Diabetes nov2019 om alhamam

1. New Trends in management of DM in cardiac
patients
DR IHAB SULIMAN
MBBS ECFMG MRCP (UK) MRCP
Spec(DM&Endoc) ABcv CBNC FESCUpdates in The management of DM in cardiac patients
DR IHAB SULIMAN
MBBS ECFMG MRCP (UK) MRCP Spec(DM&Endoc) ABcv CBNC
FESC

2. Financial disclosures
 None

3. Q1
Short-acting insulin secretagogues (repaglinide, nateglinide) are faster
acting than sulfonylureas. They may be especially effective for which
of the following?
A. Preventing overnight hypoglycemia
B. Promoting weight loss in obese patients
C. Reducing postprandial hyperglycemia
D. Improving peripheral insulin sensitivity

4. C. Reducing postprandial hyperglycemia
Answer: C: Reducing postprandial hyperglycemia. These drugs stimulate
insulin secretion in a manner similar to sulfonylureas, but they are faster
acting and may stimulate insulin secretion more during meals than at
other times. Thus, they may be especially effective for reducing
postprandial hyperglycemia. B: There may be some weight gain,
although apparently less than with sulfonylureas. D: Biguanides are
considered peripheral insulin sensitizers.

5. In many patients with type 2 DM, glucose levels are adequately
controlled with lifestyle changes or oral drugs, and insulin is added
when glucose remains inadequately controlled by ≥ 2 oral drugs. The
addition of insulin is the most effective with which of the following
oral drugs?
A. Alpha-glucosidase inhibitors (AGIs)
B. Insulin secretagogues (sulfonylureas, repaglinide, nateglinide)
C. Oral biguanides (metformin)
D. Sodium-glucose co-transporter 2 (SGLT2) inhibitors (canagliflozin and
dapagliflozin)

6. Answer: C: Oral biguanides (metformin). The rationale for combination
therapy is strongest for use of insulin with oral biguanides and insulin
sensitizers

7. Diagnosis of DM is suggested by typical symptoms and signs and is
usually best confirmed by which of the following tests?
A. Fasting plasma glucose
B. Measurement of insulin levels
C. Fasting HbA1c test
D. Urine glucose

8. Answer: A: Fasting plasma glucose (FPG). DM is indicated by typical
symptoms and signs and confirmed by measurement of plasma
glucose. Measurement after an 8- to 12-h fast or 2 h after ingestion of a
concentrated glucose solution (oral glucose tolerance testing [OGTT]) is
best. OGGT is more sensitive for diagnosing DM and impaired glucose
tolerance but is less convenient and reproducible than FPG. It is
therefore rarely used routinely, except for diagnosing gestational DM
and for research purposes. C: HbA1c measurements reflect glucose levels
over the preceding 3 mo. However, HbA1c values may be falsely high or
low, and tests must be done in a certified clinical laboratory. Point-of-
care HbA 1c tests should not be used for diagnosis, but they can be used
for monitoring DM control. D: Urine glucose measurement, once
commonly used, is no longer used for diagnosis or monitoring because it
is neither sensitive nor specific.

9. Which of the following is not a major risk factor for type 2 diabetes
mellitus?
Exposure to environmental pollutants
Hypertension
Family history of type 2 diabetes in a first-degree relative
Age older than 45 years

10. Exposure to environmental pollutants

11. The major risk factors for type 2 diabetes
mellitus are the following:
Age greater than 45 years (though type 2 diabetes mellitus is occurring with
increasing frequency in young individuals)
Weight greater than 120% of desirable body weight
Family history of type 2 diabetes in a first-degree relative (eg, parent or sibling)
Hispanic, Native American, African American, Asian American, or Pacific
Islander descent
History of previous impaired glucose tolerance or impaired fasting glucose
Hypertension (>140/90 mm Hg) or dyslipidemia (high-density lipoprotein
cholesterol level <40 mg/dL or triglyceride level >150 mg/dL)
History of gestational diabetes mellitus or of delivering a baby with a birth
weight of over 9 lb
Polycystic ovarian syndrome (which results in insulin resistance)

12. Which of the following fasting blood glucose levels signifies
prediabetes?
85-99 mg/dL
100-125 mg/dL
126-130 mg/dL
131-150 mg/dL

13. Prediabetes often precedes overt type 2 diabetes. Prediabetes is
defined by a fasting blood glucose level of 100-125 mg/dL or a 2-hour
post-oral glucose tolerance test glucose level of 140-200 mg/dL. Persons
with prediabetes are at increased risk for macrovascular disease as well
as diabetes.

14. Which of the following tests is the criterion standard for monitoring
long-term glycemic control?
Fasting C-peptide
Urine albumin excretion
Fasting plasma glucose
Glycated hemoglobin (A1c)

15. Binding of glucose to hemoglobin A is a nonenzymatic process that
occurs over the lifespan of a red blood cell, which averages 120 days.
Measurement of A1c thus reflects plasma glucose levels over the
preceding 2-3 months.
A1c measurements are the criterion standard for monitoring long-term
glycemic control. In the past, A1c measurements were not considered
useful for the diagnosis of diabetes mellitus because of a lack of
international standardization and insensitivity for the detection of
milder forms of glucose intolerance.

16. Which of the following is the most common complication in patients
with type 2 diabetes?
Stroke
Pancreatic neoplasms
Peripheral neuropathy
Diabetic nephropathy

17. Peripheral neuropathy is the most common complication observed in patients
with type 2 diabetes in outpatient clinics. Patients may have paresthesias,
numbness, or pain. The feet are involved more often than the hands.
Improved glycemic control early may alleviate some of the symptoms, although
sometimes symptoms actually worsen with lowering of blood glucose levels.
Later symptomatic therapy largely is empirical and may include the following:
Low-dose tricyclic antidepressants
Duloxetine
Anticonvulsants (eg, phenytoin, gabapentin, carbamazepine)
Topical capsaicin
Various pain medications, including nonsteroidal anti-inflammatory drugs

18. Which of the following is considered a first-line treatment for type 2
diabetes mellitus?
Dulaglutide
Rosiglitazone
Canagliflozin
Metformin

19. Although the long-term benefits and harms of diabetes medications
remain unclear, the evidence supports the use of metformin as a first-
line agent. On average, monotherapy with many of the oral diabetes
drugs reduces A1c levels by 1 percentage point (although metformin has
been found to be more efficacious than the dipeptidyl peptidase-4
inhibitors), and two-drug combination therapies reduce A1c about 1
percentage point more than do monotherapies.

20. Diabetes as a progressive disease
 Two basic underlying mechanisms lead to type 2 diabetes:
 Insulin resistance
 Impaired insulin secretion from beta cells within the
pancreas

26. Recommendations: Glycemic
Goals in Adults
A reasonable A1C goal for many nonpregnant adults is
<7% (53 mmol/mol). A
Consider more stringent goals (e.g. <6.5%) for select
patients if achievable without significant hypos or other
adverse effects. C
Consider less stringent goals (e.g. <8%) for patients with
a history of severe hypoglycemia, limited life expectancy,
or other conditions that make <7% difficult to attain. B
AMERICAN DIABETES ASSOCIATION STANDARDS OF MEDICAL CARE IN DIABETES.
DIABETES CARE VOLUME 42, SUPPLEMENT 1, JANUARY 2019
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56

27. Glycemic Recommendations for Nonpregnant
Adults with Diabetes
Postprandial glucose may be targeted if A1C goals are
not met despite reaching preprandial glucose goals.
AMERICAN DIABETES ASSOCIATION STANDARDS OF MEDICAL CARE IN DIABETES.
DIABETES CARE VOLUME 42, SUPPLEMENT 1, JANUARY 2019
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56

28. Care Delivery Systems
33-49% of patients still do not meet targets for A1C,
blood pressure, or lipids.
14% meet targets for all A1C, BP,
lipids, and nonsmoking status.
AMERICAN DIABETES ASSOCIATION STANDARDS OF MEDICAL CARE IN DIABETES.
PROMOTING HEALTH AND REDUCING DISPARITIES IN POPULATIONS. DIABETES CARE 2017; 40 (SUPPL. 1): S6-S10

29. Figure 6.1—Depicted are patient and disease factors used to determine optimal A1C targets. Characteristics and predicaments toward the left justify
more stringent efforts to lower A1C; those toward the right suggest less stringent efforts. A1C 7% = 53 mmol/mol.
American Diabetes Association Standards of Medical Care in Diabetes.
Diabetes Care Volume 42, Supplement 1, January 2019

30. A1C and CVD Outcomes
DCCT: Trend toward lower risk of CVD events with intensive
control (T1D)
EDIC: 57% reduction in risk of nonfatal MI, stroke, or CVD death
(T1D)
UKPDS: nonsignificant reduction in CVD events (T2D).
ACCORD, ADVANCE, VADT suggested no significant reduction in
CVD outcomes with intensive glycemic control. (T2D)
AMERICAN DIABETES ASSOCIATION STANDARDS OF MEDICAL CARE IN DIABETES.
GLYCEMIC TARGETS. DIABETES CARE 2017; 40 (SUPPL. 1): S48-S56
Care.DiabetesJournals.org
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56

31. Recommendations: Pharmacologic Therapy For T2DM
Metformin, if not contraindicated and if tolerated, is the preferred
initial pharmacologic agent for T2DM. A
Once initiated, metformin should be continued as long as it is
tolerated and not contraindicated; other agents, including insulin,
should be added to metformin. A
Consider insulin therapy (with or without additional agents) in
patients with newly dx’d T2DM who are markedly symptomatic
and/or have elevated blood glucose levels (>300 mg/dL) or A1C
(>10%). E
AMERICAN DIABETES ASSOCIATION STANDARDS OF MEDICAL CARE IN DIABETES.
DIABETES CARE VOLUME 42, SUPPLEMENT 1, JANUARY 2019

32. Newer Recommendations: Pharmacologic Therapy
For T2DM
Long-term use of metformin may be associated with biochemical
vitamin B12 deficiency, and periodic measurement of vitamin B12
levels should be considered in metformin-treated patients,
especially in those with anemia or peripheral neuropathy. B
For patients with type 2 diabetes who require an injectable drug,
a glucagon-like peptide 1 receptor agonist is preferred over
insulin. B
Among patients with type 2 diabetes who have established
atherosclerotic cardiovascular disease, SGLT2 inhibitors, or GLP-
1RAs with demonstrated cardiovascular disease benefit are
recommended as part of the antihyperglycemic regimen. A
American Diabetes Association Standards of Medical Care in Diabetes.
Diabetes Care Volume 42, Supplement 1, January 2019

33. Newer Recommendations: Pharmacologic Therapy
for T2DM
Among patients with atherosclerotic cardiovascular disease at
high risk of heart failure or in whom heart failure coexists, SGLT2i
are preferred. C
For patients with type 2 diabetes and chronic kidney disease,
consider the use of an SGLT2i or GLP1RA shown to reduce the risk
of CKD progression, CV events, or both. C
American Diabetes Association Standards of Medical Care in Diabetes.
Diabetes Care Volume 42, Supplement 1, January 2019

37. Recommendation 5
5. In adults with type 2 diabetes with clinical CVD in whom
glycemic targets are not achieved with existing
antihyperglycemic medication(s) and with an eGFR >30
mL/min/1.73 m2, an SGLT2 inhibitor with
demonstrated heart failure hospitalization reduction
may be added to reduce the risk of heart failure
hospitalization [Grade B, Level 2 for empagliflozin; Grade C,
Level 2 for canagliflozin]
2018 Diabetes Canada CPG – Chapter 28. Treatment of Diabetes in
People with Heart Failure 2018
CVD, cardiovascular disease

38. Thank You