a brief discussion on management on diabetes mellitus based on Davidson's principle of medicine23rd edition & ADA guideline 2019

1. MANAGEMENT OF DIABETES
MELLITUS
DEPARTMENT OF
ENDOCRINOLOGY (WARD 39)
CMCH
Dr. Samee M Adnan
Resident, Phase A (Neuromedicine)
CMCH

2. AIMS OF TREATMENT
 To make the patient symptom free.
 To maintain normal blood glucose round the clock.
 To prevent acute metabolic derangements, such as
hypoglycaemia, ketoacidosis etc.
 To prevent or delay chronic complications of
diabetes such as nephropathy, neuropathy etc.
 To ensure proper growth & development in young
patients.
 To support a productive & socially respectful life.

3. Type 1 DM is a deficiency
disorder from the onset &
it’s management is
‘efficient replacement of
deficiency’ & lifesyle
should be synchronized
with insulin
administration.
Type 2 DM is a more
complex disorder, & here
lifestyle modifications
/interventions have the
potentiality to correct
some of the factors which
are not only proven as risk
factors for developing
diabetes but also for
deterioration in glycaemic
status as well as
development of other
chronic diseases, ex- HTN,
CV disease etc.

4. PRINCIPLES / STEPS OF MANAGEMENT
Steps Description
1 Confirmation of diagnosis
2 Analysis of factors
3 Targets of treatment
4 Selection & initiation of a
treatment regimen
5 Monitoring & changing
treatment regimen
6 Screening for complications &
referral
7 Evaluation

5. STEP 1: CONFIRMATION OF DIAGNOSIS
OGTT is the most standard procedure to diagnose.
Other tests can also be done.

6. STEP 2: ANALYSIS FACTORS
Factors are:
 Type of DM.
 Age of the person.
 Body weight.
 Associated conditions, eg. acute/chronic
complications/illnesses, pregnancy/lactation, major
surgery etc.
 Lifestyle of the person.
 Degree of hyperglycemia.
 Previous anti-diabetic agents.
 Socio-economic condition.

7. STEP 3: TARGETS OF TREATMENT
Factors Target
Blood (capillary plasma)
glucose
•Fasting/ pre-meal: 4.4-7.2mmol/L
•Post-meal: <10mmol/L
HbA1c <53mmol/mol / 7%
Blood lipids •Total cholesterol: < 4mmol/L or
150mg/dl
•LDL cholesterol: < 2mmol/L or 75mg/dl
BMI & Waist circumference BMI: <25kg/m2
WC: <90 cm (male)
<80 cm (female)
Patients Teaching, training & empowerment to
take part in treatment

8. CONT.
Less strict control of blood glucose is appropriate for:
 Very young children.
 Older people.
 Persons with history of severe or repeated
hypoglycemia.
 Limited life expectancy.
 Presence of co-morbid conditions.

9. STEP 4: SELECTION & INITIATION OF A
TREATMENT REGIMEN

10. STEP 5: MONITORING & CHANGING
TREATMENT REGIME
 Blood glucose testing:
 In people with type 2 diabetes, there is not usually a
need for regular self-assessment of blood glucose,
unless they are treated with insulin, or at risk of
hypoglycaemia while taking sulphonylureas.
 Insulin-treated patients should be taught how to monitor
their own blood glucose using capillary blood glucose
meters. Immediate knowledge of blood glucose levels
can be used by patients to guide their insulin dosing and
to manage exercise and illness.
 Continuous glucose monitoring (CGM) also has an
important role in insulin treated patients.

11. CONT.
 HbA1c:

12. STEP 6: FOLLOW UP, SCREENING FOR
COMPLICATIONS & REFERRAL
Early detection & meticulous management to prevent
complications is the major challenge in diabetic
care.

13. STEP 7: EVALUATION
The whole management strategy should be analyzed
and evaluated from time to time so the best
treatment can be offered.

14. MANAGEMENT COMPONENTS
Lifestyle modifications:
 Healthy diet
 Physical activity
 Discipline
 Education
Pharmacological therapy.

15. HEALTHY DIET

16. MEDICAL NUTRITION THERAPY
Goals of dietary modification:
 To eat a balanced and regular meal.
 To achieve metabolic goals, eg. blood glucose,
lipid, hypertension etc.
 To attain and maintain desirable body weight
 To provide adequate nutrition for health and growth
in pregnant and lactating mothers, and children
 To prevent/delay complications of diabetes.
 To preserve the pleasure of eating.

17. CONT.
Nutritional therapy in diabetes can be discussed in
some broad aspects:
 Calorie intake
 Components of nutrients
 Meal timing and consistency
 Weight management

18. CALORIE INTAKE
 Total calories for an individual can be estimated by using formula
given below:
Daily calorie allowance (Kcal) = Ideal body weight (IBW) X
Calorie factor (CF).
 IBW is obtained from standard height-weight charts. It can also
roughly be calculated by subtracting 100 from height (in centimeters).
 Calorie factor:
Body weight CF for
Sedentary
CF for
moderately
active
CF for active
Obese/over-
weight
20/25 25/30 30/35
Normal 30 35 40
Under weight 35 40 45

19. COMPONENTS OF NUTRIENTS
 Carbohydrate: 45–60% Foods with high fiber, low GI (Glycaemic
Index) is encouraged. Examples include starchy foods such as
basmati rice, spaghetti, porridge, noodles, granary bread, and
beans and lentils. High fiber sources include vegetables, fruits,
legumes, whole grains, as well as dairy products.
Sucrose(table sugar, honey, glucose, fructose): up to 10%
 Fat (total): < 35%
n-6 Polyunsaturated: < 10%
n-3 Polyunsaturated: eat 1 portion (140 g) oily fish once or
twice weekly
Eating foods containing long-chain ω-3 fatty acids such as fatty
fish, nuts,
and seeds, is recommended
Monounsaturated: 10–20%
Saturated: < 10% (red meat, butter)
 Protein: 10–15% (do not exceed 1 g/kg body weight/day)
 Fruit/vegetables: 5 portions daily

20. CONT.
 Salt :people with diabetes should limit sodium
consumption to 6g/day.
 Alcohol : Adults with diabetes should drink alcohol
only in moderation. Alcohol consumption may place
people with diabetes at an increased risk for
hypoglycemia.
 Smoking cessation.

21. MEAL TIMING AND CONSISTENCY
 Total daily food intake may be distributed
consistently throughout the day as follows:
 3 main meals- breakfast, lunch and dinner
 2-3 snacks- mid morning, afternoon and bedtime snacks
etc.

22. WEIGHT MANAGEMENT
 In patients with type 2 diabetes who are overweight
or obese, modest and sustained weight loss has
been shown to improve glycemic control and to
reduce the need for glucose-lowering medications.
 Moderate sustained weight loss (5-10%, or 2-8 kg),
irrespective of initial weight, in overweight/obese
individuals can have a lasting benefit on blood
glucose, dyslipidemia and hypertension.

23. CONT.

24. PHYSICAL ACTIVITY

25. PHYSICAL EXERCISE
 Children and adolescents withtype 1 or type 2 diabetes or
prediabetes should engage in 60 min/day or more of
moderate- or vigorous-intensity aerobic activity, with vigorous
muscle-strengthening and bone-strengthening activities at
least 3 days/week.
 Most adults with type 1 and type 2 diabetes should engage in
150 min or more of moderate to-vigorous intensity aerobic
activity per week, spread over at least 3 days/week, with no
more than 2 consecutive days without activity. Shorter
durations (minimum 75 min/week) of vigorous intensity or
interval training may be sufficient for younger and more
physically fit individuals.
 Adults with type 1 and type 2 diabetes should engage in 2–3
sessions/week of resistance exercise on nonconsecutive
days.

26. CONT.
 All adults, and particularly those with type 2 diabetes, should
decrease the amount of time spent in daily sedentary
behavior. Prolonged sitting should be interrupted every 30 min
for blood glucose benefits, particularly in adults with type 2
diabetes.
 Flexibility training and balance training are recommended 2–3
times/week for older adults with diabetes. Yoga and tai chi
may be included based on individual preferences to increase
flexibility, muscular strength, and balance

27. Aerobic Exercise Anaerobic exercise
It is a type of exercise that
overloads the heart and requires
oxygen to provide energy.
Example: aerobic dance, cycling,
running, treadmill, stair climbing,
swimming, walking, jogging etc.
Benefits:
•Increases maximal oxygen
consumption.
•Improves cardiovascular and
respiratory function.
•Increases blood supply to
muscles and their ability to use
oxygen.
•Lowers resting systolic and
diastolic blood pressure in people
with high blood pressure.
•Improves glucose tolerance and
reduces insulin resistance
Anaerobic exercise is of short
duration that can be supported by
the energy sources stored in the
muscles and does not require
oxygen.
Example- strength training, weight
lifting etc.
Benefits:
•Increases muscular strength
•Potentially improves flexibility of
joints
•Reduces body fat and increases
lean body mass (muscle mass)
•Improves strength, balance and
functional ability in older adults

28. PHARMACOLOGICAL THERAPY

29. PHARMACOLOGICAL AGENTS
Oral anti-diabetic drugs Injectable agents
•Insulin sensitizers
•Insulin secretogogues
•Alpha glucosidase inhibitors
•Incretin mimetics.
•SGLT2 inhibiotrs.
•Others.
•Insulin
•Other agents

30. INSULIN SENSITIZERS
Biguanides (Metformin):
 M/A-
 The main mechanism of action of metformin is reduction
of hepatic gluconeogenesis.
 Metformin also slows intestinal absorption of sugars and
improves peripheral glucose uptake and utilization.
 Weight loss may occur because metformin causes loss
of appetite.
 Adverse effects
 GIT upset (modified release preparations)
 Lactic acidosis
 Vit B12 deficiency
 Hepatic and renal disease

31. CONT.
 Contraindications
 eGFR of below 30 mL/min. the dose should be halved
when (eGFR) is 30–45 mL/min
 Any acute illness
 Hypoxic condition(cardiac/pulmonary disease)
 Hepatic impairment

32. INSULIN SECRETOGOGUES
Sulphonylureas:
Gliclazide,
Glibenclamide,
Glimepiride etc.
 M/A- Sulphonylureas
act by closing the
pancreatic β-cell
ATP-sensitive
potassium channel,
decreasing K+ efflux,
which ultimately
triggers insulin
secretion

33. ALPHA GLUCOSIDASE INHIBITORS
 Acarbose, Miglitol
 M/A- These agents competitively block the action of the
intestinal enzyme alpha-glucosidase which breaks down
oligosaccharides (break down product of starch), and thus
inhibit the complete digestion of carbohydrate. They cause
formation of gases due to unabsorbed carbohydrate in the
colon.
 Adverse effect :GI upset

34. INCRETIN MIMETICS
 Sitagliptin, Vildagliptin , Linagliptin, Saxagliptin.
 M/A-
 Gut hormones or incretins (eg. glucacion-like peptide-1
GLP-1 and glucose,-dependent insulinotropic polypeptide
[GIP] lowers blood glucose by a) increasing insulin secretion
& reducing glucagon secretion thereby resulting in decreased
hepatic glucose production, b) slowing gastric emptying; c)
decreasing food intake (Appetitie suppression).
 Incretin hormones are rapidly inactivated by the DPP-4
enzyme. These incretin mimetic agents inhibit dipeptidyl
peptidase-4 (DPP-4) enzyme and thereby prolong incretin
activity.
 Weight neutral.
 Low risk of hypoglycemia.

35. SGLT-2 INHIBITORS
 Dapagliflozin, Canagliflozin
 M/A-
 The sodium-glucose cotransporter-2 (SGLT-2) is the main site
of reabsorption of filtered glucose in renal tubules.
 SGLT-2 inhibitors inhibit this SGLT-2 in the proximal tubules,
thus reduce the reabsorption of filtered glucose from the
tubular lumen and lower the renal threshold for glucose.
 Reduction of filtered glucose reabsorption and lowering of
renal threshold result in increased urinary excretion of
glucose, ultimately reduction of plasma glucose
concentration.
 Weight loss
 Reduction in CVS mortality
 Adverse effects: genital fungal infection

36. INITIATION
& DOSE
TITRATION
OF OADS

37. INSULIN THERAPY

38. CONT.
 In type 2 diabetes,insulin is usually initiated as a once-daily
long acting insulin 10 U/day or .1-.2 U/kg/day, either alone or
in combination with oral hypoglycaemic agents.
 Simplest regimen: Twice-daily administration of a short-acting
and intermediate-acting insulin (usually soluble and isophane
insulins), given in combination before breakfast and the
evening meal. two-thirds of the total daily requirement of
insulin is given in the morning in a ratio of short-acting to
intermediate-acting of 1 : 2, and the remaining third is given in
the evening.
 Multiple injection regimens (intensive insulin therapy) are
popular, with short-acting insulin being taken before each
meal, and intermediate- or long-acting insulin being injected
once or twice daily (basal-bolus regimen).

39. DOSE CALCULATION OF INSULIN
Three factors are considered here:
 Total Daily Insulin (TDI):
TDI= Weight in pounds / 4
Half TDI- Short / rapid acting (thrice daily)
Half TDI- Intermediate (twice) / long acting (once daily); If
intermediate is used, 2/3rd in morning & 1/3rd in night .
 Carbohydrate disposal / Intake.
 Blood glucose level correction.

40. CONT.

41. SIDE EFFECTS OF INSULIN THERAPY

42. PHARMACOLOGIC THERAPY FOR
TYPE 1 DIABETES
 Most people with type 1 diabetes should be treated with
multiple daily injections of prandial and basal
insulin, or continuous subcutaneous insulin infusion.
 Most individuals with type 1 diabetes should use rapid-
acting insulin analogs to reduce hypoglycemia risk.
 Consider educating individuals with type 1 diabetes on
matching prandial insulin doses to carbohydrate intake,
pre meal blood glucose levels, and anticipated physical
activity.

43. PHARMACOLOGICAL THERAPY FOR
TYPE 2 DIABETES
 Metformin is the preferred initial pharmacological agent.
Once initiated, it should be continued as long as it is tolerated
and not contraindicated. Other agents should be added to
metformin.
 The early introduction of insulin should be considered:
 If there is evidence of ongoing catabolism,
 If symptoms of hyperglycemia are present,
 When A1C >10% or blood glucose levels> 300mg/dl (16.7
mmol/l) are very high.

44. CONT.
 Consider initiating dual therapy in patients with newly
diagnosed type 2 diabetes who have A1C > 1.5 (12.5
mmol/mol) above their glycemic target.
 A patient-centered approach should be used to guide the
choice of pharmacologic agents. Considerations include
comorbidities ( atherosclerotic cardiovascular disease, heart
failure, chronic kidney disease), hypoglycemia risk, impact on
weight, cost, risk for side effects and patient preferences.
 type 2 diabetes with atherosclerotic cardiovascular disease /
chronic kidney disease sodium glucose cotransporter 2
inhibitors or glucagon like peptide 1 receptor agonists are
recommended
 high risk of heart failure or in whom heart failure coexists
sodium–glucose cotransporter2 inhibitors

45. CONT.
 Intensification of treatment for patients with type 2 diabetes
not meeting treatment goals should not be delayed. The
medication regimen should be reevaluated at regular intervals
(every 3-6 months) and adjusted as needed.
 Patients who need greater glucose-lowering effect of an
injectable medication, glucagon like peptide 1 receptor agonist
are preferred to insulin.

46. GLUCOSE LOWERING MEDICATION IN TYPE 2

49. REFERENCE
 Davidson’s principles & practice of medicine, 23rd
edition.
 American Diabetes Association (ADA); Standards
of Medical Care in Diabetes 2019
 IDF Clinical Practice Recommendations for
managing Type 2 Diabetes in Primary Care (2017)