD and under the age of 40 years), statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains above 100 mg/dl or in those with multiple CVD risk factors.● In individuals without overt CVD, the primary goal is an LDL cholesterol 100 mg/dl.● In individuals with overt CVD, a lower LDL cholesterol goal of70 mg/dl, using a high dose of a statin, is an option.
    • 64. Treatment recommendations and goals● If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol 30 – 40% from baseline is an alternative therapeutic goal.
    • 65. Treatment recommendations and goals● Triglycerides levels 150 mg/dl and HDL cholesterol 40 mg/dl in men and 50 mg/dl in women are desirable. However, LDL cholesterol– targeted statin therapy remains the preferred strategy.● If targets are not reached on maximally tolerated doses of statins, combination therapy using statins and other lipidlowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either CVD outcomes or safety.
    • 66. Hypoglycemia● Glucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used.If SMBG 15 min after treatment shows continued hypoglycemia, the treatment should be repeated.Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia.
    • 67. Commonly available sources of 10 g Glucose Orange juice 1 cup Grape juice ½ cup Table sugar 4 teaspoons Honey 3 teaspoons1 cup =8 ounces (fluid)1 tablespoon=3teaspoons
    • 68. Hypoglycemia● Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemiacaregivers or family members of these individuals instructed in its administration. Glucagon administration is not limited to health care professionals.
    • 69. Hypoglycemia UnawarenessIndividuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks, to partially reverse hypoglycemia unawareness and reduce risk of future episodes.
    • 70. Risk Factors for Severe Hypoglycemia• Prior episode of severe hypoglycemia• Long duration of diabetes• Current low A1C (< 6.0%)• Autonomic neuropathy• Hypoglycemia unawareness
    • 71. In elderly people with type 2 diabetes• Polypharmacy-review the medication list• Alpha-glucosidase inhibitors are modestly effective• Thiazolidinedione insulin sensitizers are effective, but should be used with caution in those at risk for fluid retention.• Sulfonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age. In general initial doses should be half dose and increased more slowly.
    • 72. In elderly people with type 2 diabetes• In elderly people, the use of premixed insulins and prefilled insulin pens should be considered to reduce dosage errors and potentially improve glycemic control.• People with clinically significant autonomic dysfunction should be appropriately assessed and referred.
    • 73. • healthy elderly people with diabetes should be treated to achieve the same glycemic,blood pressure and lipid targets as younger people.• Aerobic exercise and/or resistance training may benefit elderly people with type 2 diabetes and should be recommended if not contraindicated.• Consider an ECG stress test for previously sedentary people with risk factors for CVD who wish to undertake exercise more vigorous than brisk walking.
    • 74. • Early recognition and treatment of retinopathy can prevent blindness.• Tricyclic antidepressants and/or anticonvulsants should be considered for relief of painful peripheral neuropathy.• Patients with anaesthetic neuropathy are at very high risk of foot problems.• Ask about erectile dysfunction
    • 75. Commonly overlooked co morbid conditions • Cataracts • entrapment neuropathy (carpal tunnel) • tendon problems • dental problems
    • 76. Screening for and diagnosis of GDM• Women at very high risk should be screened for diabetes as soon as possible after the confirmation of pregnancy (at the first prenatal visit).• They should undergo GDM testing at 24– 28 weeks of gestation.
    • 77. Screening for and diagnosis of GDMCriteria for very high risk are:● Severe obesity● Prior history of GDM or delivery of large- for-gestational-age infant● Presence of glycosuria● Diagnosis of PCOS● Strong family history of type 2 diabetes
    • 78. Two approaches may be followed for GDMscreening at 24–28 weeks:1. Two-step approach:A. Perform initial screening by measuring plasma or serum glucose 1 h after a 50-g load of 140 mg/dl identifies 80% of women with GDM, while the sensitivity is further increased to 90% by a threshold of 130 mg/dl.B. Perform a diagnostic 100-g OGTT on a separate day in women who exceed the chosen threshold on 50-g screening.
    • 79. Two approaches may be followed forGDM screening at 24–28 weeks:2. One-step approach (may be preferred in clinics with high prevalence of GDM): Perform a diagnostic 100-g OGTT in all women to be tested at 24–28 weeks. The 100-g OGTT should be performed in the morning after an overnight fast of at least 8 h.
    • 80. To make a diagnosis of GDM, at least two of the following plasma glucose values must be found:● Fasting 95 mg/dl● 1-h 180 mg/dl● 2-h 155 mg/dl● 3-h 140 mg/dl
    • 81. In pregnant patients with diabetesand chronic hypertension: blood pressure target goals of 110–129/65– 79 mmHg are suggested in the interest of long term maternal health and minimizing impaired fetal growth.ACE inhibitors and ARBs are contraindicated during pregnancy.● Statin therapy is contraindicated in pregnancy.
    • 82. Coronary heart diseaseScreening● In asymptomatic patients, evaluate riskfactors to stratify patients by 10-yearrisk, and treat risk factors accordingly.
    • 83. Coronary heart diseaseTreatment:● In patients with known CVD, ACE inhibitor and aspirin and statin therapy (if not contraindicated) should be used to reduce the risk of cardiovascular events.● In patients with a prior myocardial infarction, B-blockers should be continued for at least 2 years after the event.
    • 84. Coronary heart diseasetreatment● Longer term use of B-blockers in the absence of hypertension is reasonable if well tolerated.● Avoid TZD treatment in patients with symptomatic heart failure.● Metformin may be used in patients with stable congestive heart failure (CHF) if renal function is normal. It should be avoided in unstable or hospitalized patients with CHF.
    • 85. Nephropathy screening and treatmentGeneral recommendations● To reduce the risk or slow the progression of nephropathy, optimize glucose control.● To reduce the risk or slow the progressionof nephropathy, optimize blood pressure control.
    • 86. Nephropathy screening and treatmentScreening● Perform an annual test to assess urine albumin excretion in type 1 diabetic patients with diabetes duration of 5 years and in all type 2 diabetic patients starting at diagnosis.● Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion.• The serum creatinine should be used to estimate GFR and stage the level of chronic kidney disease.
    • 87. Nephropathy screening and treatmentTreatment● In the treatment of the nonpregnant patientwith micro- or macroalbuminuria, either ACE inhibitors or ARBs should be used.
    • 88. Nephropathy screening and treatment● When ACE inhibitors, ARBs, or diureticsare used, monitor serum creatinine and potassium levels for the development of acute kidney disease and hyperkalemia.● Continued monitoring of urine albumin excretion to assess both response to therapy and progression of disease.● Consider referral when there is uncertainty about the etiology of kidney disease (activeurine sediment, absence of retinopathy, rapid decline in GFR), difficult management issues, or advanced kidney disease.
    • 89. Retinopathy screening and treatmentGeneral recommendations● To reduce the risk or slow the progressionof retinopathy, optimize glycemic & bloodPressure control.
    • 90. Retinopathy screening and treatmentScreening● Adults and children aged 10 years or older with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist within 5 years after the onset of diabetes.● Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist shortly after the diagnosis of diabetes.
    • 91. Retinopathy screening and treatment● Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist.• Less-frequent exams (every 2–3 years) may be considered following one or more normal eye exams.• Examinations will be required more frequently if retinopathy is progressing.
    • 92. Retinopathy screening and treatment● High-quality fundus photographs can detect most clinically significant diabetic retinopathy.• Interpretation of the images should be performed by a trained eye care provider.• While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional.
    • 93. Retinopathy screening and treatment● Women with preexisting diabetes who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and be counseled on the risk of development and/or progression of diabetic retinopathy.• Eye examination should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum.
    • 94. Retinopathy screening and treatmentTreatment● Promptly refer patients:any level of macular edemasevere nonproliferative diabetic retinopathyany proliferative diabetic retinopathy (PDR)to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy.
    • 95. Retinopathy screening and treatment● Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk PDR, clinically significant macular edema, and in some cases of severe NPDR.● The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as this therapy does not increase the risk of retinal hemorrhage.
    • 96. Neuropathy screening and treatment● All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests.● Electrophysiological testing is rarely needed, except in situations where the clinical features are atypical.
    • 97. Neuropathy screening and treatment● Screening for signs and symptoms of cardiovascular autonomic neuropathy should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes. Special testing is rarely needed and may not affect management or outcomes.● Medications for the relief of specific symptoms related to DPN and autonomic neuropathy are recommended, as they improve the quality of life of the patient.
    • 98. Foot care● For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
    • 99. Foot care● The foot examination should include• Inspection• assessment of foot pulses• Testing for loss of protective sensation (10-g monofilament)• plus testing any one of:o vibration using 128-Hz tuning forko pinprick sensationo ankle reflexeso vibration perception threshold.
    • 100. Foot care● Provide general foot self-care education to all patients with diabetes.● A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation.● Refer patients who smoke, have loss of protective sensation and structural abnormalities, or have history of prior lower-extremity complications to foot care specialists for ongoing preventive care and life-long surveillance
    • 101. Foot care● Initial screening for peripheral artery disease (PAD) should include a history for claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic.● Refer patients with significant claudication or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options.
    • 102. Seven self-care behaviors1 Healthy eating2 Being active3 Taking medication4 Monitoring blood glucose5 Problem-solving6 Healthy coping7 Reducing risks
    • 103. thanks

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