Ada guidelines on diabetes treatment

1. Dr VINUTHA
T
AMERICAN DIABETES
ASSOCIATION
STANDARDS OF CARE IN DIABETES
- 2023

2. • The prevalence of diabetes and impaired glucose tolerance has been
estimated to be 9.3% and 24.5%, respectively in INDIA by 2022
• Among those with diabetes (9.3%), nearly half were aware (45.8%), more
than one-third were on treatment (36.1%), and only 15.7% had their blood
glucose levels under control
• More than 50% of people are unaware of their diabetic status which leads
to health complications if not detected and treated early.
• The estimated number of people with diabetes and CKD has grown in
proportion to the rising prevalence of diabetes itself, driven largely by
obesity, sedentary lifestyle, an epidemic of type 2 diabetes
DIABETES IN INDIA

3. diagnosis requires two abnormal screening test results, either from the
same sample or in two separate test samples

5. • Intensive lifestyle behavior change to achieve and maintain a
weight reduction of 7% of initial body weight through
healthy reduced-calorie diet and ~150 min/week of moderate
intensity physical activity.
• The DPP demonstrated that intensive lifestyle intervention could
reduce the risk of incident type 2 diabetes by 58% over 3 years
• 7% weight loss during the 1st 6 months of the intervention. Maximal
prevention of diabetes with at least 7–10% weight loss . The
recommended pace of weight loss was 1–2lb/week.
Prevention or Delay of Type 2 Diabetes and Associated Comorbidities

6. • Metformin therapy for the prevention of type 2 diabetes
should be considered in adults at high risk of type 2 diabetes,
• Especially those aged 25–59 years with BMI >35 kg/m2,
higher FPG (e.g. >110 mg/dL), and higher A1C (e.g., >6.0%),
and in individuals with prior GDM.
• In people with a history of stroke and evidence of insulin
resistance and Pre diabetes, pioglitazone may be considered
to lower the risk of stroke or MI.
Pharmacological interventions

8. GLYCEMIC CONTROL ASSESSMENT
• Assess glycemic status (A1C or other glycemic measurement
such as time in range or glucose management indicator) at
least two times a year in patients who are meeting
treatment goals.
• Assess glycemic status at least quarterly and as needed
in patients whose therapy has recently changed and/or who
are not meeting glycemic goals.
• HBA1C test is the primary tool for assessing glycemic control
and has a strong predictive value for diabetes complications

9. Assessment of glycemic control

11. • An A1C goals for many non-pregnant adults of<7%
without significant hypoglycaemia is appropriate.
• intensive control had significant 57% reduction in the
risk of nonfatal myocardial infarction (MI), stroke, or
cardiovascular death than standard
• Both DCCT/ EDIC and UKPDS demonstrated
metabolic memory, or a legacy effect, in which finite
period of intensive control yielded benefits that
extended for decades after that control ended.
GLYCEMIC GOALS

14. • Nutrition, physical activity, and behavioral therapy to achieve and
maintain 5% weight loss are recommended for most people with type 2
diabetes and overweight or obesity. Additional weight loss usually
results in further improvements in the management of diabetes and
cardiovascular risk
• Medications approved by FDA for the treatment of obesity include
orlistat, phentermine , topiramate, naltrexone, bupropion , liraglutide,
and semiglutide
. OBESITY AND WEIGHT MANAGEMENT

16. • People with diabetes and hypertension qualify for antihypertensive drug
therapy when the blood pressure is persistently elevated >130/80 mmHg
• ASCVD risk calculator is generally a useful tool to estimate 10-year risk of
a 1st ASCVD event. The calculator includes diabetes as a risk factor.
• For people with diabetes, aged 40 to 75 at higher cardiovascular risk, it is
recommended to use high intensity statin therapy to reduce
LDLcholesterol by 50% of baseline, and to target LDLcholesterol of goal
<70mg/dL
• Among people with type 2 diabetes who have established atherosclerotic
cardiovascular disease or established kidney disease, a SGLT2 inhibitor
or GLP 1 receptor agonist with demonstrated cardiovascular disease
benefit is recommended as part of cardiovascular risk reduction and/or
glucose lowering regimens.

17. • Statins recommended in addition to lifestyle therapy, with
treatment initiation based on risk status rather than specific LD
cholesterol goals
• Give high-intensity statins to all patients with diabetes and
atherosclerotic cardiovascular disease, regardless of age (ADA
Grade A)
• For patients with diabetes and atherosclerotic cardiovascular
disease, if LDL cholesterol is ≥ 70 mg/dL while on maximal
tolerated statin dose, add additional LDL lowering drug such as
ezetimibe or PCSK9 inhibitor, after assessing potential for further
reduction in atherosclerotic cardiovascular disease risk (ADA
Grade

18. CKD AND RISK MANAGEMENT IN
DIABETICS

20. PATHOPHYSIOLOGY

22. • Urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and
estimated GFR should be assessed :
1. Atleast once annually in type 1 diabetes with duration of 5years and in
all type 2 diabetes regardless of treatment.
2. 1–4 times per year depending on the stage of the disease in cases of
established diabetic kidney disease
3. because of high biological variability of >20% between measurements
in urinary albumin excretion, 2/3 specimens of UACR collected
within a 3- 6 month period should be abnormal before considering a
patient to have moderately or severely elevated albuminuria
SCREENING

23. • Diabetic kidney disease is usually a clinical diagnosis based on the
presence of albuminuria and/or reduced eGFR in the absence of
signs or symptoms of other primary causes of kidney damage.
• The typical presentation of DKD is considered to include a long-
standing duration of diabetes, retinopathy, albuminuria without
gross hematuria, and gradually progressive loss of eGFR.
DIAGNOSIS

24. laboratory evaluations are generally indicated
• every 6–12 months for stage 3 CKD,
• every 3–5 months for stage 4 CKD, and
• every 1–3 months for stage 5 CKD
FOLLOW UP

25. UKPDS STUDY - The
United Kingdom
prospective diabetes
study

29. • For people with non-dialysis-dependent CKD, dietary protein intake
should be 0.8 g/kg/day (the recommended daily allowance)
• Higher levels of dietary protein intake (>20% of daily calories from
protein or >1.3 g/kg/day) have been associated with increased
albuminuria, more rapid kidney function loss, and CVD mortality
and therefore should be avoided
• Restriction of dietary sodium (to <2,300 mg/day) may be useful to
control blood pressure and reduce cardiovascular risk
• For patients on dialysis, higher levels of dietary protein intake
should be considered since malnutrition is a major problem for
some patients on dialysis
NUTRITION
INTERVENTION

30. • RAAS inhibition remains a mainstay of management for people
with DKD with albuminuria and for the treatment of hypertension
in people with diabetes (with or without diabetic kidney disease)
• Bp <130/80 mmHg is recommended to reduce CVD mortality and
slow CKD progression among all people with diabetes
• ACE inhibitors or ARBs are the preferred 1st line agents for BP
treatment among people with diabetes, hypertension, eGFR <60
mL/min/1.73 m2,and UACR >300 mg/g creatinine because of
their proven benefits for prevention of CKD progression
BP MANAGEMENT

33. • Intensive lowering of blood glucose with the goal of achieving near-
normoglycemia has been shown in large randomized studies to delay the
onset and progression of albuminuria and reduce eGFR in people with type
1 diabetes and type 2 diabetes
• If already on dual therapy or multiple glucose-lowering therapies and not
on an SGLT2 inhibitor or GLP-1 receptor agonist, consider switching to one
of these agents with proven cardiovascular benefit
• Introduce SGLT2 inhibitors or GLP-1 receptor agonists in people with CVD
at A1C goal (independent of metformin) for cardiovascular benefit
independent of baseline A1C or individualized A1C target
GLYCEMIC TARGETS

35. • The revised FDA guidance states that
1)Metformin is contraindicated in patients with an eGFR <30
mL/min/1.73 m2
2)eGFRshould be monitored while taking metformin,
3) metformin should not be initiated for patients with an eGFR <45
mL/min/1.73 m2
4) Metformin should be temporarily discontinued at the time of or before
iodinated contrast imaging procedures in patients with eGFR 30–
60mL/min/1.73m2.
METFORMIN

36. • SGLT2 inhibitors reduce renal tubular glucose reabsorption, weight,
systemic blood pressure, intraglomerular pressure, and albuminuria
and slow GFR loss through mechanisms that appear independent of
glycemia
• SGLT2 inhibitors reduce oxidative stress in the kidney by >50%
• In type 2 diabetes and established HFpEF or HFrEF, an SGLT2 is
recommended to reduce the risk of worsening heart failure and
cardiovascular death.
• In patients with NYHA class II–IV heart failure with an EF>40%,
treatment with empagliozin reduced the combined risk of death,
hospitalization for heart failure
SGLT2 INHIBITORS

38. • GLP-1 RAs also have direct effects on the kidney and have been
reported to improve renal outcomes compared with placebo
• GLP-1 RAs are suggested for cardiovascular risk reduction if such risk
is a predominant problem, and appear to possibly slow CKD
progression
• GL P1 RA have moderate benefits on MACE and also reduce
hospitalisation for heart failure and allcause mortality. They also have
robust benefits and reducing the incidence of macroglobunuria
GLP 1 RECEPTOR AGONISTS

41. • Finerenone is a novel , non steroidal, selective mineralocorticoid receptor
antagonist with anti-inflammatory and anti-fibrotic effects.
• It has higher potency and less hyperkalaemia than steroidal MRAs
• Nonsteroidal MRA are most appropriate for patients with type 2 DM who
are at high risk of CKD progression, and cardiovascular events, as
demonstrated by persistent albuminuria despite other standard-of-care
therapies.
• only a small reduction in SBP (3 mm Hg) with finerenone compared to
placebo, and no effect on HbA1c, no increase in hypo- or hyperglycemia
MINERALOCORTICOID RECEPTOR ANTAGONISTS

44. • The analysis showed a 14% reduction in composite
cardiovascular death, nonfatal myocardial infarction, nonfatal
stroke, and hospitalization for heart failure for finerenone vs.
placebo
• 23% reduction in the composite kidney outcome, consisting of
sustained >57% decrease in eGFR from baseline over
>4weeks,or renal death, for finerenone vs. placebo
FIDELITY STUDY

45. • Hypoglycaemia is the major limiting factor in the glycaemic
management of type1 and type 2 diabetes
HYPOGLYCEMIA

46. • Insulin treated patients with hyperglycaemic unawareness — one
level3 d event or a pattern of Unexplained level 2 hypoglycaemia
should be advised to raise their glycaemic targets to strictly avoid
hypoglycaemia for at least several weeks or in order to partially
reverse the unawareness and reduce the risk of future episodes
• Glucose(15–20g) is the preferred treatment for the conscious
individual with bloodglucose<70mg/dL
• The use of glucagon is indicated for the treatment of hypoglycemia in
people unable to consume carbohydrates by mouth.