Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions This presentation will briefly tackle management of Diabetes

1. Management of Diabetes
Dr. ORIBA DAN LANGOYA, MBChB
Resident Internal Medicine,
Supervisor: Dr. Edrisa Mutebi, Endocrinologist, Lecturer
Makerere University College of Health Sciences

2. Introduction
• The treatment of diabetes has traditionally concentrated on
correcting hyperglycemia.
• Intensive control of hyperglycemia has been shown to reduce both
microvascular & macrovascular complications of DM
• The principal cause of morbidity & premature death is CVD.
• Control of hyperlipidemia & hypertension are key factors in reducing
CVD events

3. Diet and lifestyle modification &
management of obesity
• About 80% of patients with type 2 diabetes are
obese
•

4. Diet & activity recommendations
• Correct obesity
• Reduce CVD risk,
By limiting fat, cholesterol, sodium, and alcohol intakes
• Avoid hypoglycaemia in patients receiving insulin
or sulphonylureas
By optimizing the timing and content of meals
• Current advice is close to the healthy eating
recommendations for the whole population

5. PROPERTIES OF INSULIN PREPARATIONS

6. Pharmacologic Approaches to
Glycemic Treatment
• PHARMACOLOGIC THERAPY FOR ADULTS WITH TYPE 1
DIABETES
Most individuals with type 1 diabetes should be treated with
multiple daily injections of prandial and basal insulin, or
continuous subcutaneous insulin infusion. A
Most individuals with type 1 diabetes should use rapid-
acting insulin analogs to reduce hypoglycemia risk. A
Individuals with type 1 diabetes should receive education on
how to match mealtime insulin doses to carbohydrate intake,
fat and protein content, and anticipated physical activity. B

8. Insulin regimens

9. TYPE 2 DIABETES MELLITUS
Essential elements in comprehensive care of type 2 diabetes

10. Glucose-lowering agents

11. AGENTS USED FOR TREATMENT OF TYPE 1 OR TYPE 2
DIABETES

12. AGENTS USED FOR TREATMENT OF TYPE 1 OR TYPE 2
DIABETES

13. AGENTS USED FOR TREATMENT OF TYPE 1 OR TYPE 2
DIABETES

14. Pharmacologic Approaches to
Glycemic Treatment
• PHARMACOLOGIC THERAPY FOR ADULTS WITH TYPE 2
DIABETES
First-line therapy depends on comorbidities, patient-centered
treatment factors, and management needs and generally
includes metformin and comprehensive lifestyle
modification.
Other medications (GLP 1 receptor agonists, SGLT-2
inhibitors), with or without metformin based on glycemic
needs, are appropriate initial therapy for individuals with
type 2 DM with or at high risk for atherosclerotic CVD,
heart failure, and/or CKD

15. Glycemic management o f Type-2 DM
 Agents that can be
combined with metformin
include
 Insulin secretagogues,
 Thiazolidinediones,
 α-glucosidase inhibitors,
 DPP-IV inhibitors,
 GLP-1 receptor agonists,
 SLGT2 inhibitors,
 Insulin.

16. PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT
Glucose-
lowering
Medication in
Type 2
Diabetes:
2021 ADA
Professional
Practice
Committee
(PPC)
adaptation of
Davies et al.
and Buse et
al.
Pharmacologic
Approaches to
Glycemic
Management:
Standards of Medical
Care in Diabetes -
2022. Diabetes Care
2022;45(Suppl.
1):S125-S143

17. Acute metabolic complications of
diabetes and their treatment
• Diabetic ketoacidosis
 This is uncontrolled hyperglycemia with hyperketonemia
severe enough to cause metabolic acidosis.
o Causes
Diabetic ketoacidosis only develops when severe insulin
deficiency, compounded by an excess of glucagon,
stimulates lipolysis and a massive increase in ketogenesis

18. Pathophysiology of Diabetic
Ketoacidosis
Cellular dysfunction induced by intracellular acidosis, as well as cerebral
oedema & shock are potentially life-threatening.

19. Mechanisms for increased ketone bodies in
DKA

20. Clinical features
In pts with DM always think on DKA!

21. MANIFESTATIONS OF DKA

22. DKA Diagnostic criteria

23. Guidelines for the management of diabetic
ketoacidosis

24. Hyperglycemic hyperosmolar state
(HHS)
• HHS is distinguished from DKA by the absence of
marked hyperketonemia (<3.0mmol/l) & metabolic
acidosis (pH >7.3).
• Hyperglycemia can be greater than in DKA
(typically >30mmol/l)
• Rise in urea due to dehydration & prerenal failure, may
elevate the plasma osmolality to well over 350mosmol/kg
• Complications include thrombotic events due apparently
to increased blood viscosity.

25. Management of hypoglycaemia

26. .
Cardiovascular
Disease and Risk
Management

27. Screening and Diagnosis
Cardiovascular Disease and Risk
Management
 Blood pressure should be measured at every routine clinical
visit.
 When possible, patients found to have elevated BP (140/90
mmHg), should have BP confirmed using multiple readings,
including measurements on a separate day, to diagnose
hypertension. A
 Patients with blood pressure 180/110 mmHg & CVD could be
diagnosed with hypertension at a single visit.
 All hypertensive patients with diabetes should monitor their
BP at home. A

28. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Cardiovascular Disease and Risk Management:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S144-S174

29. | 29
Treatment Goals
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
 For patients with DM & HTN, BP targets should be individualized
through a shared decision-making process that addresses CVD
risk, potential adverse effects of antihypertensive medications, and
patient preferences. B
 For individuals with DM & HTN at higher CVD risk (existing
atherosclerotic, CVD [ASCVD] or 10-year ASCVD risk ≈15%), a BP
target of <130/80 mmHg may be appropriate, if it can be safely
attained. B
 For individuals with DM & HTN at lower risk for CVD (10- year
atherosclerotic CVD risk <15%), treat to a BP target of <140/90
mmHg. A
 In pregnant patients with DM and preexisting HTN, a BP target of
110–135/85 mmHg is suggested in the interest of reducing the risk
for accelerated maternal HTN A & minimizing impaired fetal growth

30. | 30
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Randomized
controlled trials
of intensive
versus standard
hypertension
treatment
strategies
Cardiovascular
Disease and Risk
Management:
Standards of Medical
Care in Diabetes -
2022. Diabetes Care
2022;45(Suppl.
1):S144-S174

31. | 31
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Recommendations
for the Treatment of
Confirmed
Hypertension in
People with
Diabetes (1 of 2)
Cardiovascular Disease and Risk Management:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S144-S174

32. | 32
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Recommendations
for the Treatment of
Confirmed
Hypertension in
People with
Diabetes (2 of 2)
Cardiovascular Disease and Risk Management:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S144-S174

33. Lipid Management—Lifestyle
Intervention
• Lifestyle modification focusing on weight loss (if indicated);
application of a Mediterranean style or Dietary Approaches
to Stop Hypertension (DASH)
• Intensify lifestyle therapy & optimize glycemic control for
patients with elevated triglyceride levels (≥150 mg/Dl [1.7
mmol/L]) and/or low HDL cholesterol (<40 mg/dL [1.0 mmol/L]
for men, <50 mg/dL [1.3 mmol/L] for women).

34. | 34
Statin Treatment—Primary Prevention
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
 For patients with DM aged 40–75 years without atherosclerotic CVD, use
moderate-intensity statin therapy in addition to lifestyle therapy. A
 For patients with DM aged 20–39 years with additional atherosclerotic CVD risk
factors, it maybe reasonable to initiate statin therapy in addition to lifestyle
therapy. C
 In patients with DM at higher risk, especially those with multiple atherosclerotic
CVD risk factors or aged 50–70 years, it is reasonable to use high-intensity
statin therapy. B
 In adults with DM & 10-year ASCVD risk of 20% or higher, it may be reasonable
to add ezetimibe to maximally tolerated statin therapy to reduce LDL cholesterol
levels by 50% or more. C

35. | 35
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Cardiovascular Disease and Risk Management:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S144-S174

36. Antiplatelet Agents
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
 Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy
in those with DM & a history of ASCVD. A
 For patients with ASCVD and documented aspirin allergy, clopidogrel (75
mg/day) should be used. B
 Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is
reasonable for a year after an ACS and may have benefits beyond this
period. A
 Long-term treatment with dual antiplatelet therapy should be considered
for patients with prior coronary intervention, high ischemic risk, and low
bleeding risk to prevent major adverse cardiovascular events. A

37. Cardiovascular Disease—Treatment
(continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
 In patients with type 2 DM & established HFrEF, a SGLT-2 inhibitor with
proven benefit in this patient population is recommended to reduce risk of
worsening heart failure and cardiovascular death. A
 In patients with known atherosclerotic cardiovascular disease, particularly
CAD, ACE inhibitor or ARB therapy is recommended to reduce the risk of
cardiovascular events. A
 In patients with type 2 DM and established atherosclerotic CVD or multiple
risk factors for atherosclerotic CVD, a GLP-1 receptor agonist with
demonstrated cardiovascular benefit is recommended to reduce the risk of
major adverse cardiovascular events A

38. | 38
Cardiovascular Disease—Treatment (continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
 In patients with prior myocardial infarction, b-blockers should be continued for 3
years after the event. B
 Treatment of patients with heart failure with reduced ejection fraction should
include a b-blocker with proven cardiovascular outcomes benefit, unless
otherwise contraindicated. A
 In patients with type 2 diabetes with stable heart failure, metformin may be
continued for glucose lowering if estimated glomerular filtration rate remains
>30 mL/min/1.73 m2 but should be avoided in unstable or hospitalized patients
with heart failure. B

39. | 39
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Figure 10.3—Approach
to risk reduction with
SGLT2 inhibitor or GLP-
1 receptor agonist
therapy in conjunction
with other traditional,
guideline-based
preventive medical
therapies for blood
pressure, lipids, and
glycemia and
antiplatelet therapy
Cardiovascular
Disease and Risk
Management:
Standards of Medical
Care in Diabetes -
2022. Diabetes Care
2022;45(Suppl.
1):S144-S174

40. Chronic Kidney
Disease and
Risk
Management

41. Chronic Kidney Disease
• At least annually, urinary albumin (e.g., spot urinary albumin-to-
creatinine ratio) and eGFR should be assessed in patients with type
1 DM with duration of ≥5 years and in all patients with type 2 DM
regardless of Rx.
• Patients with DM & urinary albumin ≥300 mg/g creatinine and/or
an eGFR of 30–60 mL/min/1.73 m2 should be monitored twice
annually to guide therapy.

42. Date of Download: 4/19/2022 Copyright © 2022 American Diabetes Association. All rights reserved.
From: 11. Chronic Kidney Disease and Risk Management: Standards of
Medical Care in Diabetes—2022
Diabetes Care. 2021;45(Supplement_1):S175-S184. doi:10.2337/dc22-S011
Risk of chronic kidney disease (CKD) progression, frequency of visits, and referral to a nephrologist according to glomerular filtration rate (GFR)
and albuminuria are depicted. The GFR and albuminuria grid depicts the risk of progression, morbidity, and mortality by color, from best to worst
(green, yellow, orange, red, dark red). The numbers in the boxes are a guide to the frequency of visits (number of times per year). Green can
reflect CKD with normal eGFR and albumin-to-creatinine ratio only in the presence of other markers of kidney damage, such as imaging
showing polycystic kidney disease or kidney biopsy abnormalities, with follow-up measurements annually; yellow requires caution and
measurements at least once per year; orange requires measurements twice per year; red requires measurements three times per year; and
Figure Legend:

43. Anti-hyperglycemic drugs for patients with
T2D & CKD

44. Retinopathy,
Neuropathy, and
Foot Care

45. Diabetic Retinopathy
RETINOPATHY, NEUROPATHY, AND FOOT CARE
 Optimize glycemic control to reduce the risk or slow the progression of
diabetic retinopathy. A
 Optimize blood pressure and serum lipid control to reduce the risk or slow
the progression of diabetic retinopathy. A
 Adults with type 1 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist or optometrist
within 5 years after the onset of diabetes. B
 Patients with type 2 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist or optometrist at
the time of the diabetes diagnosis. B

46. Diabetic Retinopathy—Treatment
RETINOPATHY, NEUROPATHY, AND FOOT CARE
 Promptly refer patients with any level of macular edema, moderate or
worse nonproliferative diabetic retinopathy (a precursor of proliferative
diabetic retinopathy), or any proliferative diabetic retinopathy to an
ophthalmologist who is knowledgeable and experienced in the
management of diabetic retinopathy. A
 Panretinal laser photocoagulation therapy is indicated to reduce the risk of
vision loss in patients with high-risk proliferative diabetic retinopathy
and, in some cases, severe nonproliferative diabetic retinopathy. A

49. RETINOPATHY, NEUROPATHY, AND FOOT CARE
The risk of ulcers or amputations is increased in people who have the
following risk factors:
• Poor glycemic control
• Peripheral neuropathy with LOPS
• Cigarette smoking
• Foot deformities
• Pre-ulcerative callus or corn
• PAD
• History of foot ulcer
• Amputation
• Visual impairment
• CKD (especially patients on dialysis)