Type 2 dm gdm new updates & guidelines

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Type 2 diabetes is a multifactorial disorder characterised by progressive pancreatic beta-cell dysfunction and insulin- resistance, leading to relative insulin deficiency, chronic hyperglycaemia, and various complications.
The treatment options for this disorder, which aim at correcting one or other of the two major pathophysiological mechanisms, have been hamstrung by unacceptable side-effects, lack of patient acceptability, and loss of efficacy over time.

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Type 2 dm gdm new updates & guidelines

  1. 1. Type 2 DM / GDM new updates & guidelines Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Ivy Hospital Sector 71 MohaliWeb:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495
  2. 2. INTRODUCTIONType 2 diabetes is a multifactorial disorder characterised by progressive pancreatic beta- cell dysfunction and insulin- resistance, leading to relative insulin deficiency, chronic hyperglycaemia, and various complications.The treatment options for this disorder, which aim at correcting one or other of the two major pathophysiological mechanisms, have been hamstrung by unacceptable side- effects, lack of patient acceptability, and loss of efficacy over time.
  3. 3. Current Criteria for diagnosis as per ADA 20101. A1C > 6.5%. OR2. FPG > 126 mg/dl OR3. two-hour plasma glucose > 200 mg/dl during an OGTT. OR4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose> 200 mg/dl A1C test to be done at least two times a year in patient meeting treatment goal and quarterly in patients whose therapy has changed or who are not meeting glycemic goals.
  4. 4. Antiplatelet Therapy in DiabetesADA & AHA 2007 recommends aspirin therapy asprimary prevention strategy in those withdiabetes at increased cardiovascular risk whichincludes1. Age > 40 yrs2. Family history of cardiovascular disease3. Hypertension4. Smoking5. Dyslipidemia6. Albuminuria
  5. 5. • New antiplatelet therapy includes – prasugrel,ticagrelor, congrelor , elinogel.• OPTIMUS- 3 trial presented at AHA meeting in 2009 compares the pharmacodynamic effect of 60 mg loading dose of prasugrel vs. 600 mg loading dose of clopidogrel in terms of inhibition of platelet aggregation. Maintenance dose of prasugrel was 10 mg daily.• CONCLUSION- Prasugrel have demonstrated superior antiplatelet activity in diabetes both with respect to clinical parameter & in terms of inhibition of platelet aggregation.
  6. 6. UPCOMING CHANGES IN MANAGEMENT GUIDELINES OF DIABETIC KETOACIDOSIS (DKA)• Use capillary blood ketone measurement instead of urinay ketone measurement.• Reduced maintenance fluid rates.In 1st hour administer 2-3 litres of fluid.crystalloids especially 0.9 % normal saline is the preferred solution.• Continuation of NS for the first 12 hour of rehydration• Delay insulin administration until fluid has been running for an hour.• Option to continue insulin glargine during treatment.• Use hypertonic saine instead of mannitol for the treatment of cerebral oedema(after excluding electrolyte imbalance).
  7. 7. ROUTE OF ADMINISTRATION OF INSULIN• Continuous infusion through a pump is ideal• When not available i/m insulin is preferred over s/c route.• Insulin through a dripset results in very erratic administration of insulin as insulin also attaches to the tubing.
  8. 8. RECOMMENDATION FOR THE USE OF ORAL ANTIDIABETIC AGENT IN PATIENT WITH DIABETES & RENAL DISEASE
  9. 9. CLASS OF DRUG SAFETY PROFILE IN REMARKS RENAL DISEASE 1ST generation Unsafe risk of prolonged hypoglycemiasulfonylureas2nd generation glipizide safe rest unsafe glipizide is preferred.Others to besulfonylureas avoided.Risk of hypoglycemiaα -glucosidase Unsafe possible hepatotoxicityinhibitorBiguanides unsafe risk of lactic acidosisThiazolidinediones Safe volume retention may occur especially with insulinMeglitinides repaglinide safe short half life & minimal renal excretion nateglinide not of repaglinide. completely safe Significant risk of hypoglycemia with nateglinideDPP-4 inhibitors relatively safe dose adjustment needed for moderate to severe renal diseaseamylin analogues safe no dose adjustment required for moderate to severe renal disease. no data available for ESRD & dialysis patient.
  10. 10. SITAGLIPTIN DOSE ADJUSTMENT• Creatinine clearance 50-80 ml/min –100 mg qd• Creatinine clearance 30-50 ml/min –50 mg qd• Creatinine clearance ,30 ml/min or ESRD (approx. serum cretinine . 3 mg/dl for male & 2.5 mg/dl for women, or on dialysis) –25mg qd
  11. 11. ADVANCES IN THERAPY FOR TYPE 2 DIABETES MELLITUSINCRETIN GROUP OF DRUGS –• Glucagon like peptide 1 (GLP 1) receptor agonists.• Dipeptidyl peptidase 4 (DPP 4) inhibitor. GLP 1 analog control blood glucose through regulation of islet function principally with the stimulation of insulin & inhibition of glucagon secretion . they also inhibit gastric emptying & reduce food intake leading to weight loss.they may reduce blood pressure & plasma lipid profile in patient of type 2 diabetes mellitus leading to decrease in incidence of cardiovascular event. Treatment related adverse events include nausea, vomiting & rarely pancreatitis.marketed as exenatide & liraglutide.
  12. 12. DPP 4 inhibitors (gliptins) –GLP 1 has a very short halflife of 2-3 min. due to hydrolysis by DPP 4 .DPP 4inhibitors enhance & prolong the action of incretinhormones by competitively antagonizing with theenzyme DPP 4.they causes modest reductioninglycated hb of around 0.7 – 1.0 % .they appear to bewell tolerated, low risk of hypoglycemia, donot causeweight gain , given as once a day oral therapy.adverseeffects includes adverse immunologic reaction, longterm safety data are awaited.It is indicated in obese patient with type 2 DM incombination with metform in or glitazone or both.
  13. 13. • SODIUM GLUCOSE TRANSPORTER -2 INHIBITORS (SGLT-2 INHIBITORS)- SGLT-2 INHIBITORS are said to act by suppressing the glucose reabsorption in the S1 segment of the proximal tubules of the kidney thus enhancing urine glucose excretion. These drugs are in phase 3 trials.potential theoretical side effects includes urinary tract & genital tract infections, electrolyte imbalance, increased urinary frequency, stroke, disturbed sleep• BROMOCRIPTINE :-USFDA has approved use of a special formulation of the centrally acting dopamine agonist bromocriptine either as monotherapy orin conjunction with other antidiabetic agents. Mechanism of action may involve improvement of glucose & energy metabolism through activation of central dopaminergic pathway.
  14. 14. DIABETES IN PREGNANCYDiabetes in pregnancy is classified as1. Pregestational diabetes which may be typa 1 or type 2 &2. Gestational diabetes mellitus DIAGNOSIS OF GDM :- ADA procedure :-• ADA recommends two step procedure in step 1, 50 gm glucose challenge test is used for screening without regards to the time of last meal or time of the day.In step 2 if 1 hr GCT value is more than 140 mg/dl than 100gm OGTT is recommended & plasma glucose is estimated at 0, 1, 2 & 3 hours.GDM is diagnosed if any 2 values meet or exceed the cutoff values of 95, 180, 155, &140 mg/dl respectively.
  15. 15. WHO procedure :- WHO recommends using a 2 hr 75 gm OGTT with a threshold plasma glucose concentration of more then 140 mg/dl at 2hrs, similar to that of IGT outside pregnancy.• The introduction of single step procedure for both screening & diagnosis has made it clear & simple.

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