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Diabetes Update for registrars 
PART 1- Type 2 Diabetes-an 
overview 
C McNamara
Learning objectives: 
 Understand progressive nature of DM 
 Aim for early diagnosis & patient empowerment – 
(better se...
Progressive Decline of 
B Cell Function in UKPDS 
100 
80 
% 
Function 60 
40 
Cell B 20 
0 
Years 100 
80 
60 
40 
20 
““...
Type 2 Diabetes 
A growing epidemic 
Approximately 200,000 in New Zealand 
and 25,000 plus in WDHB. 
A growing epidemic 
A...
Risk factors for Type 2 Diabetes 
 Ethnicity- twice as common in Maori, Pacific 
Island and Indian (South-East Asian) 
 ...
What to do following a screening test for 
type 2 diabetes 
Result Action 
HbA1c ≥ 50mmol/mol 
and, if measured, 
Fasting ...
What to do following a screening test for type 2 
diabetes 
Result Action 
HbA1c ≥ 50mmol/mol 
and, if measured, 
Fasting ...
Prediabetes? 
Result Action 
HbA1c 41-49 
mmol/mol 
and, if measured, 
Fasting glucose 6.1– 
6.9 mmol/L 
Advise on diet an...
HbA1c reporting (% to mmol/mol) 
NPS
Lifestyle Education Prevention and early detection 
and support: 
(see www.nzssd.org.nz) 
•Self Management education(DSME)...
TTyyppee 22 ddiiaabbeetteess ((SSEEEE AAllggoorriitthhmm)) 
PPaarrtt ooff ““mmeettaabboolliicc ssyynnddrroommee”” 
· Vascu...
Be sure of Type of Diabetes 
 Consider autoimmune diabetes 
(adult Type 1) if slimmer, younger, 
history of autoimmune di...
SET TARGET for each patient 
 HbA1c target depends on age, 
co-morbidities, diabetes duration, e.g.: 
 50-55 (6.7-7.2%) ...
Next step after Metformin 
Diet & Exercise 
 
Metformin 
    
 
Sulphonylurea 
e.g. Glipizide 
Gliclazide 
Glitazone...
INCRETINS 
a) Sitagliptin (Januvia) DPPIV inhibitor 
 GLP is a gut hormone from the ileum which is reduced in type 2 
dia...
b) GLP-agonists 
 Given by S.C. injection once or twice daily, possibly 
soon once weekly 
e.g. Exanatide B.D., Liragluti...
Checklist ffoorr PPrree--iinnssuulliinn aasssseessssmmeenntt 
 MMaaxxiimmuumm ttaabblleettss 
 ddoo tthheeyy ttaakkee tt...
Diabetes update for registrars   part 1 - 13 08 14
Diabetes update for registrars   part 1 - 13 08 14
Diabetes update for registrars   part 1 - 13 08 14
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Diabetes update for registrars part 1 - 13 08 14

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Diabetes update for registrars part 1 - 13 08 14

  1. 1. Diabetes Update for registrars PART 1- Type 2 Diabetes-an overview C McNamara
  2. 2. Learning objectives:  Understand progressive nature of DM  Aim for early diagnosis & patient empowerment – (better self-management)  Screen for complications (and treat if +ve)  Optimise function (ie. keep patients well and informed)  Understand treatments, how to uptitrate and move to insulin where necessary  Understand the difference between Type 1 & Type 2 DM
  3. 3. Progressive Decline of B Cell Function in UKPDS 100 80 % Function 60 40 Cell B 20 0 Years 100 80 60 40 20 ““IInnssuulliinn RReessiissttaannccee uunncchhaannggeedd”” ““5500%% ooff ppaattiieennttss nneeeedd iinnssuulliinn aafftteerr 66 yyeeaarrss”” -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 Years B Cell Function % PPrrooggrreessssiivvee DDeecclliinnee ooff BB CCeellll FFuunnccttiioonn iinn UUKKPPDDSS 0 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 DDiiaaggnnoossiiss
  4. 4. Type 2 Diabetes A growing epidemic Approximately 200,000 in New Zealand and 25,000 plus in WDHB. A growing epidemic Approximately 180,000 in New Zealand and 20,000 plus in WDHB.  5% in European NZ  10-13% in Maori and Pacific Island people.
  5. 5. Risk factors for Type 2 Diabetes  Ethnicity- twice as common in Maori, Pacific Island and Indian (South-East Asian)  Positive family history  Obesity and sedentary life-style  Mainly occurs at age>50y BUT THE OBESITY EPIDEMIC IS MAKING TYPE 2 DIABETES COMMON IN KIDS.  Evidence of other vascular risk factors
  6. 6. What to do following a screening test for type 2 diabetes Result Action HbA1c ≥ 50mmol/mol and, if measured, Fasting glucose ≥7.0 mmol/L Or Random blood glucose ≥11.1mmol/L No further tests required Diabetes is confirmed Symptomatic
  7. 7. What to do following a screening test for type 2 diabetes Result Action HbA1c ≥ 50mmol/mol and, if measured, Fasting glucose ≥7.0 mmol/L Or Random blood glucose ≥11.1mmol/L Repeat HbA1c or a fasting plasma glucose Two results above the diagnostic cut-offs, on separate occasions are required for the diagnosis of diabetes* asymptomatic
  8. 8. Prediabetes? Result Action HbA1c 41-49 mmol/mol and, if measured, Fasting glucose 6.1– 6.9 mmol/L Advise on diet and lifestyle Redo test in 6-12 m Results indicate ‘pre-diabetes’ or impaired fasting glucose asymptomatic
  9. 9. HbA1c reporting (% to mmol/mol) NPS
  10. 10. Lifestyle Education Prevention and early detection and support: (see www.nzssd.org.nz) •Self Management education(DSME) •Smoking cessation DIAGNOSIS •Dietary advice (HbA1c>50mmol/mol) •Exercise/Green RX •Family support •Psychological support (see www.nzssd.org.nz •Dental Health for guidelines) •Diabetes NZ Support Groups WEIGHT Target BMI <28 (or 5-10% weight loss) Dietitian Refer: Consider bariatric surgery if BMI > 35 LIPIDS Target TG <1.7; LDL < 2 Total <4; HDL>1 Statin Combine with ezetimibe or nicotinic acid if predominately hypercholesterolaemia Combine with fibrate if predominately hypertriglyceridaemia CV Risk >15%: consider aspirin, statin and antihypertensive Refer: If not attaining targets despite dietician and maximal therapy GLYCAEMIC CONTROL Target 50 –60 mmol/mol (but individualise) Metformin (caution if eGFR < 40 and stop if eGFR<30) Add Sulphonylureas (or pioglitazone or gliptin if not tolerated) See useful tips Insulin (see Insulin initiation algorithm) Refer: If unable to initiate insulin or target not reached within 3 - 4months RENAL FUNCTION Micro/ macro albumniuria or low eGFR for age ACEI or ARB initially targetting BP Consider Intrinsic renal disease or raised BP if not improving and no retinopathy Refer: •eGFR < 60 and age <50years •eGFR < 40 •20% reduction eGFR over 3 months Progressive increase in ACR on therapy •BP target not achieved with multiple agents FOOT CARE NEUROPATHY Annual foot check Refer Podiatrist for at risk/high risk foot: Previous amputation, ulcers or Charcot foot Peripheral arterial disease Peripheral neuropathy Foot deformity, significant callous formation or preulcerative lesions Refer to High risk Foot clinic and/or relevant speciality: Active ulceration Suspected Charcot Non-responsive painful peripheral neuropathy Urgent admission: Severe or spreading infection Critical limb ischaemia BLOOD PRESSURE Target usually < 130/80 (but individualise) ACEI or ARB Add calcium channel blocker (CCB), thiazide diuretic or chlorthalidone Add another thiazide diuretic or CCB Add one of: alpha, beta blocker or potassium sparing diuretic Add another of above Refer: BP targets not reached on multiple agents Associated diabetes nephropathy EYE CARE 2 yearly retinal screening if no retinopathy 1 yearly retinal check for those with retinopathy (especially if poor glycaemic control) (First trimester retinal screening in pregnant diabetes patients) Refer Ophthalmology: Acute changes in vision Type 2 Diabetes Algorithm Northern Region Diabetes Clinical Network - 2012 Aim to reduce complications and morbidity. 3 monthly evaluation of BP, HbA1C, lipids, ACR, creatinine, eGFR then lipids 12 monthly once controlled Referral at diagnosis: •Severe hyperglycaemia ie glucose > 25mmol/l or ketonuria (urgent) •Intercurrent severe illness (urgent) •Complications of diabetes at diagnosis (semi-urgent) •Pregnant or gestational diabetes diagnosed (semi-urgent) •Type 2 adults < 30 years old (semi-urgent)
  11. 11. TTyyppee 22 ddiiaabbeetteess ((SSEEEE AAllggoorriitthhmm)) PPaarrtt ooff ““mmeettaabboolliicc ssyynnddrroommee”” · Vascular Disease · Hypertension · Proteinuria · Raised lipids · Obesity (apples vs pears) Insulin Resistance
  12. 12. Be sure of Type of Diabetes  Consider autoimmune diabetes (adult Type 1) if slimmer, younger, history of autoimmune disease.  GAD Ab positive
  13. 13. SET TARGET for each patient  HbA1c target depends on age, co-morbidities, diabetes duration, e.g.:  50-55 (6.7-7.2%) for younger fitter  55-64 (7.2 – 8.0%) in others with vascular co-morbidities, especially over 70 yrs  LDL cholesterol to 2.5 or better (TG <3.0)  BP 130/80
  14. 14. Next step after Metformin Diet & Exercise  Metformin      Sulphonylurea e.g. Glipizide Gliclazide Glitazone eg. Pioglitazone Incretins e.g. Sitagliptin Byetta Liraglutide Insulin
  15. 15. INCRETINS a) Sitagliptin (Januvia) DPPIV inhibitor  GLP is a gut hormone from the ileum which is reduced in type 2 diabetes. Restoring GLP levels leads to:   insulin from ß cell -  Glucagon from α cell   Gastric emptying; -  Appetite  Sitagliptin is a DPPIV inhibitor which inhibits the enzyme that breaks down GLP and therefore increases GLP levels PPrrooss: CCoonnss::  Once/day and tablet form  No hypogylcaemia  Weight neutral  HbA1c 0.5-1.0%  on average  COST  Limited experience so far
  16. 16. b) GLP-agonists  Given by S.C. injection once or twice daily, possibly soon once weekly e.g. Exanatide B.D., Liraglutide once daily PPrrooss: CCoonnss::  HbA1c  1.0-1.5%  Weight loss  No hypoglycaemia   B.P.  May preserve ß cell  As good as insulin in some studies  COST  S.C. injection  Nausea (usually wears off)
  17. 17. Checklist ffoorr PPrree--iinnssuulliinn aasssseessssmmeenntt  MMaaxxiimmuumm ttaabblleettss  ddoo tthheeyy ttaakkee tthheemm??  aatt tthhee rriigghhtt ttiimmeess??  PPhhyyssiiccaall aaccttiivviittyy-- ccaann iitt bbee iinnccrreeaasseedd??  FFoooodd-- CCaarrbbss//ccaallss  BBlloooodd MMoonniittoorriinngg--ttoo llooookk ffoorr ppaatttteerrnnss aanndd uunnddeerrssttaanndd hhooww lliiffeessttyyllee aaffffeeccttss bblloooodd gglluuccoossee  UUnnddeerrssttaanndd  ddiiaabbeetteess ‘‘rriisskkss’’  HHbbAA11cc  bblloooodd gglluuccoossee ttaarrggeettss

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