An Overview of Diabetes
Sid McNulty
Consultant Physician &
Endocrinologist
Constructivism and Experiential
learning and the brain
Sensory
Integrative
Making sense
Integrative
Planning
‘Motor’
(plus...
Neuronal networks
Tap into and build on what the learner already
knows
ACEi actions
K+ sparing
Diuretic
Antihypertensive
P...
Diagnosis of Diabetes
WHO (adopted in UK 6/00):
Symptoms of hyperglycaemia plus 1 blood
Random/2 hr plasma gluc > 11.1 mmo...
Diagnostic dilemma
Sensitivity: positives identified as positive
Specificity: negatives identified as negative
100% specif...
Lethal Disease X
Affects 1 in 10,000
100% fatal – horrible and painful death
Fantastic test for it 99% (99% sensitive ie p...
Please stand up
Condition
Positive Negative
Test
Result
Positive True +ve False +ve +ve predictive
value
TP/TP+FP
Negative False -ve True ...
A ‘Good’ Test?
The Devil is in the detail!
Condition
Positive Negative
Test
Result
Positive True +ve False +ve +ve predictive
value
TP/TP+FP
Negative False -ve True ...
What tests means
Sensitivity: about the disease…the people you identify
with the disease/total number with the disease
(TP...
Gedankenversuch
Test: being called mags to diagnose
being a woman
Male Female
True positive
False
negative
False positive
True
negative
What being called mags means
Sensitivity (disease): if you’re a woman, how likely
is it you’ll be called mags (low 1%)
Spe...
Lethal Disease X
Affects 1 in 10,000
100% fatal – horrible and painful death
Fantastic test for it 99% (99% sensitive ie p...
Please stand up, again
One million people
1 in 10,000 with disease 1 in 100 with false +ve
1 in 10,000 with
disease and +ve
test
ie 100 people
1 ...
One million people
How many have disease?
1 in 10,000
100 people
How many would test positive?
1 in 100
10,000
If positive...
What tests means
Sensitivity: about the disease…the people you identify
with the disease/total number with the disease
(TP...
Incidence of Diabetes
The incidence is increasing steeply
World diabetic population is estimated to
reach 221 million peop...
Types of diabetes
Type 1 (IDDM)
Absolute insulin
deficiency
ß-cell failure
Young, thin
Prone to DKA
Type 2 (NIDDM)
Relativ...
Insulin balance with age T1DM
0
20
40
60
80
100
120
insulin req
insulin T1
‘Event’
Obesity and T2DM
Obesity
Inactivity
Insulin resistance
Hyperglycaemia
Micro- and macro-vascular
complications
Hypertension...
The Progress to T2DM
Wt 70 kg
Requires 60 U
Panc Res 200 U
Level: 60 U
Normal
Wt 100 kg
Requires 150 U
PR 200 U
Level: 150...
12 v 121 v 1210 units?
8 v 81 v 810 units/hr?
50 v 501 v 5010 units/50ml?
1010 units Actrapid at 100 mls/hr?
Insulin balance with age T2DM
0
20
40
60
80
100
120
insulin T1
insulin T2
Insulin balance with age T2DM
0
20
40
60
80
100
120
insulin req0
insulin T1
insulin T2
Why worry with diabetic in-patients
Avoid emergencies:
Main aim of your Mx
Plus tighten peri-operative glucose control
Diabetic emergencies
Hypoglycaemia
Hyperglycaemia
DKA: Type 1
HHS/HONK: Type 2
Hypoglycaemia
BMs 2-4
Autonomic symptoms: Sympathetic
Sweaty, agitated, nausea, shaky, pale, hungry
BMs 0-2
Neuroglycopeni...
Mechanism of Normoglycaemia
β cell
Proinsulin
Insulin C Peptide
↓ Glucose
Pancreas
Pancreas
Glucagon Glycogen Liver
↑ Gluc...
Mechanism of Hypoglycaemia
β cell
Proinsulin
Insulin C Peptide
↓ Glucose
Pancreas
Pancreas
Glucagon Glycogen Liver
↑ Gluco...
Treatment of Hypo
Treatment:
IV glucose 50ml 50%
IM glucagon 1 mg
?Treat cause
steroids (Addison’s, NICTH)
surgery (Insuli...
Presentation & definition of DKA
Young, thin, T1DM
Poly-uria, -dypsia, weight loss (passing sugar water)
SOB (kussmal - bl...
Mechanism of DKA
Intercurrent illness
Increased counter-regulatory
hormones (Cats and cortisol)
Severe insulin deficiency
...
Mechanism of DKA
Hormone-sensitive lipase
TriglycerideNon-esterified fatty acids
Acetoacetate
3-HydroxybutyrateAcetone
Gly...
Mechanism of DKA
Intercurrent illness
Increased counter-regulatory
hormones (Cats and cortisol)
Severe insulin deficiency
...
Mechanism of DKA
Hyperglycaemia Ketone bodies
Osmotic
diuresis Vomiting Acidosis
Electrolyte
depletion
Dehydration Vasodil...
Management of DKA General
NG tube
Reduced consciousness
Gastroparesis
IV access
? Central line only if indicated
Catheter
...
Management DKA Specific
T1DM
Acute decompensation
pH <7.3, Bicarb <15, Ketosis, Gluc >15
IV insulin 0.1 unit/kg/hr = 6-8 u...
13th
May 2010
Died July 1997
Retired last year and
still facing 12 charges!
HyperOsmotic NonKetotic Coma (AKA)
Hyperglycaemic HyperOsmolar Syndrome
Presentation & Definition
In Type 2 DM
Longer Hx -...
Management of HHS Summary
T2DM, older, co-morbidity, more sick
Osmol > 350 mmol/Ltr
Gluc usually >>30 mmol/Ltr
Same genera...
GKI/Alberti (to give insulin to T1DM)
15 units Actrapid
500 ml 10% Dextrose
10 mmol KCl
80-100ml/hour
If BMs high add anot...
Complications & Diabetes
Microvascular v Macrovascular
‘KNIVES’
K - kidneys
N - nerves
I - impotence, infection
V – vascul...
Macrovascular risk factors
Male
Age
Family History
Other Vascular Disease:
CVA, TIA
LVH
Diabetes
Hypertension
Lipids:
↑Cho...
Diabetic complications
Prevention of complications
Risk reduction – relative versus absolute
Risk elimination
Residual risk
Intervention studies - Drug X
Reduces total chol 70%
Reduces LDL 50%
Increases HDL 10%
Would you take it?
Surrogate marker...
Relative risk reduction
RR↓ 50%
RR↓ 50%
RR↓ 50%
Risk of AE Relative versus absolute risk
RR↓ 50%
Absolute risk reduction
Absolute risk reduction
Absolute risk reduction
Lies, damn lies and statistics
6/49 x 5/48 x 4/47 x 3/46 x 2/45 x 1/44 =
720/10,068,347,520 =
1 in 13,983,816
Increase you...
Numbers Needed to Treat….
100 patients
10 events
100 patients
5 events
Relative risk reduction 50%
Treat 100 people, 5 eve...
This maybe all that we can offer you
1000 patients
10 events
1000 patients
5 events
Relative risk reduction 50%
Treat 1000...
Intervention studies - Drug X
Reduces total chol 70%
Reduces LDL 50%
Increases HDL 10%
Would you take it?
Surrogate marker...
What does risk reduction mean?
What was not going
to happen
When does this not
happen
What did happen
in spite of
interven...
RR reduction 50% with 20% side effects
What was not going
to happen
Plus SE
Primum non nocere
First do no harm!
What did h...
Maximilien François Marie Isidore de Ro
(May 6, 1758–July 28, 1794),
On ne peut pas faire
d'omelette sans casser des
oeufs...
Risk of crossing the road
Park cars
Eyes closed
Heavy traffic
Run out
Pedestrian crossing
Wait for green man
Look both way...
Prevention of macrovascular
complications
Primary prevention
All T2DM & most T1DM (10y risk <15%)
Tight glycaemic control ...
Glycaemia in T2DM
HbA1c 2/12 marker (area under the curve)
Mean 5.4%, SD 0.4%
i.e. normal <6.2
HbA1c <7.5 <6.5
Normality
Mean
1 SD
2 SDs
3 SDs
68%
95%
99%
HbA1c: mean 5.4%, SD 0.4%
5.4%
6.2%
68%
95%
99.5%
7.0%4.6%
2.5% ‘normal
population’
0.25%
Oral Hypoglycaemics
Metformin (if BMI >24)
500 - 1000mg b.d - t.d.s
Side effects - GI….lactic acidosis
Contraindications -...
Hypoglycaemics
Incretins – Exanatide, gliptins
Insulins:
long v short
free v pre-mixed
human v pork v analogue
?CSII etc
C...
Normal person
0
2
4
6
8
10
12
14
16
18
1 3 5 7 9 11 13 15 17 19 21 23
Isulin
Glusose
BD Mix
0
5
10
15
20
25
30
35
40
short
long
7am 6pm
Breakfast
Lunch
Dinner
Snack
Basal Bolus
0
5
10
15
20
25
30
35
1
3
5
7
9
11
13
15
17
19
21
23
Basal
Bolus
am short
Lunch short
Dinner short
Evening bac...
Titrating Insulin-
BD mix
BM reading Insulin
7 am Nocte long
Noon Mane short
6 pm Mane long
10 pm Nocte short
Titrating Insulin-
Basal Bolus
BM reading Insulin
7 am Nocte basal
Noon Mane short
6 pm Noon short
10 pm Supper short
Lipid lowering
Diet/lifestyle/co-morbid/smoking
CVS equivalent (or CVS risk >15%@10 yr)
LDL/Total Chol (>2.0/4.0) - Statin...
ABCD tool
Anti-hypertensives
ACE I/AT2A
Ramipril 2.5 - 10mg, Irebesartan 150 - 300mg
Partic if: CCF, IHD, MI, nephropathy, CVA
CI: p...
Microvascular Complications
Retinopathy
Nephropathy
Neuropathy
Erectile dysfunction
Prevention of microvascular
complications
Primary prevention
Tighten control:
Glycaemia, BP, Lipids
Aspirin, ACE I, Anti O...
Annual Screen
HbA1c/Lipids/Creat/BP/Wt
Alb:Creat Ratio
Feet - pulses, sensation (10g MF), ulcers
Eyes - dilated funduscopy...
Mx T2DM Conclusions
Lifestyle: Smoking, Diet, Exercise & Weight
Annual screen for complications
Glycaemic control (UKPDS M...
Questions?
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Diabetes Overview by Dr McNulty

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The Diabetes Overview lecture given by Dr McNulty to Surgical Scousers on Nov 2, 2010.

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Diabetes Overview by Dr McNulty

  1. 1. An Overview of Diabetes Sid McNulty Consultant Physician & Endocrinologist
  2. 2. Constructivism and Experiential learning and the brain Sensory Integrative Making sense Integrative Planning ‘Motor’ (plus verbal) Concrete experience Active reflection Abstract conceptualisation Active experimentation
  3. 3. Neuronal networks Tap into and build on what the learner already knows ACEi actions K+ sparing Diuretic Antihypertensive Postural hypotension Insulin action Hypoglycaemia Addison’s Lack of RAAS drive Lack of insulin antagonism Cushing’s opposite of Addison’s and therefore opposite of: Insulin and diuretics, and therefore…. Blockage of RAAS
  4. 4. Diagnosis of Diabetes WHO (adopted in UK 6/00): Symptoms of hyperglycaemia plus 1 blood Random/2 hr plasma gluc > 11.1 mmol/l, or Fasting plasma glucose > 7.0 mmol/l In the absence of symptoms, there must be 2 plasma glucose results in the diabetic range on separate days.
  5. 5. Diagnostic dilemma Sensitivity: positives identified as positive Specificity: negatives identified as negative 100% specific Over 10m long Over 15,000 mph Over 6,000 Km high No false alarms Lots of false -ve 100% sensitive Over 1m long Over 10mph Off the ground Don’t miss a strike Lots of false +ve
  6. 6. Lethal Disease X Affects 1 in 10,000 100% fatal – horrible and painful death Fantastic test for it 99% (99% sensitive ie picks up disease as disease, and 99% specific ie picks up normal as normal) You have the test 1 week later the results You are positive What is your probability you have disease? What do you do?
  7. 7. Please stand up
  8. 8. Condition Positive Negative Test Result Positive True +ve False +ve +ve predictive value TP/TP+FP Negative False -ve True –ve -ve predictive value TN/TN+FN Sensitivity 99% TP/TP+FN x100 Specificity 99% TN/TN+FP x 100 A ‘Good’ Test
  9. 9. A ‘Good’ Test?
  10. 10. The Devil is in the detail!
  11. 11. Condition Positive Negative Test Result Positive True +ve False +ve +ve predictive value TP/TP+FP Negative False -ve True –ve -ve predictive value TN/TN+FN Sensitivity 99% TP/TP+FN x100 Specificity 99% TN/TN+FP x 100 A ‘Good’ Test
  12. 12. What tests means Sensitivity: about the disease…the people you identify with the disease/total number with the disease (TP/TP+FN)…if you have disease, you test positive Specificity: about the disease…the people you identify without the disease/total number without the disease (TN/TN+FP)… if you don’t have disease you test negative Positive predictive value: about the test…the number of people you test positive with the disease/total number you test positive (TP/TP+FP)… if you test positive, likelihood you have disease Negative predictive value: about the test…the number of people you test negative without the disease/total number you test negative (TN/TN+FN)… if you test negative, likelihood you don’t have the disease
  13. 13. Gedankenversuch
  14. 14. Test: being called mags to diagnose being a woman Male Female True positive False negative False positive True negative
  15. 15. What being called mags means Sensitivity (disease): if you’re a woman, how likely is it you’ll be called mags (low 1%) Specificity (disease): if you’re not a woman, how likely is it you’ll not be called mags (v high 99.99%) Positive predictive value (test): if you’re called mags, how likely are you to be a woman (high 99%) Negative predictive value (test): if you’re not called mags, how likely you’re not a woman (poor 50%)
  16. 16. Lethal Disease X Affects 1 in 10,000 100% fatal – horrible and painful death Fantastic test for it 99% (99% sensitive ie picks up disease as disease, and 99% specific ie picks up normal as normal) You have the test 1 week later the results You are positive What is your probability you have disease? What do you do?
  17. 17. Please stand up, again
  18. 18. One million people 1 in 10,000 with disease 1 in 100 with false +ve 1 in 10,000 with disease and +ve test ie 100 people 1 in 100 with +ve test and no disease ie 10,000 people
  19. 19. One million people How many have disease? 1 in 10,000 100 people How many would test positive? 1 in 100 10,000 If positive do you have disease? What is the positive predictive value TP/TP+FP: 100/10,100 ie 1 in 100 chance! Therefore – even the best test should be interpreted with clinical data, and should only be asked for in the right people (ETT ECGs, VQs etc etc)
  20. 20. What tests means Sensitivity: about the disease…the people you identify with the disease/total number with the disease (TP/TP+FN)…if you have disease, you test positive Specificity: about the disease…the people you identify without the disease/total number without the disease (TN/TN+FP)… if you don’t have disease you test negative Positive predictive value: about the test…the number of people you test positive with the disease/total number you test positive (TP/TP+FP)… if you test positive, likelihood you have disease Negative predictive value: about the test…the number of people you test negative without the disease/total number you test negative (TN/TN+FN)… if you test negative, likelihood you don’t have the disease
  21. 21. Incidence of Diabetes The incidence is increasing steeply World diabetic population is estimated to reach 221 million people by 2010 (double the number in 1994). Over 1.4 million people in the United Kingdom (3% of the pop) have diagnosed diabetes mellitus, with perhaps another million as yet undiagnosed. Amos AF et al.The rising global burden of diabetes...Diabetic Med 1997;14(suppl 5):S1-85.
  22. 22. Types of diabetes Type 1 (IDDM) Absolute insulin deficiency ß-cell failure Young, thin Prone to DKA Type 2 (NIDDM) Relative insulin deficiency Insulin resistance Old, ↑BMI (kg/m2 ) Usually on tablets or diet (can be on insulin) No DKA : instead HONK
  23. 23. Insulin balance with age T1DM 0 20 40 60 80 100 120 insulin req insulin T1 ‘Event’
  24. 24. Obesity and T2DM Obesity Inactivity Insulin resistance Hyperglycaemia Micro- and macro-vascular complications Hypertension Dyslipidaemia Endothelial dysfunction Prothombotic state
  25. 25. The Progress to T2DM Wt 70 kg Requires 60 U Panc Res 200 U Level: 60 U Normal Wt 100 kg Requires 150 U PR 200 U Level: 150 U ‘Normal’ Wt 70 kg Requires 60 U Panc Res 100 U Level: 60 U Normal Wt 100 kg Requires 150 U Panc Res 100 U Level: 100 U DM & Hyperinsulin NORMAL T2DM
  26. 26. 12 v 121 v 1210 units? 8 v 81 v 810 units/hr? 50 v 501 v 5010 units/50ml? 1010 units Actrapid at 100 mls/hr?
  27. 27. Insulin balance with age T2DM 0 20 40 60 80 100 120 insulin T1 insulin T2
  28. 28. Insulin balance with age T2DM 0 20 40 60 80 100 120 insulin req0 insulin T1 insulin T2
  29. 29. Why worry with diabetic in-patients Avoid emergencies: Main aim of your Mx Plus tighten peri-operative glucose control
  30. 30. Diabetic emergencies Hypoglycaemia Hyperglycaemia DKA: Type 1 HHS/HONK: Type 2
  31. 31. Hypoglycaemia BMs 2-4 Autonomic symptoms: Sympathetic Sweaty, agitated, nausea, shaky, pale, hungry BMs 0-2 Neuroglycopenic: Confusion, aggression, agitation, coma, hemiparesis etc
  32. 32. Mechanism of Normoglycaemia β cell Proinsulin Insulin C Peptide ↓ Glucose Pancreas Pancreas Glucagon Glycogen Liver ↑ Glucose
  33. 33. Mechanism of Hypoglycaemia β cell Proinsulin Insulin C Peptide ↓ Glucose Pancreas Pancreas Glucagon Glycogen Liver ↑ Glucose 1.Sulphonylureas 3.Exogenous 4.Lack of antagonist (cortisol etc) 5.IGF 2 6.Excess use 2.Excess 7.Lack of 8.Lack of
  34. 34. Treatment of Hypo Treatment: IV glucose 50ml 50% IM glucagon 1 mg ?Treat cause steroids (Addison’s, NICTH) surgery (Insulinoma, NICTH) Diazoxide & high dose BFZ (Paliative Insulinoma) DSN review/ Psych review
  35. 35. Presentation & definition of DKA Young, thin, T1DM Poly-uria, -dypsia, weight loss (passing sugar water) SOB (kussmal - blowing off CO2 to ↓pH), dehydrated, ↓ BP, vasodilated, drowsy Raised blood glucose (>15 mmol/L) Metabolic acidosis: pH <7.3, Bicarb <15 mmol/L Ketosis: ketostix > ++
  36. 36. Mechanism of DKA Intercurrent illness Increased counter-regulatory hormones (Cats and cortisol) Severe insulin deficiency Hyperglycaemia
  37. 37. Mechanism of DKA Hormone-sensitive lipase TriglycerideNon-esterified fatty acids Acetoacetate 3-HydroxybutyrateAcetone Glycerol + Insulin -
  38. 38. Mechanism of DKA Intercurrent illness Increased counter-regulatory hormones (Cats and cortisol) Severe insulin deficiency Hormone-sensitive lipase TriglycerideNon-esterified fatty acids Acetoacetate 3-HydroxybutyrateAcetone Glycerol + + + Hyperglycaemia
  39. 39. Mechanism of DKA Hyperglycaemia Ketone bodies Osmotic diuresis Vomiting Acidosis Electrolyte depletion Dehydration Vasodilatation Hypotension Hypothermia
  40. 40. Management of DKA General NG tube Reduced consciousness Gastroparesis IV access ? Central line only if indicated Catheter ?UTI may have precipitated DKA Dehydrated and immunosuppressed Serious risk of introducing ascending infection Therefore only if not PU’d in 3 hours Remove / treat precipitator (low threshold for Abs) ?Heparin (coma or Osmolality >350 mOsm/L)
  41. 41. Management DKA Specific T1DM Acute decompensation pH <7.3, Bicarb <15, Ketosis, Gluc >15 IV insulin 0.1 unit/kg/hr = 6-8 units/hr IV fluids 5 Ltr/24hr ? Abs (WCC/Temp mean little) No Bicarb Inform your senior
  42. 42. 13th May 2010 Died July 1997 Retired last year and still facing 12 charges!
  43. 43. HyperOsmotic NonKetotic Coma (AKA) Hyperglycaemic HyperOsmolar Syndrome Presentation & Definition In Type 2 DM Longer Hx -poly-uria/dypsia Dehydration, ↓BP, unwell High RBG (usually >>30 mmol/L) Osmolality >350 (Na+ + K+ ) x2 + Urea + Glucose = Osmol
  44. 44. Management of HHS Summary T2DM, older, co-morbidity, more sick Osmol > 350 mmol/Ltr Gluc usually >>30 mmol/Ltr Same general management as DKA IV insulin 0.1 units/kg/hr = 6-8 units/hour IV fluids 3-5 Ltr/24hr Go more gentle! ?Full heparin dose Abs, MI screen etc Inform your senior
  45. 45. GKI/Alberti (to give insulin to T1DM) 15 units Actrapid 500 ml 10% Dextrose 10 mmol KCl 80-100ml/hour If BMs high add another 5 units (and on) If BMs low add 5 units less (and on) Check K 1 hour before bag change Restart sc insulin 1/2 hour before eating
  46. 46. Complications & Diabetes Microvascular v Macrovascular ‘KNIVES’ K - kidneys N - nerves I - impotence, infection V – vascular (IHD, CVA, PVD) E - eyes S - skin infections
  47. 47. Macrovascular risk factors Male Age Family History Other Vascular Disease: CVA, TIA LVH Diabetes Hypertension Lipids: ↑Chol, ↑LDL, ↓HDL, ↑ TGs Smoking Obesity Exercise
  48. 48. Diabetic complications Prevention of complications Risk reduction – relative versus absolute Risk elimination Residual risk
  49. 49. Intervention studies - Drug X Reduces total chol 70% Reduces LDL 50% Increases HDL 10% Would you take it? Surrogate markers Losing weight reduces chol Losing weight by losing legs Reduces relative risk of MI 50% Would you take it?
  50. 50. Relative risk reduction RR↓ 50% RR↓ 50% RR↓ 50%
  51. 51. Risk of AE Relative versus absolute risk RR↓ 50% Absolute risk reduction Absolute risk reduction Absolute risk reduction
  52. 52. Lies, damn lies and statistics 6/49 x 5/48 x 4/47 x 3/46 x 2/45 x 1/44 = 720/10,068,347,520 = 1 in 13,983,816 Increase your relative risk by 100% To 1 in 6,991,908 Absolute risk increase 1 in 13 million Reduce your relative risk by 50% 1 in 27,967,632 Absolute risk reduction 1 in 13 million
  53. 53. Numbers Needed to Treat…. 100 patients 10 events 100 patients 5 events Relative risk reduction 50% Treat 100 people, 5 events prevented, therefore treat 20 to prevent 1
  54. 54. This maybe all that we can offer you 1000 patients 10 events 1000 patients 5 events Relative risk reduction 50% Treat 1000 people, 5 events prevented, therefore treat 200 to prevent 1
  55. 55. Intervention studies - Drug X Reduces total chol 70% Reduces LDL 50% Increases HDL 10% Would you take it? Surrogate markers Losing weight reduces chol Losing weight by losing legs Reduces relative risk of MI 50% Would you take it? Serious adverse event 1% per year Would you take it?
  56. 56. What does risk reduction mean? What was not going to happen When does this not happen What did happen in spite of intervention.. When did you cause this? What didn’t happen with intervention… When does this not happen When did you prevent this?
  57. 57. RR reduction 50% with 20% side effects What was not going to happen Plus SE Primum non nocere First do no harm! What did happen in spite of intervention.. When did you cause this? Plus SE What didn’t happen with intervention… When did you prevent this? Plus SE
  58. 58. Maximilien François Marie Isidore de Ro (May 6, 1758–July 28, 1794), On ne peut pas faire d'omelette sans casser des oeufs You can't make an omelette without breaking eggs Primum non nocere
  59. 59. Risk of crossing the road Park cars Eyes closed Heavy traffic Run out Pedestrian crossing Wait for green man Look both ways Walk briskly don’t run No guarantee to be or not be run over NB you do get to the other side. The prevention of accident happens in definite time frame
  60. 60. Prevention of macrovascular complications Primary prevention All T2DM & most T1DM (10y risk <15%) Tight glycaemic control (~UKPDS & DCCT) Tight BP control (UKPDS) Tight lipid management Aspirin, ACE I/AT2A, smoking, BMI Secondary prevention Hx of CVA, MI, IHD, PVD, Amputation
  61. 61. Glycaemia in T2DM HbA1c 2/12 marker (area under the curve) Mean 5.4%, SD 0.4% i.e. normal <6.2 HbA1c <7.5 <6.5
  62. 62. Normality Mean 1 SD 2 SDs 3 SDs 68% 95% 99%
  63. 63. HbA1c: mean 5.4%, SD 0.4% 5.4% 6.2% 68% 95% 99.5% 7.0%4.6% 2.5% ‘normal population’ 0.25%
  64. 64. Oral Hypoglycaemics Metformin (if BMI >24) 500 - 1000mg b.d - t.d.s Side effects - GI….lactic acidosis Contraindications - CRF, CCF, hepatic problems No weight gain, no hypos Gliclazide (if BMI <22) 40 - 320mg per day (od - bd) Side effects weight gain & hypos Glitazones (pioglitazone > rosiglitazone), acarbose etc
  65. 65. Hypoglycaemics Incretins – Exanatide, gliptins Insulins: long v short free v pre-mixed human v pork v analogue ?CSII etc Combination with OHA
  66. 66. Normal person 0 2 4 6 8 10 12 14 16 18 1 3 5 7 9 11 13 15 17 19 21 23 Isulin Glusose
  67. 67. BD Mix 0 5 10 15 20 25 30 35 40 short long 7am 6pm Breakfast Lunch Dinner Snack
  68. 68. Basal Bolus 0 5 10 15 20 25 30 35 1 3 5 7 9 11 13 15 17 19 21 23 Basal Bolus am short Lunch short Dinner short Evening background
  69. 69. Titrating Insulin- BD mix BM reading Insulin 7 am Nocte long Noon Mane short 6 pm Mane long 10 pm Nocte short
  70. 70. Titrating Insulin- Basal Bolus BM reading Insulin 7 am Nocte basal Noon Mane short 6 pm Noon short 10 pm Supper short
  71. 71. Lipid lowering Diet/lifestyle/co-morbid/smoking CVS equivalent (or CVS risk >15%@10 yr) LDL/Total Chol (>2.0/4.0) - Statins HDL/Trigs (<1, >2.2) - ? Fibrates Statins - Simva 40, Atova 40-80mg nocte good for total and LDL chol Fibrates - Fenofibrate micro 267mg mane good for trigs and HDL Nicotinic acid - good for trigs and HDL Ezetimibe - add on therapy, Omacor - post MI
  72. 72. ABCD tool
  73. 73. Anti-hypertensives ACE I/AT2A Ramipril 2.5 - 10mg, Irebesartan 150 - 300mg Partic if: CCF, IHD, MI, nephropathy, CVA CI: pregnant, renovascular disease (watch Creat) Thiazide diuretics (low dose!) - BFZ 2.5 mg o.d β blockers - atenolol 50mg Partic if MI, IHD, CCF CCB - Amolidipine 5-10mg o.d α blockers - Doxazosin XL 4-16mg (BPH) Central acting etc
  74. 74. Microvascular Complications Retinopathy Nephropathy Neuropathy Erectile dysfunction
  75. 75. Prevention of microvascular complications Primary prevention Tighten control: Glycaemia, BP, Lipids Aspirin, ACE I, Anti Obesity Secondary prevention Catch & Treat early (as above, laser Rx etc) Therefore screen for them Funduscopy, feet inspection, urine & blood tests
  76. 76. Annual Screen HbA1c/Lipids/Creat/BP/Wt Alb:Creat Ratio Feet - pulses, sensation (10g MF), ulcers Eyes - dilated funduscopy, VAs Kidneys - BP/ACR/Creat Smoking status
  77. 77. Mx T2DM Conclusions Lifestyle: Smoking, Diet, Exercise & Weight Annual screen for complications Glycaemic control (UKPDS Metformin > Glic) CVS Risk Calculation (>15%) v Equiv Lipid control LFD, Statin, ?Fibrates BP control ACE I, ATII, Diuretics, β Blocker, CCB, other Other drug Rx: Aspirin,?anti obesity,?anti smoking, ?HRT
  78. 78. Questions?

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