This document provides information on the diagnosis and management of type 2 diabetes mellitus. It discusses the different types of diabetes, risk factors for type 2 diabetes, acute and chronic complications, glucose monitoring techniques, lifestyle management including diet and exercise, oral and injectable drug therapies, and considerations for diabetes management in special populations and situations.
2. ο Diabetes mellitus is a syndrome with disordered
metabolism & inappropriate hyperglycaemia due to
either deficiency of insulin secretion or combination of
insulin resistance & inadequate insulin secretion.
3. β’ Type 1 DM
β’ Type 2 DM
β’ Other specific types:
1. Genetic defects of Beta cells ( MODY)
2. Genetic defects in insulin action
3. diseases of exocrine pancreas(pancreatitis)
4.endocrine diseases like cushing synd, phaeochromocytoma,
hyperthyroidism
5. Drugs glucocorticoids, beta blockers
thiazides,antipsychotics
β’ Gestational DM (GDM)
4. ο Type 1 A due to destruction of beta cells by auto
immune process
Type 1 B idiopathic
Younger age ,ketosis prone
Antibodies present ICA,GAD, IAA
5. ο Occurs in adults
ο Ketosis is not common
ο Insulin resistance leads to hyperglycaemia
ο Genetic factors
ο Environmental factors
obesity ....visceral BMI>25
physical inactivity
h/o GDM
HT
6. ο Due to insulin resistance related to metabolic changes
in late pregnancy
ο Reverts to normal glucose tolerance after delivery
ο 35 to 50% will develop dm in next 10 yrs follow up
12. ο In general most patient is advised 45% of total calories
as carbohydrates,30% as fat,25% as proteins.
ο Dietary fibres delay absorption of glucose & may have
beneficial effect on colonic function
ο Low glycemic index foods are prefered
13.
14.
15.
16.
17.
18.
19.
20. ο Oral glucose leads to higher insulin response with
equivalent dose of i.v..This is because oral glucose
releases gut hormone GLP1 which stimulates insulin
secretion (incretin effect)
ο GLP1 is proteolysed by enzyme DPP4 (dipeptidyl
peptidase 4 )
ο GLP1 agonist are with longer half life e.g.Exenetide,
Liraglutide
ο DPP4 inhibitors inhibit enzyme & prolongs action of
GLP1 e.g.Teneligliptin,vildagliptin,linagliptin,sitagliptin
21. ο Glucose is filtered freely by glomeruli & is reabsorbed
by proximal convolated tubules by sodium-glucose co-
transporter 2(SGLT2)
ο SGLT2 inhibitors leads to glycosuria & lowering plasma
glucose levels
ο Canagliflozine,dapa &empagliflozines are commonly
used
22. ο Bromocriptin is dopamin recepter agonist inhibites
sympathetic tone in CNS resulting decrease plasma
glucose
ο Hydroxychlroquine (HCQS) acts by altering insulin
metabolism
23. Which patients require insulin?
1. type 1 dm
2. type 2 dm with OAD failure (sec. Failure)
3.during major surgery
4.pregnancy
5. FPG>250 or RPG >300 or HbA1c >10%
25. ο Insulin which resembles nomal secretery pattern of
insulin i.e. Basal insulin for 24 hrs control & additional
insulin to control prandial glucose increase
ο Basal bolus regime
26. ο Start with 0.1 to 0.2 units/kg
ο Or 10 units at bed time
ο Adujust the dose to achieve target FPG <100
ο If FPG 100 -120 increase by 2units
ο 120-140 4
ο 140-160 6
ο 160-180 8
27. ο Initial dose of prandial insulin is decided by fixed dose
of 4 units each meal
ο Further titration is done acc to ppg value
ο If ppg>140-180 4units & so on
ο Total dose of insulin calculated as 0.3-0.5units/kg &
given as 50% bolus & 50% basal
28. ο Hyperglycemia in hospital is defined as RBS>140mg/dl
ο If not addressed leads to poor clinical outcome
ο Hyperglysemia may be in ICU setting or may be in non
critical setting i.e. In wards
29. ο Glycemic targets in icu
ο 140-180 mg/dl
ο RBS <110 or >180 is not recommended
ο Intensive glycemic control leads to increase mortality
ο OADs should be avoided
ο Continuous IV insulin infusion (CII)is prefered method
ο Initial rate of insulin infusion is RBS/100 units/hr
30. Blood glucose With any increase in
BG from prior BG
BG decrease <30
from prior BG
BG decrease >30
from prior BG
>240 Increase rate
3unit/hr
Inrse 3units/hr No change
210-240 2units/hr 2 No change
180-210 1 1 no
140-180 no no no
110-140 decrease d d
90-110 hold h h
31. ο Calculate insulin requirement for last 6 hrs for i. V.
Insulin * 4
ο Give 80% of total dose as s.c.
ο Give 50% basal 50% bolus
ο Start s.c. Insulin 1-2 hrs before discontinuing i v insulin
infusion
32. ο Administer basal insulin along with rapid acting analogs
ο Test RBS before each feed
33. ο Usually S.C. Insulin is given
ο Basal βbolus is preferred
ο Supplemental insulin (correctional) insulin is given for
dose adjustment
34. ο Calculate total daily dose as below
ο If BG 140-200 0.4 units/kg
ο BG 200-400 0.5 units/kg
ο 50% basal 50% bolus
ο Glycemic targets in non icu settings
ο premeal glucose <140
ο RBS <180
ο Supplemental insulin is given to correct hypeaglycemia
35. BLOOD GLUCOSE Usual insulin
140-180 4
180-220 6
220-260 8
260-300 10
300-340 12
340-380 14
Insulin resistant may require more doses Insulin sensitive may require less dose
36. ο All OAD should be stopped on morning of surgery
ο Stop long acting insulin 1 day before surgery
ο Omit morning dose of s.c.insulin
ο Start 5% DNS with regular insulin at breakfast time 8
a.m. 100ml/hr
ο Monitor BG 2hrly during surgery
ο Target BG is <140-180
37. ο Diabetes management involves targeting
FPG,PPG,HBA1C,Glycemic variability,quality of life
ο Glycemic variability is swings in blood glucose levels
that occur throughout day
ο BG swings is responsible for increase in cvs morbidiy
ο Glycemic variability can be measured by CGM studies
(continuous glucose monitoring)
38. ο Involves inserting subcutaneus sensor that measures
glucose concentration in interstitial fluid for 14 days
ο Graphs are created & with the help of software
ambulatory glucose profile (AGP) is created for analysis
ο Episodes of hypo or hyperglycemia can be identified
with glucose variability
39. ο Is an estimation of health &effects of health care.
ο Concept of disease specific QoL is a treatment goal
ο Philosophy has changed from physician-centered to
patient centered