The document provides guidelines for the management of type 2 diabetes. It discusses several key points:
- It recommends an algorithmic approach to treatment that begins with lifestyle modifications and progresses to oral medications and potentially insulin depending on a patient's ability to achieve blood glucose targets.
- Metformin is recommended as the first-line medication due to its efficacy and side effect profile. Other oral medications and potentially insulin are options if targets are not met.
- The goal of treatment is to achieve an A1C level below 7% to reduce the risk of diabetes-related complications like cardiovascular disease, nerve damage, and kidney disease.
- A team-based approach is emphasized to help patients self-manage their diabetes
This document discusses the natural history of type 2 diabetes, including:
1) Type 2 diabetes progresses from normal glucose tolerance to prediabetes and eventually overt diabetes, driven by deteriorating beta cell function and insulin resistance over time.
2) Several pathophysiological defects contribute to type 2 diabetes, including insulin resistance, relative insulin deficiency, and impaired incretin effect.
3) Obesity is a major risk factor for developing insulin resistance and type 2 diabetes by promoting increased secretion of fatty acids and inflammatory cytokines from abdominal fat cells.
This document provides information on diabetes management priorities and complications. It discusses monitoring glucose and lipids, treating hypertension, screening for microvascular complications, and the benefits of glucose control in reducing retinopathy, nephropathy, and neuropathy based on findings from the DCCT and UKPDS trials. It also outlines the natural history of type 1 and type 2 diabetes, chronic microvascular complications including retinopathy, nephropathy and neuropathy, and their prevention and treatment.
- T2DM accounts for 90-95% of all diagnosed diabetes cases. It is a growing epidemic affecting 246 million people worldwide in 2007.
- The main pathophysiology of T2DM includes insulin resistance in muscle, liver and fat tissues as well as insulin deficiency due to impaired insulin secretion from pancreatic beta cells over time.
- Current treatment options for T2DM like metformin, sulfonylureas and thiazolidinediones have limitations such as side effects of weight gain, hypoglycemia, edema and heart failure which impact efficacy and safety.
Type 2 diabetes mellitus (T2DM) is a chronic condition characterized by insulin resistance and an inability to properly regulate blood sugar levels. The two most important risk factors for T2DM are a family history of diabetes and obesity, though age, race, diet, and exercise level also impact risk. Common symptoms include frequent urination, nerve damage, and dark skin patches. Treatment involves lifestyle changes like diet and exercise as well as medications like metformin, which improves insulin sensitivity and decreases glucose production in the liver. Patients are counseled on managing diabetes-related risks and provided support through organizations and groups.
Management of diabetes with risk factors getting to goal in glycemic control ...Mahir Khalil Ibrahim Jallo
This document discusses the management of diabetes with risk factors and glycemic control. It covers the objectives of examining the epidemiology of diabetes in the UAE, recent ADA-EASD guidelines on managing hyperglycemia in type 2 diabetes, cardiovascular risks of diabetes, the role of DPP-4 inhibitors, hypoglycemia and its consequences, and diabetes and Ramadan. It also summarizes three major clinical trials (ACCORD, ADVANCE, and VADT) that examined the effects of intensive glucose control on cardiovascular outcomes in type 2 diabetes patients.
Diabetic nephropathy is a leading cause of end-stage renal disease worldwide. Strict control of blood glucose, blood pressure, angiotensin system inhibitors, and other risk factors can help prevent or slow the progression of kidney damage. The stages include early hyperfiltration, development of microalbuminuria, progression to macroalbuminuria and renal failure. Management focuses on glycemic control, blood pressure reduction, angiotensin blockade, cholesterol control, and management of anemia and cardiovascular risk factors to preserve kidney function for as long as possible.
Modern modalities for management of diabetes dr mahir jallo gulf medical univ...Mahir Khalil Ibrahim Jallo
This document discusses modern modalities for managing diabetes. It begins by defining the main types of diabetes - type 1, type 2, and gestational diabetes. It then discusses diabetes complications and treatments, including various classes of oral medications and insulins to manage blood glucose levels. Newer classes of medications that work by different mechanisms, such as DPP-4 inhibitors and SGLT2 inhibitors, are also covered. The document emphasizes the importance of a multifactorial treatment approach to diabetes management.
This document provides information on insulin therapy for type 2 diabetes. It discusses:
1) The scientific foundation for insulin therapy, noting that insulin is needed to achieve glycemic targets, and is most effective when started earlier and matched to a patient's glucose profile and lifestyle.
2) Glycemic targets for type 2 diabetes according to different organizations like the ADA and IDF.
3) Steps for starting insulin therapy, including setting targets, determining the appropriate regimen, calculating starting doses, and educating patients.
This document discusses the natural history of type 2 diabetes, including:
1) Type 2 diabetes progresses from normal glucose tolerance to prediabetes and eventually overt diabetes, driven by deteriorating beta cell function and insulin resistance over time.
2) Several pathophysiological defects contribute to type 2 diabetes, including insulin resistance, relative insulin deficiency, and impaired incretin effect.
3) Obesity is a major risk factor for developing insulin resistance and type 2 diabetes by promoting increased secretion of fatty acids and inflammatory cytokines from abdominal fat cells.
This document provides information on diabetes management priorities and complications. It discusses monitoring glucose and lipids, treating hypertension, screening for microvascular complications, and the benefits of glucose control in reducing retinopathy, nephropathy, and neuropathy based on findings from the DCCT and UKPDS trials. It also outlines the natural history of type 1 and type 2 diabetes, chronic microvascular complications including retinopathy, nephropathy and neuropathy, and their prevention and treatment.
- T2DM accounts for 90-95% of all diagnosed diabetes cases. It is a growing epidemic affecting 246 million people worldwide in 2007.
- The main pathophysiology of T2DM includes insulin resistance in muscle, liver and fat tissues as well as insulin deficiency due to impaired insulin secretion from pancreatic beta cells over time.
- Current treatment options for T2DM like metformin, sulfonylureas and thiazolidinediones have limitations such as side effects of weight gain, hypoglycemia, edema and heart failure which impact efficacy and safety.
Type 2 diabetes mellitus (T2DM) is a chronic condition characterized by insulin resistance and an inability to properly regulate blood sugar levels. The two most important risk factors for T2DM are a family history of diabetes and obesity, though age, race, diet, and exercise level also impact risk. Common symptoms include frequent urination, nerve damage, and dark skin patches. Treatment involves lifestyle changes like diet and exercise as well as medications like metformin, which improves insulin sensitivity and decreases glucose production in the liver. Patients are counseled on managing diabetes-related risks and provided support through organizations and groups.
Management of diabetes with risk factors getting to goal in glycemic control ...Mahir Khalil Ibrahim Jallo
This document discusses the management of diabetes with risk factors and glycemic control. It covers the objectives of examining the epidemiology of diabetes in the UAE, recent ADA-EASD guidelines on managing hyperglycemia in type 2 diabetes, cardiovascular risks of diabetes, the role of DPP-4 inhibitors, hypoglycemia and its consequences, and diabetes and Ramadan. It also summarizes three major clinical trials (ACCORD, ADVANCE, and VADT) that examined the effects of intensive glucose control on cardiovascular outcomes in type 2 diabetes patients.
Diabetic nephropathy is a leading cause of end-stage renal disease worldwide. Strict control of blood glucose, blood pressure, angiotensin system inhibitors, and other risk factors can help prevent or slow the progression of kidney damage. The stages include early hyperfiltration, development of microalbuminuria, progression to macroalbuminuria and renal failure. Management focuses on glycemic control, blood pressure reduction, angiotensin blockade, cholesterol control, and management of anemia and cardiovascular risk factors to preserve kidney function for as long as possible.
Modern modalities for management of diabetes dr mahir jallo gulf medical univ...Mahir Khalil Ibrahim Jallo
This document discusses modern modalities for managing diabetes. It begins by defining the main types of diabetes - type 1, type 2, and gestational diabetes. It then discusses diabetes complications and treatments, including various classes of oral medications and insulins to manage blood glucose levels. Newer classes of medications that work by different mechanisms, such as DPP-4 inhibitors and SGLT2 inhibitors, are also covered. The document emphasizes the importance of a multifactorial treatment approach to diabetes management.
This document provides information on insulin therapy for type 2 diabetes. It discusses:
1) The scientific foundation for insulin therapy, noting that insulin is needed to achieve glycemic targets, and is most effective when started earlier and matched to a patient's glucose profile and lifestyle.
2) Glycemic targets for type 2 diabetes according to different organizations like the ADA and IDF.
3) Steps for starting insulin therapy, including setting targets, determining the appropriate regimen, calculating starting doses, and educating patients.
Diabetic nephropathy has become a leading cause of end-stage renal failure. Approximately 40% of patients with diabetes develop nephropathy, which is characterized by persistent albuminuria, elevated blood pressure, and decline in kidney function. Good glycemic and blood pressure control can delay the onset and slow the progression of diabetic nephropathy. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are effective in treating diabetic nephropathy through their blood pressure lowering effects and additional renal protection. Intensive management of all cardiovascular risk factors can further slow the progression of kidney damage in patients with diabetes.
This document discusses different types of iatrogenic (medically induced) diabetes, including:
1) Pancreatogenic diabetes caused by pancreatic diseases or procedures that damage the pancreas.
2) Drug-induced diabetes caused by medications like corticosteroids, antipsychotics, immunosuppressants, protease inhibitors, and chemotherapy drugs.
3) Post-transplant diabetes that develops in some organ transplant recipients due to immunosuppressant drugs and other risk factors.
The document provides details on the mechanisms and risk factors for each type of iatrogenic diabetes.
Diabetic nephropathy medical managementNilesh Jadhav
1. Diabetic nephropathy is a chronic kidney disease caused by damage to the kidneys over many years as a result of diabetes. It is the most common cause of end-stage renal disease.
2. Management of diabetic nephropathy focuses on optimal control of blood glucose, blood pressure, lipids through medication, lifestyle changes, and monitoring for progression of kidney disease.
3. RAAS blockade using ACE inhibitors, ARBs, or renin inhibitors is important treatment but requires monitoring of potassium and kidney function. Referral to a nephrologist is recommended for atypical cases or rapid decline in kidney function.
This document provides information on diabetic nephropathy and diabetic kidney disease (DKD) for healthcare professionals. It covers the causes and risk factors of DKD, how to screen for and diagnose it, treatment options, and guidelines for when to refer patients to specialists. It emphasizes the importance of controlling blood glucose and blood pressure to prevent and slow the progression of DKD. Lifestyle modifications and medication adjustments may be needed for patients with reduced kidney function.
This document discusses diabetic neuropathy. It begins with some global statistics on the prevalence and costs of diabetic neuropathy. It then discusses the pathology, risk factors, presentations, diagnosis and treatments of various types of diabetic neuropathy, including diffuse symmetrical sensorimotor polyneuropathy, autonomic neuropathy, and diffuse small fibre neuropathy. Tight glycemic control is emphasized as an important part of prevention and treatment.
This document provides an overview of diabetes mellitus including definitions, classification, epidemiology, pathophysiology of type 1 and type 2 diabetes, and goals of treatment. Key points include:
- Type 1 diabetes results from autoimmune destruction of pancreatic beta cells in genetically predisposed individuals and requires lifelong insulin treatment.
- Type 2 diabetes involves both insulin resistance and impaired insulin secretion and is strongly associated with obesity and physical inactivity. It can often be managed through lifestyle modifications and oral medications.
- Medical nutrition therapy, physical activity, weight loss (if indicated), glucose monitoring, and pharmacologic therapy including insulin are important components of diabetes management and prevention of complications.
This document discusses ways to protect the kidney in patients with diabetes. It summarizes that diabetic kidney disease (DKD) is a common complication of diabetes and the leading cause of end-stage renal disease. The stages of DKD range from microalbuminuria to proteinuria to declining kidney function. The progression of DKD to chronic kidney disease can be delayed through strict control of blood pressure, cholesterol, diet, education, and use of ACE inhibitors or ARBs which help preserve kidney function.
This document discusses dysglycemia and chronic kidney disease (CKD). It begins with an agenda that covers background, pathophysiology, glycemic control, and insulin therapy and conclusions. It then discusses how diabetes is the most common cause of end-stage renal disease. It explains how dysglycemia includes sustained hyperglycemia and acute glucose fluctuations. The kidney plays an important role in glucose homeostasis by filtering, reabsorbing, and producing glucose. Both hyperglycemia and glucose variability can drive diabetic kidney disease through various pathways like protein kinase C activation and oxidative stress. Maintaining good glycemic control through lowering HbA1c can significantly reduce microvascular and cardiovascular complications in patients with CKD.
Slide Presentation
Diabetes Melliuts Type 2 management basics are life style modifications followed by use of Metformin
What is the best and safest next pharmacologic choice
This document provides information about diabetes statistics, pathophysiology, diagnosis, management, and complications. Some key points:
- 29.1 million Americans have diabetes, with costs totaling $245 billion in 2012. Rates are highest among racial/ethnic minorities.
- Type 1 diabetes results from autoimmune destruction of pancreatic beta cells causing absolute insulin deficiency. Type 2 is caused by insulin resistance and relative insulin deficiency.
- Diagnosis is based on HbA1c levels, fasting plasma glucose, and oral glucose tolerance tests. Goals are to maintain HbA1c under 7% and limit pre- and post-prandial hyperglycemia.
- Strict glucose control can reduce risk
Recent advancement in managing diabetic nephropathypp_shivgunde
This document discusses recent advances in managing and understanding diabetic nephropathy. It begins with an introduction to diabetes and chronic kidney disease prevalence and prognosis. It then covers the pathophysiology of diabetic nephropathy and the current standard tripartite approach of intensive blood glucose control, blood pressure control, and RAAS blockade. Novel therapeutic modalities such as exploiting the renin-angiotensin-aldosterone axis through dual or combined blockade and aldosterone antagonism are also discussed.
Empagliflozin and Cardiovascular OutcomesUyen Nguyen
1) The EMPA-REG OUTCOME trial evaluated the cardiovascular outcomes of empagliflozin compared to placebo in over 7000 patients with type 2 diabetes at high risk of cardiovascular events.
2) Empagliflozin was found to significantly reduce the risk of the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to placebo.
3) Additional benefits observed with empagliflozin included a significant reduction in all-cause mortality, cardiovascular mortality, and hospitalization for heart failure.
This document discusses the classification and types of diabetes mellitus. It covers the following key points:
1) Diabetes is classified into type 1, type 2, and other specific types based on etiology. Type 1 is characterized by beta cell destruction and insulin deficiency. Type 2 involves insulin resistance with relative insulin deficiency or secretory defects.
2) Other types include genetic defects of beta cell function or insulin action, diseases of the pancreas, and diabetes due to other causes like drugs.
3) Diagnosis of diabetes is based on symptoms and elevated blood glucose levels based on standards from ADA and WHO. Treatment involves lifestyle changes, oral medications, and insulin for management of blood sugar levels and prevention of complications
Diabetic nephropathy is a clinical syndrome characterized by persistent albuminuria and a progressive decline in kidney function. It is the leading cause of end-stage renal disease. Risk factors include poor blood glucose control, high blood pressure, smoking, and family history of kidney disease. The pathophysiology involves changes in the kidney's small blood vessels caused by high blood glucose levels over time. Common signs and symptoms include edema, trouble sleeping, weakness, and itching skin. Medical diagnosis involves blood and urine tests to assess kidney function and detect albuminuria. Management focuses on tight blood glucose and blood pressure control through medication, diet, exercise and lifestyle changes to slow disease progression and prevent complications like heart disease.
Diabetic neuropathy is a serious and common complication of type 1 and type 2 diabetes.
Ocurres over 90% of diabetes people.
Presence of symptoms and or signs of nerve dysfunction in people with diabetes after all other causes have been excluded.
It’s a type of nerve damage caused by long-term high blood sugar levels.
The condition usually develops slowly, sometimes over the course of several decades.
Distal Symmetrical Neuropathy(DSN) most common form of DN.
DSN affects the toes and distal foot, but slowly progresses proximally to involve the feet and legs in a stocking distribution.
It is also characterized by a progressive loss of nerve fibers affecting both the autonomic and somatic divisions, thereby diabetic retinopathy and nephropathy can occur.
Foot ulceration and painful neuropathy are the main clinical consequences of DSPN, linked with higher morbidity and mortality
This document discusses cardiovascular risk reduction strategies for a patient with type 2 diabetes and a strong family history of cardiovascular disease. It reviews the cardiovascular safety data of various anti-diabetic medications and recommends intensifying treatment to achieve an A1C less than 7%, blood pressure lower than 130/80 mmHg, high-intensity statin therapy, and aspirin. For this patient's secondary prevention, drugs like liraglutide, empagliflozin, canagliflozin, and pioglitazone that have demonstrated cardiovascular benefits in clinical trials are preferable additions to metformin over sulfonylureas. While these newer anti-diabetic drugs have robust evidence for secondary prevention, data for their use in
This document discusses guidelines for glycemic control in patients with diabetes and chronic kidney disease. It recommends monitoring HbA1c levels twice per year and targeting levels between 6.5-8%. Clinical trials showed that intensive glycemic control can reduce kidney disease progression but may increase mortality risk if targets are too low. The document also discusses guidelines for blood pressure control and the renoprotective effects of blocking the renin-angiotensin system with ACE inhibitors or ARBs. Combination therapy with an ACE inhibitor and ARB or adding an MRA may provide additional benefits but also increase risks like hyperkalemia.
Diabetes is a chronic disease characterized by high blood sugar levels that can damage organs and blood vessels. There are three main types of diabetes: type 1, type 2, and gestational diabetes. The goals of diabetes management are to control blood sugar levels through lifestyle modifications like diet, exercise, smoking cessation, and medication if needed. Treatment involves medical nutrition therapy, oral medications or insulin injections, glucose monitoring, and managing complications. The standard targets for blood sugar control are an A1C under 7% for most adults and under 7.5% for children.
The document discusses cardiovascular risk and management in patients with diabetes, including treating cardiovascular risk factors as aggressively in diabetic patients as in non-diabetic patients with prior heart attacks, aiming for tighter glycemic control to reduce cardiovascular events and mortality, and considering individual patient factors and comorbidities when setting glycemic targets and selecting antihyperglycemic therapies, particularly in acute care settings where basal insulin regimens are preferred over sliding scales.
Diabetes Mellitus is one of the leading causes of death through its effects on cardiovascular disease. It is also a leading cause of blindness, renal failure and lower limb amputation, with type 2 diabetes accounting for 85-95% of cases. The global prevalence of type 2 diabetes is projected to increase significantly by 2025, including in India where it is expected to grow to 80 million cases by 2030. Screening guidelines recommend screening those over age 30, overweight individuals, those with family history or other risk factors. Treatment targets glycemic control through monitoring HbA1c, lipids, blood pressure, weight, and screening for complications.
Diabetic nephropathy has become a leading cause of end-stage renal failure. Approximately 40% of patients with diabetes develop nephropathy, which is characterized by persistent albuminuria, elevated blood pressure, and decline in kidney function. Good glycemic and blood pressure control can delay the onset and slow the progression of diabetic nephropathy. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are effective in treating diabetic nephropathy through their blood pressure lowering effects and additional renal protection. Intensive management of all cardiovascular risk factors can further slow the progression of kidney damage in patients with diabetes.
This document discusses different types of iatrogenic (medically induced) diabetes, including:
1) Pancreatogenic diabetes caused by pancreatic diseases or procedures that damage the pancreas.
2) Drug-induced diabetes caused by medications like corticosteroids, antipsychotics, immunosuppressants, protease inhibitors, and chemotherapy drugs.
3) Post-transplant diabetes that develops in some organ transplant recipients due to immunosuppressant drugs and other risk factors.
The document provides details on the mechanisms and risk factors for each type of iatrogenic diabetes.
Diabetic nephropathy medical managementNilesh Jadhav
1. Diabetic nephropathy is a chronic kidney disease caused by damage to the kidneys over many years as a result of diabetes. It is the most common cause of end-stage renal disease.
2. Management of diabetic nephropathy focuses on optimal control of blood glucose, blood pressure, lipids through medication, lifestyle changes, and monitoring for progression of kidney disease.
3. RAAS blockade using ACE inhibitors, ARBs, or renin inhibitors is important treatment but requires monitoring of potassium and kidney function. Referral to a nephrologist is recommended for atypical cases or rapid decline in kidney function.
This document provides information on diabetic nephropathy and diabetic kidney disease (DKD) for healthcare professionals. It covers the causes and risk factors of DKD, how to screen for and diagnose it, treatment options, and guidelines for when to refer patients to specialists. It emphasizes the importance of controlling blood glucose and blood pressure to prevent and slow the progression of DKD. Lifestyle modifications and medication adjustments may be needed for patients with reduced kidney function.
This document discusses diabetic neuropathy. It begins with some global statistics on the prevalence and costs of diabetic neuropathy. It then discusses the pathology, risk factors, presentations, diagnosis and treatments of various types of diabetic neuropathy, including diffuse symmetrical sensorimotor polyneuropathy, autonomic neuropathy, and diffuse small fibre neuropathy. Tight glycemic control is emphasized as an important part of prevention and treatment.
This document provides an overview of diabetes mellitus including definitions, classification, epidemiology, pathophysiology of type 1 and type 2 diabetes, and goals of treatment. Key points include:
- Type 1 diabetes results from autoimmune destruction of pancreatic beta cells in genetically predisposed individuals and requires lifelong insulin treatment.
- Type 2 diabetes involves both insulin resistance and impaired insulin secretion and is strongly associated with obesity and physical inactivity. It can often be managed through lifestyle modifications and oral medications.
- Medical nutrition therapy, physical activity, weight loss (if indicated), glucose monitoring, and pharmacologic therapy including insulin are important components of diabetes management and prevention of complications.
This document discusses ways to protect the kidney in patients with diabetes. It summarizes that diabetic kidney disease (DKD) is a common complication of diabetes and the leading cause of end-stage renal disease. The stages of DKD range from microalbuminuria to proteinuria to declining kidney function. The progression of DKD to chronic kidney disease can be delayed through strict control of blood pressure, cholesterol, diet, education, and use of ACE inhibitors or ARBs which help preserve kidney function.
This document discusses dysglycemia and chronic kidney disease (CKD). It begins with an agenda that covers background, pathophysiology, glycemic control, and insulin therapy and conclusions. It then discusses how diabetes is the most common cause of end-stage renal disease. It explains how dysglycemia includes sustained hyperglycemia and acute glucose fluctuations. The kidney plays an important role in glucose homeostasis by filtering, reabsorbing, and producing glucose. Both hyperglycemia and glucose variability can drive diabetic kidney disease through various pathways like protein kinase C activation and oxidative stress. Maintaining good glycemic control through lowering HbA1c can significantly reduce microvascular and cardiovascular complications in patients with CKD.
Slide Presentation
Diabetes Melliuts Type 2 management basics are life style modifications followed by use of Metformin
What is the best and safest next pharmacologic choice
This document provides information about diabetes statistics, pathophysiology, diagnosis, management, and complications. Some key points:
- 29.1 million Americans have diabetes, with costs totaling $245 billion in 2012. Rates are highest among racial/ethnic minorities.
- Type 1 diabetes results from autoimmune destruction of pancreatic beta cells causing absolute insulin deficiency. Type 2 is caused by insulin resistance and relative insulin deficiency.
- Diagnosis is based on HbA1c levels, fasting plasma glucose, and oral glucose tolerance tests. Goals are to maintain HbA1c under 7% and limit pre- and post-prandial hyperglycemia.
- Strict glucose control can reduce risk
Recent advancement in managing diabetic nephropathypp_shivgunde
This document discusses recent advances in managing and understanding diabetic nephropathy. It begins with an introduction to diabetes and chronic kidney disease prevalence and prognosis. It then covers the pathophysiology of diabetic nephropathy and the current standard tripartite approach of intensive blood glucose control, blood pressure control, and RAAS blockade. Novel therapeutic modalities such as exploiting the renin-angiotensin-aldosterone axis through dual or combined blockade and aldosterone antagonism are also discussed.
Empagliflozin and Cardiovascular OutcomesUyen Nguyen
1) The EMPA-REG OUTCOME trial evaluated the cardiovascular outcomes of empagliflozin compared to placebo in over 7000 patients with type 2 diabetes at high risk of cardiovascular events.
2) Empagliflozin was found to significantly reduce the risk of the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to placebo.
3) Additional benefits observed with empagliflozin included a significant reduction in all-cause mortality, cardiovascular mortality, and hospitalization for heart failure.
This document discusses the classification and types of diabetes mellitus. It covers the following key points:
1) Diabetes is classified into type 1, type 2, and other specific types based on etiology. Type 1 is characterized by beta cell destruction and insulin deficiency. Type 2 involves insulin resistance with relative insulin deficiency or secretory defects.
2) Other types include genetic defects of beta cell function or insulin action, diseases of the pancreas, and diabetes due to other causes like drugs.
3) Diagnosis of diabetes is based on symptoms and elevated blood glucose levels based on standards from ADA and WHO. Treatment involves lifestyle changes, oral medications, and insulin for management of blood sugar levels and prevention of complications
Diabetic nephropathy is a clinical syndrome characterized by persistent albuminuria and a progressive decline in kidney function. It is the leading cause of end-stage renal disease. Risk factors include poor blood glucose control, high blood pressure, smoking, and family history of kidney disease. The pathophysiology involves changes in the kidney's small blood vessels caused by high blood glucose levels over time. Common signs and symptoms include edema, trouble sleeping, weakness, and itching skin. Medical diagnosis involves blood and urine tests to assess kidney function and detect albuminuria. Management focuses on tight blood glucose and blood pressure control through medication, diet, exercise and lifestyle changes to slow disease progression and prevent complications like heart disease.
Diabetic neuropathy is a serious and common complication of type 1 and type 2 diabetes.
Ocurres over 90% of diabetes people.
Presence of symptoms and or signs of nerve dysfunction in people with diabetes after all other causes have been excluded.
It’s a type of nerve damage caused by long-term high blood sugar levels.
The condition usually develops slowly, sometimes over the course of several decades.
Distal Symmetrical Neuropathy(DSN) most common form of DN.
DSN affects the toes and distal foot, but slowly progresses proximally to involve the feet and legs in a stocking distribution.
It is also characterized by a progressive loss of nerve fibers affecting both the autonomic and somatic divisions, thereby diabetic retinopathy and nephropathy can occur.
Foot ulceration and painful neuropathy are the main clinical consequences of DSPN, linked with higher morbidity and mortality
This document discusses cardiovascular risk reduction strategies for a patient with type 2 diabetes and a strong family history of cardiovascular disease. It reviews the cardiovascular safety data of various anti-diabetic medications and recommends intensifying treatment to achieve an A1C less than 7%, blood pressure lower than 130/80 mmHg, high-intensity statin therapy, and aspirin. For this patient's secondary prevention, drugs like liraglutide, empagliflozin, canagliflozin, and pioglitazone that have demonstrated cardiovascular benefits in clinical trials are preferable additions to metformin over sulfonylureas. While these newer anti-diabetic drugs have robust evidence for secondary prevention, data for their use in
This document discusses guidelines for glycemic control in patients with diabetes and chronic kidney disease. It recommends monitoring HbA1c levels twice per year and targeting levels between 6.5-8%. Clinical trials showed that intensive glycemic control can reduce kidney disease progression but may increase mortality risk if targets are too low. The document also discusses guidelines for blood pressure control and the renoprotective effects of blocking the renin-angiotensin system with ACE inhibitors or ARBs. Combination therapy with an ACE inhibitor and ARB or adding an MRA may provide additional benefits but also increase risks like hyperkalemia.
Diabetes is a chronic disease characterized by high blood sugar levels that can damage organs and blood vessels. There are three main types of diabetes: type 1, type 2, and gestational diabetes. The goals of diabetes management are to control blood sugar levels through lifestyle modifications like diet, exercise, smoking cessation, and medication if needed. Treatment involves medical nutrition therapy, oral medications or insulin injections, glucose monitoring, and managing complications. The standard targets for blood sugar control are an A1C under 7% for most adults and under 7.5% for children.
The document discusses cardiovascular risk and management in patients with diabetes, including treating cardiovascular risk factors as aggressively in diabetic patients as in non-diabetic patients with prior heart attacks, aiming for tighter glycemic control to reduce cardiovascular events and mortality, and considering individual patient factors and comorbidities when setting glycemic targets and selecting antihyperglycemic therapies, particularly in acute care settings where basal insulin regimens are preferred over sliding scales.
Diabetes Mellitus is one of the leading causes of death through its effects on cardiovascular disease. It is also a leading cause of blindness, renal failure and lower limb amputation, with type 2 diabetes accounting for 85-95% of cases. The global prevalence of type 2 diabetes is projected to increase significantly by 2025, including in India where it is expected to grow to 80 million cases by 2030. Screening guidelines recommend screening those over age 30, overweight individuals, those with family history or other risk factors. Treatment targets glycemic control through monitoring HbA1c, lipids, blood pressure, weight, and screening for complications.
This document provides information about diabetes and diabetic retinopathy for medical students. It outlines learning objectives related to understanding diabetes demographics, diagnosis, complications, and treatments. Key points include that diabetes affects over 29 million Americans and has significant medical costs. Diabetic retinopathy is a leading cause of blindness and its progression can be slowed by controlling blood sugar and blood pressure. The document also defines the stages of diabetic retinopathy and diabetic macular edema.
Heart Failure An Underappreciated Complication of Diabetes.pptxParikshitMishra15
- Heart failure is an underappreciated complication of diabetes that occurs earlier than myocardial infarction and stroke. It is linked to higher mortality.
- Sodium-glucose cotransporter-2 inhibitors (SGLT2i) like empagliflozin, canagliflozin, and dapagliflozin lower the risks of cardiovascular events like heart failure in patients with type 2 diabetes through mechanisms like weight loss, blood pressure lowering, and reduced blood volume.
- Large clinical trials demonstrated that empagliflozin, canagliflozin, and dapagliflozin reduced cardiovascular deaths and hospitalization for heart failure compared to placebo in patients with type 2 diabetes at high
This document provides an introduction and overview of diabetes. It begins with definitions of diabetes and describes the three main types: type 1 diabetes is caused by a lack of insulin production and requires insulin treatment; type 2 diabetes involves insulin resistance and inadequate insulin production and may be treated with lifestyle changes or medications; gestational diabetes occurs during pregnancy. Statistics on the growing prevalence of diabetes in the US are presented. Risk factors, symptoms, diagnostic tests, potential complications, and strategies for prevention and control of diabetes are discussed.
The document discusses diabetes, providing statistics on its prevalence and discussing advances in treatment. While medical advances have improved diabetes management, better control has not been achieved for all as it requires a team approach and access to care. The elimination of diabetes listings may lead to a more stringent disability standard given impairments from conditions like neuropathy and retinopathy. Proper management of diabetes is challenging and requires ongoing medical care and self-care.
This document discusses diabetes mellitus (DM), including its definition, etiology, pathogenesis, classification, clinical manifestations, and complications. DM is defined as a chronic condition of hyperglycemia resulting from defects in insulin secretion or insulin action. It discusses the two main types of DM - type 1 characterized by pancreatic beta cell destruction and absolute insulin deficiency, and type 2 characterized by insulin resistance and relative insulin deficiency. The document outlines the clinical differences between the two types and describes the potential complications affecting multiple organ systems that can develop from long-term hyperglycemia if DM is not adequately controlled.
EPIDEMIOLOGY AND RECENT ADVANCES IN DIABETES & OBESITY - HARIMU.pptxDrHarimuBargayary
Diabetes and obesity are growing global health problems. Screening high risk groups is important for early detection and treatment. Lifestyle changes like maintaining a healthy weight and regular exercise can help prevent diabetes. For those with diabetes, treatment aims to control blood sugar and prevent complications through medication, monitoring, and self-care. Government programs are also working to improve prevention, care and control of diabetes and obesity in India.
This document discusses diabetes mellitus. It begins by stating that the global incidence of both type 1 and type 2 diabetes is rising, with an estimated 171 million cases in 2000 projected to double to over 300 million by 2030. Type 2 diabetes is the most common form, influenced by factors like aging, obesity, diet, physical activity, and urbanization. The document then provides details on the classification, causes, pathology, and metabolic disturbances of types 1 and 2 diabetes.
All what you have to know about Diabetes MellitusYapa
All what you have to know about Diabetes Mellitus is here.Introduction of Diabetes,Regulation of blood glucose,Predisposing factors of DM,Clinical presentation,DM and pregnancy ,Diabetes ketoacidosis ,Complications of DM ,Diagnosis ,Dietary management of DM & Prevention of DM.
Student seminar on Diabetes Mellitus presented by 2007/2008 Batch students of Faculty of Medicine,University of Peradeniya,Sri Lanka.
This document provides current guidelines for the diagnosis of diabetes. It defines diabetes and outlines the main types and stages. It describes the diagnostic tests used, including A1C, fasting plasma glucose and oral glucose tolerance tests. Criteria for diagnosing diabetes and prediabetes are provided. Guidelines are given for testing asymptomatic adults and children. Targets for glycemic control in nonpregnant adults are also summarized.
This document provides an overview of diabetes mellitus, including its epidemiology, classification, pathogenesis, symptoms, diagnosis, and management. It discusses the two main types of diabetes - type 1 and type 2 - and covers topics such as gestational diabetes, prediabetes, and diabetes complications and their treatment. The document presents information on diabetes in a structured outline format.
Diabetes is classified and diagnosed based on glucose levels and symptoms. The document discusses the classification of diabetes into types 1, 2, and other specific types based on underlying causes. It also addresses diagnosis of diabetes through glucose testing and thresholds. Assessment of newly diagnosed patients involves determining immediate management needs and the underlying diabetes type through medical history, examination, and laboratory tests.
The document discusses the epidemiology of diabetes, noting that the number of cases is rising worldwide and will continue to do so. It presents statistics on the economic burden of diabetes, especially in poorer countries. It then focuses on diabetes in India, where prevalence is highest. It provides classifications and descriptions of the main types of diabetes and discusses risk factors such as genetics, lifestyle, diet and environment.
Management of diabetes with risk factors getting to goal in glycemic control ...Mahir Khalil Ibrahim Jallo
This document discusses the management of diabetes with risk factors and glycemic control. It covers the objectives of examining the epidemiology of diabetes in the UAE, recent ADA-EASD guidelines on managing hyperglycemia in type 2 diabetes, cardiovascular risks of diabetes, the role of DPP-4 inhibitors, hypoglycemia and its consequences, and diabetes and Ramadan. It also summarizes three major clinical trials (ACCORD, ADVANCE, and VADT) that examined the effects of intensive glucose control on cardiovascular outcomes in type 2 diabetes patients.
This document discusses type 2 diabetes, including:
- It affects over 25 million Americans and is the 7th leading cause of death in the US.
- Symptoms include increased urination, thirst, and hunger. Diagnosis involves blood tests measuring glucose levels.
- Treatment focuses on lifestyle changes like diet, exercise, weight loss and medication to control blood sugar and prevent complications like heart disease and nerve damage.
This document provides an overview of diabetes mellitus (DM), including its pathogenesis, signs and symptoms, diagnostic criteria, complications, and management. It discusses the two main types of DM (type 1 and type 2), their distinguishing characteristics, and the role of insulin in the body. The document outlines microvascular and macrovascular complications of long-term hyperglycemia, such as retinopathy, nephropathy, neuropathy, and cardiovascular disease. It also covers diabetic ketoacidosis, risk factors for type 2 DM, and the increased risk of coronary heart disease in diabetic patients.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
3. share our experiences of management
of diabetes in local perspective.
early identify the diabetic pts and
complications of DIABETES
motivate patients to achieve targets
understand the advantages of
treatment and disadvantages of not
achieving targets
attain Hb A1c less than 7%
4.
5. Principal Aims in Diabetes Care
Medical/Diabetes Care Team-orientated
( A)Promote overall well-being and a normal life expectancy
(B) Prevent/delay the onset of cardiovascular disease
(C)Manage diabetes-related complications early and aggressively as appropriate
(D) Minimize hypo glycaemia and adverse drug event rate
(E) Provide specialist care at optimal time points
Patient/Care-orientated
(1)To acquire the education and skills to self-manage
(2) Maintain an optimal level of physical and cognitive function
(3) To be confident of access to services and support where necessary to manage their
DIABETES
6. Definition
Diabetes mellitus is a
complex metabolic disorder
characterised by persistent
hyperglycaemia due to relative or
absolute deficiency of insulin or
insulin resistance
9. TYPES of DIABETES
Type 1 Diabetes: 5 to 10% patients
have type 1 diabetes.
Type 2 Diabetes: 90 to 95% patient
have type 2 diabetes.
Other Types.
GDM
IGT
IFG
10. Characteristic Type 1 ( 10% ) Type 2
Onset (Age) Usually < 30 Usually > 40
Type of onset Abrupt Gradual
Nutritional status Usually thin Usually obese
Clinical symptoms Polydipsia, polyphagia, Often asymptomatic
polyurea, Wt loss
Ketosis Frequent Usually absent
Endogenous insulin Absent Present, but relatively
ineffective (in. resistance)
Related lipid Hypercholesterolemia Cholesterol & triglycerides
abnormalities frequent, all lipid fractions often elevated; carb
elevated in ketosis induced hyper TG
common
Insulin therapy Required FOR WHOLE Required in only 20 - 30%
LIFE(DEPENDS ON INSULIN) of patients FOR CONTROL
Hypoglycemic drugs Should not be used Clinically indicated
Diet Mandatory with insulin Mandatory with or without
drug
COMPLICATIONS AFTER 5 40-50% AT DIAGNOSIS
YEARS(MAJORITY)
11. DIFFERENCE
TYPE 2 (TYPE II,
TYPE 1(TYPE I, IDDM) NIDDM)
YOUNGER AGE
OVER 35 , ANY AGE
ABRUPT ONSET
INSIDOUS ONSET
NO FAMILY HIST.
SIGNIFICANT FAMILY HIST.
VIRUS,TOXINS,
OVEREATING ATTITUDE
AUTOIMMUNITY
OVERWEIGHT
MINIMAL OR ABSENT INSULIN
DELAYED OR REDUCED INSULIN
THIN OR CATABOLIC STATE
OBESE OR NORMAL STATE
CLASSICAL SYMPTOMS
NONE OR MILD SYMPTOMS
KETOSIS PRONE
KETOSIS RESISTANT
DIET ESSENTIAL
DIET ESSENTIAL
INSULIN ESSENTIAL(FOR
INSULIN MAY BE REQUIRED
SURVIVAL) (20 – 30%) FOR CONTROL.
SU S NOT EFFICACIOUS
SU S EFFICACIOUS
Complications .AFTER 5 YRS IN
FREQUENT(35-50%) INITIALLY /
MAJORITY. at diagnosis/PC
12. Table 4—Criteria for testing for diabetes in
asymptomatic adult individuals
1. Testing should be considered in all adults who
are overweight (BMI 25 kg/m2*) and
have additional risk factors:
● physical inactivity
● first-degree relative with diabetes
● members of a high-risk ethnic population (e.g.,
African American, Latino, Native
American, Asian American, Pacific Islander)
● women who delivered a baby weighing 9 lb or
were diagnosed with GDM
● hypertension (140/90 mmHg or on therapy for
hypertension)
● HDL cholesterol level 35 mg/dl (0.90 mmol/l)
and/or a triglyceride level 250mg/dl (2.82 mmol/l)
13. ● women with polycystic ovary syndrome
● A1C 5.7%--6.4%, IGT, or IFG on previous
testing
● other clinical conditions associated with insulin
resistance (e.g., severe obesity,
acanthosis nigricans)
● history of CVD
2. In the absence of the above criteria, testing
diabetes should begin at age 45 years
3. If results are normal, testing should be
repeated at least at 3-year intervals, with
consideration of more frequent testing depending
on initial results and risk
status.
*At-risk BMI may be lower in some ethnic groups
14. The foundation of our current practices in
diabetes stems from large prospective
studies, such as the
UK Prospective Diabetes Study (UKPDS)
and the
Diabetes Control and Complications Trial
(DCCT),
which suggested that better control of
blood glucose reduces complications
15. Diabetes Mellitus:
Health Impact of the Disease
6th leading cause
of death
Renal Life expectancy
failure 5 to 10 yr
↑
↑
Blindness
Diabetes Cardiovascular
disease ↑ 2 to 4X
Nerve damage in
Amputation 60 to 70% of patients
e most common cause of renal failure, blindness, and nontraumatic amputations
16. UKPDS: decreased risk of diabetes-related complications
associated with a 1% decrease in A1C
Observational analysis from UKPDS study data
corresponding to a 1% decrease in HbA1C
Any
Percentage decrease in relative risk
diabetes- Diabetes- All Peripheral Micro-
related related cause Myocardial vascular vascular Cataract
endpoint death mortality infarction Stroke disease† disease extraction
12%
14% 14%
* 19%
21% 21% ** **
**
** **
37%
†
Lower extremity amputation or fatal peripheral vascular disease 43%
*P = 0.035; **P < 0.0001
**
**
Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412.
17.
18.
19.
20. Stages of Type 2 Diabetes—
UKPDS
100
75
β-Cell Function (%)
50
IGT Postprandial Type 2 Type 2 Diabetes
25 Hyperglycemia Diabetes
Type 2 Phase III
Phase I
Diabetes
Phase II
0
-12 -10 -6 -2 0 2 6 10 14
Years From Diagnosis
Lebovitz H. Diabetes Review. 1999;7:139.
21.
22. TABLE OF OHAS / OADS
SECRETOGOGUES INSULIN INHIBITORS OF
SENSITIZERS CHO
ABSORPTION
SULFONYLUREAS BIGUANIDES ALPHA
GLUCOSIDASE
INHIBITORS
GLICLAZIDE METFORMIN ACARBOSE
TZDS OTHERS-
GLIBENCLAMIDE NEW
GLIMEPIRIDE PIOGLITAZONE DI -PEPTIDYL
PEPTIDASE-4
INHIBITORS
NON ROSIGLITAZONE GLIPTINS
Black box warning
-SULFONYLUREAS
REPAGLINIDE
26. The Moral of the Tale
Aslong as we
reach the
objective
(TARGETS), it
doesn’t matter
how we get there
27. Tools to manage Diabetes
Whether it is pills,
insulin shots or both
GOAL IS CONTROL
HbA1c <7%
28.
29. The August 2006 guidelines from the
ADA
and the European Association for
the Study
of Diabetes recommends the
inclusion of
METFORMIN
in initial diabetes treatment,
AS PART OF TLC
31. Clinical implications
Algorithm encourages flexibility and clinical judgement in
Type 2 diabetes treatment
Algorithm is cautious in use of newer treatments
Lack of head-to-head trials continues to impede informed
comparisons of strategies
In severely uncontrolled diabetes, lifestyle + insulin is
preferred regimen
Long-term ability to control diabetes or reduce
cardiovascular complications still a concern
35. Advantages of Insulin Therapy
Most clinical experience
Most effective (lowering
glycemia)
Can decrease any level of elevated HbA1c
No maximum dose of insulin beyond
which a therapeutic effect will not occur
Beneficial effects on triglyceride
and HDL cholesterol levels
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
36.
37.
38. Why Aren’t Patients Achieving
Blood Glucose Goals?
Physicians not setting appropriate
glycemic targets
Type 2 diabetes is progressive -
what works now may not work in
the future
Type of medications used are not
appropriate
Insulin therapy only used as a
“threat”
39. Yikes! I have
5 minutes to
tell this
patient
everything
about
diabetes!!
40.
41.
42. (ABC )–ALPHABET STRETEGY)
JOINT BRITISH
SOCIETIES GUIDELINES- 2005
A ADVICE EDUCATION, COMPLIANCE, SMOKING
CESSATION, DIET,
PHYSICAL ACTIVITY,WEIGHT REDUCTION.
B BLOOD PRESSURE < 130/80, ACE/ARB, DIURETICS, CCB
C CHOLESTREROL < 160 MG/DL, LDL<100MG/DL, TG<160,
HDL>40 IN MALES >50 IN FEMALES
D DIABETES CONTROL HBA1C < 6.5% METFORMIN 1ST
CHOICE
E EYE CARE ANNUAL OPHTHALMOLOGICAL EXAM
F FOOT CARE ANNUAL EXAM
G GUARDIAN DRUGS ASPIRIN > 50 YRS, > 10 YRS DM,
HTN / PROTEINUREA( NEPHROPATHY)
ACE/ARB
STATINS(EVEN IF LIPID PROFILE
IS WITHIN NORMAL LIMITS)
43.
44. TAKE HOME
MESSAGE
“Insulin should not be the
treatment of last resort for many
of our patients, but should be the
treatment of best resort. Starting
insulin is always resisted. A lot
depends on the clinician to handle
the different situations in a tactful
way”
45. TAKE HOME
MESSAGE
DIABETES”S therapy should be
individualized
and adjusted according to the
changing needs of the patients
UKPDS 35 was a prospective observational study to determine the relationship between exposure to hyperglycemia over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes who were participants in the UKPDS. 3,642 white, Asian Indian and Afro-Caribbean UKPDS patients who had HbA 1c measured 3 months after their diabetes diagnosis and with complete data for potential confounders were included in the sub-analysis of relative risk. Reductions in the risk of microvascular and macrovascular complications that might be achieved by lowering HbA 1c by 1% were estimated. The incidence of clinical complications was found to be significantly associated with hyperglycemia. While any reduction in HbA 1c is likely to reduce the risk of complications, the lowest risk was observed in those with HbA 1c values in the normal range (< 6.0%). A 1% decrease in HbA 1c was estimated to correspond with significant reductions in any diabetes-related endpoint, diabetes-related death, all cause mortality, myocardial infarction, stroke, peripheral vascular disease, microvascular disease and cataract extraction. Stratton IM, et al. UKPDS 35. BMJ 2000; 321 :405–412.
This is Mr. M.C.’s left heel ulcer. Note the maggots infesting – but perhaps also debriding – this wound.
Slide 1-24 Stages of Type 2 Diabetes Epidemiological studies suggest that the onset of diabetes occurs 10 to 12 years before a clinical diagnosis is made. (Harris 1997) In the UKPDS study of type 2 diabetics, at least 50% of the patients had evidence of diabetic tissue damage when diabetes was first diagnosed. (UKPDS Study 16, 1995) In the earliest phase, when beta-cell function is not impaired, the ability of the beta-cells to hypersecrete insulin masks the impaired glucose tolerance, often for years. During the IGT phase, the FPG will be higher than the normal 110 mg/dL but lower than the 126 mg/dL that is indicative of diabetes. As beta-cell function continues to decline, mild postprandial hyperglycemia develops, reflecting the inability of the beta-cell to hypersecrete enough insulin to overcome insulin resistance. At the end of this prediabetic phase, the first phase of type 2 diabetes typically produces symptoms that lead to a diagnosis. During phase I, in the first 2 years after diagnosis of diabetes, beta-cell function decreases to between 70% and 40% of normal function. CORE
The classical approach to treating type 2 diabetes can be described as stepped management. The first step is to encourage the patient to reduce hyperglycemia through a combination of diet and exercise followed by support with an oral antidiabetic agent in monotherapy. If glycemic control continues to deteriorate, additional oral agents are added in a step-wise fashion followed by insulin where necessary. Slide 17
Published simultaneously in the August 2006 issues of Diabetes Care and Diabetologia , the new consensus statement takes into account the characteristics of individual interventions, their synergies, and expenses (Figure 1) to facilitate the management of hyperglycemia. “We have developed a step-by-step algorithm that simplifies how and when treatments should be administered [Figure 2],” says Dr. Nathan. “We want to achieve and maintain glycemic levels as close to the non-diabetic range as possible and to change interventions at as rapid a pace as titration of medications allows.”
Key Points Insulin is the oldest of the currently available medications for the management of hyperglycemia in type 2 diabetes and has the most clinical experience. It is the most effective of diabetes medications in lowering glycemia: when used in adequate doses it can decrease any level of elevated HbA 1c to, or close to, the therapeutic goal, and there appears to be no maximum dose beyond which a therapeutic effect will not occur. Insulin has also been shown to beneficially affect triglyceride and HDL cholesterol levels. Reference: Nathan DM et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 2006;29(8):1963-72 .
We as health care providers need to know blood glucose goals and develop strategies for our patients to reach these goals. However, it must be made clear that regardless of appropriate control, changes in blood glucose is part of the disease’s progressions. This may have a psychological impact on the patient. Insulin is used as a punishment, therefore, it is often used too late. Insulin must be presented as a wonderful tool to control blood glucose levels.
According to Dr. Nathan, there are several key points for physicians to remember when using the newly created algorithm. “First, physicians need to quickly and aggressively move onto the next step if A1C improvements do not occur. The earlier these new interventions are initiated, the better chance we have at preventing complications. Second, we must recognize that lifestyle interventions [eg, a healthy diet and regular exercise] and early administration of metformin are essential throughout treatment. Patients should receive these interventions as soon as a diabetes diagnosis is made and continue them. Third, physicians should not hesitate to initiate early and aggressive insulin therapy because it can further prevent diabetes-related complications. Lastly, each treatment goal will need to be individualized based on the patient’s characteristics. What may work for some patients will not work for all.”