Updates of Diabetes Management by Dr Selim
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This document provides an overview of diabetes management guidelines from the American Diabetes Association. It defines diabetes, classifies the different types, and outlines diagnostic criteria. It discusses the major components of treatment including medical nutrition therapy, physical activity, smoking cessation, comprehensive medical evaluation, glycemic targets, glucose monitoring, and pharmacological therapies. Glycemic goals and treatment approaches are presented for both type 1 and type 2 diabetes in adults and children.
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Updates of Diabetes Management by Dr Selim
- 1. 1 Diabetes Management Updates Dr Shahjada Selim Assistant Professor Department of Endocrinology Bangabandhu Sheikh Mujib Medical University Email: selimshahjada@gmail.com
- 2. Diabetes: A global emergency
- 3. Diabetes around the world
- 4. Diabetes around the world
- 5. Diabetes mellitus Definition: Diabetes mellitus (DM) is a state of chronic hyperglycemia due to defect in insulin secretion action or both. 08/12/17 5
- 7. 1. Type 1 diabetes • β-cell destruction 1. Type 2 diabetes • Progressive insulin secretory defect 1. Gestational Diabetes Mellitus (GDM) 2. Other specific types of diabetes • Monogenic diabetes syndromes • Diseases of the exocrine pancreas, e.g., cystic fibrosis • Drug- or chemical-induced diabetes American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 7
- 8. Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) OR 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT OR A1C ≥6.5% OR Random plasma glucose ≥200 mg/dL (11.1 mmol/L) Criteria for the Diagnosis of Diabetes American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 8
- 9. • At 24-28 weeks gestation in women not previously diagnosed with overt diabetes • 75-g OGTT; Measure plasma glucose at fasting and at 1 and 2 hours. Gestational Diabetes American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 9
- 10. • GDM is diagnosed when plasma glucose exceeds: • Fasting: 92 mg/dL (5.1 mmol/L) • 1 h: 180 mg/dL (10.0 mmol/L) • 2 h: 153 mg/dL (8.5 mmol/L) Gestational Diabetes American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 10
- 11. Management of DM American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 11
- 12. The major components of the treatment of diabetes are: 12
- 13. Medical Nutrition Therapy (MNT) ● An individualized MNT program is recommended for all people with type 1 and type 2 diabetes. ● For people with T1DM or those with T2DM who are on a flexible insulin program, education on carb counting or estimation. American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 13
- 14. …….MNT ● For patients on a fixed insulin program, having a consistent pattern of carbohydrate intake with respect to time and amount can result in improved glycemic control and a reduced risk of hypoglycemia. American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 14
- 15. • Adults with diabetes: at least 150 min/wk of moderate-intensity aerobic activity or 30 minutes brisk walking over at least 3 days/week with no more than 2 consecutive days without exercise Physical Activity American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35 15
- 16. • Children with diabetes/prediabetes: at least 60 min/day physical activity Physical Activity American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 16
- 17. • All individuals, including those with diabetes, should reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting. Physical Activity American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35 17
- 18. • Advise all patients not to use cigarettes, other tobacco products, or e-cigarettes. • Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. Smoking Cessation American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 18
- 19. A complete medical evaluation should be performed at the initial visit to: • Confirm & classify diagnosis • Detect complications & potential comorbid conditions Comprehensive Medical Evaluation American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 19
- 20. • Review prior treatment & risk factor control • Begin formulation of care management plan • Develop a continuing care plan ….Comprehensive Medical Evaluation American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 20
- 21. Components of the Comprehensive Diabetes Evaluation Laboratory Evaluation • A1C, if results not available within past 3 months American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 21
- 22. ….Components of the Comprehensive Diabetes Evaluation •If not performed/available within past year: • Fasting lipid profile • Liver function tests • Spot urine albumin-to-creatinine ratio • Serum creatinine and eGFR • Thyroid-stimulating hormone in patients with type 1 diabetes or dyslipidemia or women aged >50 years American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S35 22
- 24. • Two primary techniques available for health providers and patients to assess effectiveness of management plan on glycemic control 1. Patient self-monitoring of blood glucose (SMBG) 2. A1C ..Glycemic Control American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 24
- 25. • CGM or interstitial glucose may be a useful adjunct to SMBG in selected patients. Glycemic Control American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 25
- 26. • Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG B • Prior to meals and snacks • At bedtime • Prior to exercise • When they suspect low blood glucose Glucose Monitoring American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 26
- 27. • When they suspect low blood glucose • After treating low blood glucose until they are normoglycemic • Prior to critical tasks such as driving • Possibly also post-prandially Glucose Monitoring American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 27
- 28. • Perform the A1C test at least twice annually in patients that meet treatment goals (and have stable glycemic control). • Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. A1C Testing American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 28
- 29. • Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. • Use of point-of-care (POC) testing for A1C provides the opportunity for more timely treatment changes. A1C Testing American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 29
- 30. • Lowering A1C to <7% has been shown to reduce microvascular complications and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease. Glycemic Goals in Adults American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 30
- 31. • Consider more stringent goals (e.g. <6.5%) for select patients if achievable without significant hypos or other adverse effects. Glycemic Goals in Adults American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 31
- 32. • Consider more stringent goals (e.g. <6.5%) for select patients if achievable without significant hypos or other adverse effects. Glycemic Goals in Adults American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 32
- 33. • Consider less stringent goals (e.g. <8%) for patients with a hx of severe hypoglycemia, limited life expectancy, or other conditions that make <7% difficult to attain. B Glycemic Goals in Adults American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 33
- 34. Approach to the Management of Hyperglycemia low high newly diagnosed long-standing long short absent severeFew/mild absent severeFew/mild highly motivated, adherent, excellent self-care capabilities readily available limited less motivated, nonadherent, poor self-care capabilities A1C 7% more stringent less stringent Patient/Disease Features Risks associated with hypoglycemia & other drug adverse effects Disease Duration Life expectancy Important comorbidities Established vascular complications Patient attitude & expected treatment efforts Resources & support system American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 34
- 35. A1C <7.0%* Preprandial capillary plasma glucose 4.4–7.2 mmol/L* (80–130 mg/dL) Peak postprandial capillary plasma glucose† <10.0 mmol/L* (<180 mg/dL) Glycemic Recommendations for Nonpregnant Adults with Diabetes * Goals should be individualized. † Postprandial glucose measurements should be made 1–2 hours after the beginning of the meal. American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S46 35
- 36. • An A1C goal of <7.5% is recommended across all pediatric age-groups. E Type 1 Diabetes: Glycemic Control American Diabetes Association Standards of Medical Care in Diabetes. Children and adolescents. Diabetes Care 2017; 39 (Suppl. 1): S86-S93 36
- 37. Blood glucose goal range A1C Rationale Before meals Bedtime/ overnight 5.0–7.2 mmol/L (90–130 mg/dL) 5.0–8.3 mmol/L (90–150 mg/dL) <7.5% A lower goal (<7.0%) is reasonable if it can be achieved without excessive hypos T1 DM: Glycemic Control 1. Goals should be individualized; lower goals may be reasonable. 2. Modify BG goals in youth w/ frequent hypos or hypoglycemia unawareness. 3. Measure postprandial BG if discrepancy between preprandial BG and A1C & to assess glycemia in basal–bolus regimens. American Diabetes Association Standards of Medical Care in Diabetes. Children and adolescents. Diabetes Care 2017; 39 (Suppl. 1): S86-S93 37
- 39. • Most people with T1DM should be treated with multiple dose insulin (MDI) injections (3–4 injections /day of basal & prandial insulin) or continuous subcutaneous insulin infusion (CSII). • Individuals who have been successfully using CSII should have continued access after they turn 65 years old. Pharmacological Therapy for T1DM American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S59 39
- 40. Pharmacological Therapy for T1DM • Consider educating individuals with T1DM on matching prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity. • Most individuals with T1DM should use insulin analogs to reduce hypoglycemia risk. American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59 40
- 41. Pramlintide • FDA approved for T1DM • Amylin analog • Delays gastric emptying, blunts pancreatic glucose secretion, enhances satiety • Induces weight loss, lowers insulin dose • Requires reduction in prandial insulin to reduce risk of severe hypos American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S59 41
- 42. • Can normalize glucose but require lifelong immunosuppression. • Reserve for T1D patients: • Undergoing renal transplant • Following renal transplant • With recurrent ketoacidosis or severe hypos Pancreas and Islet Cell Transplantation American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S59 42
- 43. • Can normalize glucose but require lifelong • Islet cell transplant investigational • Consider for patients requiring pancreatectomy who meet eligibility criteria. Pancreas and Islet Cell Transplantation American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S59 43
- 44. PharmacologicalPharmacological Therapy for T2DMTherapy for T2DM American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S59 44
- 45. 45
- 46. DRUG CLASS AGENT Sulfonylureas First generation Acetohexamide, Chlorpropamide Tolazamide, Tolbutamide Second generation Glyburide, Glipizide, Glimepiride Meglitinides Repaglinide Nateglinide Biguanides Metformin Thiazolidinediones Pioglitazone Rosiglitazone α-glucosidase inhibitors Acarbose Miglitol 08/12/17 46 Oral Antihyperglycemic Drugs (OADs)
- 47. DRUG CLASS AGENT DPP4 inhibitors Sitagliptin (FDA approved Oct 2006) Vildagliptin (EU Approved 2008) Saxagliptin (FDA Approved July 2009) Linagliptin (FDA Approved May 2, 2011) and Alogliptin, Septagliptin, Teneligliptin SGLT-2 inhibitors Canagliflozin (USFDA approved in March 2013) Dapagliflozin Empagliflozin 08/12/17 47
- 48. • The progressive nature of T2DM should be regularly & objectively explained to T2DM patients. • For T2DM patients not achieving glycemic goals, promptly initiate insulin therapy. • Avoid using insulin as a threat, describing it as a failure or punishment. • Give patients a self-titration algorithm. Insulin Therapy in T2DM American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59 48
- 49. 49
- 50. 50 Insulin initiation in Type 2 DM: When 1. HbA1c ≥ 10% [start combination insulins] (ADA 2017) but if HbA1c ≥ 9%, Basal alone may be initiated 2. Symptomatic hyperglycemia 3. PPG > 19.4 mmol/L, FPG> 16.6 moml/L 4. If the glycemic target is not achieved by using three non-insulin agents (metformine/pioglitazone, secretagogue, Gi/DPP4i/SGLT2i) by at least 3 monthsɑ 5. In some specific situations
- 51. Short term use of insulin therapy in patients with T2DM may also be considered in the following conditions: • Acute illness, surgery, stress and emergencies • Pregnancy and lactation • As initial therapy in T2DM with severe hyperglycemia • Severe metabolic decompensation (eg. DKA, HHS)
- 52. Types of insulin Type of Insulin Onset Peak Duration Role in Blood Sugar Management Rapid-Acting Lispro 15-30 min. 30-90 min 3-5 hours Covers insulin needs for meals eaten at the same time as the injection.Aspart 10-20 min. 40-50 min. 3-5 hours Glulisine 20-30 min. 30-90 min. 1-2½ hours Short-Acting Regular (R) 30 min- 60 min 2-5 hours 5-8 hours Covers insulin needs for meals eaten within 30-60 minutes Intermediate-Acting NPH (N) 1-2 hours 4-12 hours 18-24 hours Covers insulin needs for about half the day or overnight.
- 53. Types of insulin Name of Insulin Onset Duration Role in Blood Sugar Management Long-Acting Long-acting insulin covers insulin needs for about one full day. Degludec 30-90 min No peak: insulin is delivered at a steady level. Longer than 24 hours Glargine 30-90 min Up to 24 hours Detemir 1-120 min 20-24 hours
- 54. Types of insulin Type of Insulin Onset Peak Duration Role in Blood Sugar Management Pre-Mixed* 30/70 30 min. 2-4 hours 14-24 hours These products are generally taken two or three times a day before mealtime. 50/50 30 min. 2-5 hours 18-24 hours 25/75 15 min. 30 min.-2½ hours 16-20 hours Inhaler Exubera Banned Afrezza With in min 12 to 15 min 2-3 hours Post prandial effects. *Premixed insulins are a combination of specific proportions of intermediate-acting and short-acting insulin in one bottle or insulin pen (the numbers the brand name indicate the percentage of each type of insulin).
- 55. Common Insulin Regimens Split Mix Regimens Two injections (intermediate + soluble) per day * before breakfast & before bedtime Proportion/dosage of insulin titrated based on BG profile Drawback Mixing insulins is tedious and problematic Inaccuracy of dose Not preferred –more problems for patients 55
- 56. Common Insulin Regimens Basal insulin Usually given at night Proportion/dosage of insulin titrated based on FBG Drawback Expensive Fasting blood glucose is primary targeted May be with sensitizer and or secretagogue 56
- 57. Common Insulin Regimens Basal Plus Basal insulin at night Any rapid acting insulin premeal. May be useful during early years of T2DM and in uncomplicated well motivated patients. May be needed to shifted to Basal bolus regimen titrated based on BG profile Drawback Mixing insulins is tedious and problematic Inaccuracy of dose Not preferred –more problems for patients 57
- 58. Common Insulin Regimens (4) Basal Bolus Basal insulin at night and one rapid acting insulin immediately before each major meal (3 times). Basal insulin is titrated following FBG Rapid acting insulin is titrated by post meal BGs Drawback Expensive 4 times needle prick a day. Most preferred –most flexible 58
- 59. 59 GLP-1 Receptor Agonists Emerging Treatments in Diabetes Therapeutics
- 60. Continuously Infused GLP-1 Improved the Defects of T2D T2D Defects1 Continuously Infused GLP-11,2 Insulin production First-phase insulin response Glucagon; glucose output Gastric emptying Food intake 1. Aronoff SL, et al. Diabetes Spectrum 2004;17:183-190. 2. Nielsen LL, et al. Regul Pep. 2004;117:77-88.
- 61. 61 • Currently only Liraglutide is available in Bangldadesh • Semaglutide amd Albiglutide are awaiting to come to the global market.
- 62. 62 SGLT2 inhibition - A novel approach for diabetes management
- 64. Canagliflozin inhibits SGLT2 thereby reduces blood glucose through urine. What has historically been viewed as a sign of diabetes — glucose in the urine — may also reflect the efficacy of a new and unique approach to treatment." Mechanism of action of SGLT-2i Canagl iflozin
- 66. • Provide preconception counseling that addresses the importance of tight glycemic control, ideally <6.5%, to reduce the risk of congenital anomalies. Pregestational Diabetes American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98 66
- 67. 67 • Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98
- 68. • Women preexisting type 1 or type 2 diabetes who are pregnant or planning to become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye exams should occur before pregnancy or in the first trimester & then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. Pregestational Diabetes American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98 68
- 69. • Lifestyle change is an essential part GDM mgmt. and may suffice for many women. Add medications if needed to achieve glycemic targets. Gestational Diabetes Mellitus (GDM) American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98 69
- 70. • Preferred medications in GDM are insulin and metformin; glyburide may be used but may have higher rate of neonatal hypoglycemia & macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta and all lack long- term safety data. A Gestational Diabetes Mellitus (GDM) American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2017. Diabetes Care 2016;39(Suppl. 1):S94–S98 70
- 71. • Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. General Principles for Management of Diabetes in Pregnancy American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98 71
- 72. • Fasting, preprandial & postprandial SMBG are recommended in both GDM and pregestational diabetes in pregnancy to achieve glycemic control. General Principles for Management of Diabetes in Pregnancy American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98 72
- 73. • Due to increased red blood cell turnover, A1C is lower in normal pregnancy than in normal nonpregnant women. A1C target in pregnancy is 6 – 6.5%; <6% may be optimal if achievable without significant hypoglycemia, but the target may be relaxed to <7% if necessary to prevent hypoglycemia. …General Principles for Management of Diabetes in Pregnancy American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98 73
- 74. The following targets for women with pregestational type 1 or type 2 diabetes: • Fasting ≤90 mg/dL (5.0 mmol/L) • One-hour postprandial ≤130–140mg/dL (7.2–7.8 mmol/L) • Two-hour postprandial ≤120 mg/dL (6.7 mmol/L) Glycemic Targets in Pregnancy (Preexisting Type 1 or Type 2) American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98 74
- 75. Treatment of GDM • MNT [Dietary Therapy, Exercise] • Self BG monitoring • Administration of Insulin if target blood glucose level are not met by diet alone • Fetal surveillance • Intrapartum care • Post partum care
- 76. Insulin therapy Recommendations for starting Insulin (ADA guideline) FPG> 5.8mmol/l or 1 hr PG> 8.6 mmol/l 2hr PG > 7.2 mmol/l Target blood glucose: Pre prandial <5.3mmol/l 1 hr post prandial <7.8 mmol/l 2 hr post prandial <6.7 mmol/l
- 77. Insulin therapy cont. Calculating dose: Total insulin- 20-30 U/day ½ Basal or 2/3rd intermediate acting ½ Bolus or 1/3rd regular Insulin Calculated daily dose of insulin: 1st trimester-0.8 unit ×kg BW 2nd trimester- 1 unit ×kg BW 3rd trimester- 1.3 unit×kg BW
- 78. The dose and type of insulin used is calculated according to the blood glucose level If the FBG is high then, a long acting (or intermediate- acting insulin), is given before bedtime. If postprandial blood glucose levels are high, then regular rapid-acting insulin are added before meals. Insulin Therapy cont.
- 79. Regular Insulin is withheld during labor; a sliding scale of soluble insulin should be started (or infusion pump as may be fit) Maternal hyperglycemia should be avoided during labor to prevent fetal hyperinsulinemia and subsequent neonatal hypoglycemia Maternal blood glucose should be maintained between 4- 5 mmol/L. Peripartum Management:
- 80. Key Take-Home MessagesKey Take-Home Messages • MNT is the corner stone of diabetes management. • MNT is also essential to reach optimal glycemic control with fewer hypoglycemic episodes 80
- 81. Key Take-Home MessagesKey Take-Home Messages • OADs may attain or maintain good glycemic control for a variable periods • Insulin may need to be started in any time mean while. 81
- 82. Key Take-Home MessagesKey Take-Home Messages • Premixed insulin is not preferred during dos adjustment. 82
- 83. Key Take-Home MessagesKey Take-Home Messages • When initiating insulin, start with bedtime or morning long-acting insulin. • After 2-3 months, if FBG levels are in target range but HbA1c ≥7%, check BG before lunch, dinner, and bed, and, depending on the results, add 2nd injection. 83
- 84. Key Take-Home MessagesKey Take-Home Messages • It is difficult to obtain optimal control without occasional, mild episodes of hypoglycemia. 84
- 85. 85 Thanks to All
Editor's Notes
- The classification of diabetes includes four clinical categories: Type 1 diabetes, due to β-cell destruction, usually leading to absolute insulin deficiency; [CLICK] Type 2 diabetes, due to a progressive insulin secretory defect on the background of insulin resistance; [CLICK] Gestational diabetes mellitus, which is diabetes diagnosed during pregnancy that is not clearly overt diabetes [CLICK] Other specific types of diabetes due to other causes; e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation) [SLIDE]
- The same tests are used to screen for and diagnose diabetes and to detect people with prediabetes. These include: Fasting plasma glucose (FPG) ≥126 mg/dL OR 2-hour plasma glucose ≥200 mg/dL during an OGTT OR A1C ≥6.5% Or in a patient with classic symptoms of hyperglycemia a random plasma glucose ≥ 200 can also be used. The subsequent slides examine each of the criteria in greater detail. [SLIDE]
- First, the one-step strategy, which consists of a 75g OGTT. In women between 24 and 28 weeks gestation not previously diagnosed with overt diabetes, perform a 75-g OGTT in the morning after an overnight fast of at least 8 hours. Measure plasma glucose measurement fasting and at 1 and 2 hours. Gestational diabetes is diagnosed if the fasting glucose is higher than 92 mg per dL, if the 1 hour glucose is higher than 180, or if the 2 hour is over 153. [SLIDE]
- First, the one-step strategy, which consists of a 75g OGTT. In women between 24 and 28 weeks gestation not previously diagnosed with overt diabetes, perform a 75-g OGTT in the morning after an overnight fast of at least 8 hours. Measure plasma glucose measurement fasting and at 1 and 2 hours. Gestational diabetes is diagnosed if the fasting glucose is higher than 92 mg per dL, if the 1 hour glucose is higher than 180, or if the 2 hour is over 153. [SLIDE]
- First, the one-step strategy, which consists of a 75g OGTT. In women between 24 and 28 weeks gestation not previously diagnosed with overt diabetes, perform a 75-g OGTT in the morning after an overnight fast of at least 8 hours. Measure plasma glucose measurement fasting and at 1 and 2 hours. Gestational diabetes is diagnosed if the fasting glucose is higher than 92 mg per dL, if the 1 hour glucose is higher than 180, or if the 2 hour is over 153. [SLIDE]
- Moving on to recommendations in the area of nutrition therapy, first, an individualized medical nutrition therapy program, preferably provided by a registered dietitian, is recommended for al patients with type 1 and type 2 diabetes. For people with type 1 diabetes or type 2 who are prescribed a flexible insulin therapy program, education carb counting or estimation to determine mealtime insulin dosing is recommended as it can improve glycemic control. [SLIDE]
- And the final points under the effectiveness of nutrition therapy: For your patients with type 2 diabetes who are not on insulin who have limited health literacy or are elderly and prone to hypoglycemia, it may make more sense to simply emphasize healthy food choices and portion control. And finally, because diabetes nutrition therapy can result in cost savings and improved outcomes (e.g., A1C reduction), MNT should be adequately reimbursed by insurance and other payers. [SLIDE]
- Recommendations for physical activity for people with diabetes1 are summarized on this slide • As with all children, children with diabetes or prediabetes should be encouraged to engage in at least 60 minutes of physical activity each day. [CLICK] Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (with “moderate” defined as 50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. [CLICK] All individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (&gt;90 min) spent sitting. [CLICK] And finally, in the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. [CLICK] [SLIDE]
- Recommendations for physical activity for people with diabetes1 are summarized on this slide • As with all children, children with diabetes or prediabetes should be encouraged to engage in at least 60 minutes of physical activity each day. [CLICK] Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (with “moderate” defined as 50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. [CLICK] All individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (&gt;90 min) spent sitting. [CLICK] And finally, in the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. [CLICK] [SLIDE]
- Recommendations for physical activity for people with diabetes1 are summarized on this slide • As with all children, children with diabetes or prediabetes should be encouraged to engage in at least 60 minutes of physical activity each day. [CLICK] Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (with “moderate” defined as 50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. [CLICK] All individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (&gt;90 min) spent sitting. [CLICK] And finally, in the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. [CLICK] [SLIDE]
- The Association offers two key recommendations in the areas of tobacco and e-cigarettes. First, do advise all patients not to use cigarettes, other tobacco products, or e-cigarettes. This last one – e-cigarettes– is hard, but there just are no rigorous studies demonstrating that e-cigarettes are a healthier alternative to smoking or that e-cigarettes can facilitate smoking cessation. More extensive research of their short- and long-term effects is needed to determine their safety and their cardiopulmonary effects in comparison with smoking and standard approaches to smoking cessation so the Association recommends against their use. [CLICK] And secondly, do include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. [SLIDE]
- Moving on to the medical evaluation, a comprehensive medical evaluation should be performed at the initial visit in order to accomplish several things: First, to confirm the diagnosis and classify diabetes; [CLICK] To detect any potential diabetes complications and potential comorbid conditions; [CLICK] In patients with established diabetes, to review previous treatment and risk factor control; [CLICK] To Begin patient engagement in the formulation of a care management plan, and finally, [CLICK] To develop a continuing care plan [SLIDE[
- Moving on to the medical evaluation, a comprehensive medical evaluation should be performed at the initial visit in order to accomplish several things: First, to confirm the diagnosis and classify diabetes; [CLICK] To detect any potential diabetes complications and potential comorbid conditions; [CLICK] In patients with established diabetes, to review previous treatment and risk factor control; [CLICK] To Begin patient engagement in the formulation of a care management plan, and finally, [CLICK] To develop a continuing care plan [SLIDE[
- And finally, the last components of the comprehensive exam, the laboratory evaluation. Perform an A1C if results are not available from within the past 3 months. And the rest of these if you don’t have them from within the past year: a fasting lipid profile, liver function tests, spot urine albumin-to-creatinine ratio, serum creatinine and estimated glomerular filtration rate, and, finally, in patients with type 1 or dyslipidemia, or women over age 50, get a thyroid stimulating hormone. [SLIDE]
- And finally, the last components of the comprehensive exam, the laboratory evaluation. Perform an A1C if results are not available from within the past 3 months. And the rest of these if you don’t have them from within the past year: a fasting lipid profile, liver function tests, spot urine albumin-to-creatinine ratio, serum creatinine and estimated glomerular filtration rate, and, finally, in patients with type 1 or dyslipidemia, or women over age 50, get a thyroid stimulating hormone. [SLIDE]
- Section 5. Glycemic Targets
- In addition to an initial evaluation and management, diabetes care requires an assessment of glycemic control Two primary techniques available for health providers and patients to assess the effectiveness of the management plan on glycemic control are summarized on this slide Patient self-monitoring of blood glucose (SMBG) A1C Continuous Glucose Monitoring or interstitial glucose may be a useful adjunct to SMBD in some patients. Recommendations for glucose monitoring, A1C testing, correlation of A1C with average glucose, glycemic goals in adults, intensive glycemic control and cardiovascular outcomes, and recommended glycemic goals for many nonpregnant adults with diabetes as well as glycemic goals in pregnant women are summarized in the following slides. [SLIDE]
- In addition to an initial evaluation and management, diabetes care requires an assessment of glycemic control Two primary techniques available for health providers and patients to assess the effectiveness of the management plan on glycemic control are summarized on this slide Patient self-monitoring of blood glucose (SMBG) A1C Continuous Glucose Monitoring or interstitial glucose may be a useful adjunct to SMBD in some patients. Recommendations for glucose monitoring, A1C testing, correlation of A1C with average glucose, glycemic goals in adults, intensive glycemic control and cardiovascular outcomes, and recommended glycemic goals for many nonpregnant adults with diabetes as well as glycemic goals in pregnant women are summarized in the following slides. [SLIDE]
- Recommendations for glucose monitoring are summarized on three slides Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving This may mean testing 6-10 times per day, though individual needs vary. But at least in studies of children with type 1 diabetes, increased daily frequency of SMBG was significantly associated with lower A1C. SMBG frequency and timing should be dictated by the patient’s specific needs and goals SMBG is especially important for patients treated with insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia [SLIDE]
- Recommendations for glucose monitoring are summarized on three slides Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving This may mean testing 6-10 times per day, though individual needs vary. But at least in studies of children with type 1 diabetes, increased daily frequency of SMBG was significantly associated with lower A1C. SMBG frequency and timing should be dictated by the patient’s specific needs and goals SMBG is especially important for patients treated with insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia [SLIDE]
- A1C reflects average glycemia over several months and has strong predictive value for diabetes complications. Thus, A1C testing should be performed routinely in all patients with diabetes—at initial assessment and as part of continuing care. Measurement about every 3 months determines whether patients’ glycemic targets have been reached and maintained, though the frequency of A1C testing should depend on the clinical situation, the treatment regimen, and the clinician’s judgment. For your patients meeting treatment goals and with stable control, check the A1C at least twice a year, and for your patients whose therapy has changed or who aren’t meeting glycemic goals, test quarterly. You may also have patients who are unstable or highly intensively managed, such as pregnant women with type 1, whom you may wish to test more frequently than every 3 months. Point of care A1C testing can help accommodate more timely decisions, for example on when to change therapy. The A1C test is subject to certain limitations: conditions that affect erythrocyte turnover (e.g., hemolysis, blood loss) and hemoglobin variants must be considered, particularly when the A1C result does not correlate with the patient’s clinical situation;2 in addition, A1C does not provide a measure of glycemic variability or hypoglycemia For patients prone to glycemic variability (especially type 1 diabetic patients, or type 2 diabetic patients with severe insulin deficiency), glycemic control is best judged by the combination of result of self-monitoring of blood glucose (SMBG) testing and A1C The A1C may also confirm the accuracy of a patient’s meter (or the patient’s reported SMBG results) and the adequacy of the SMBG testing schedule [SLIDE]
- A1C reflects average glycemia over several months and has strong predictive value for diabetes complications. Thus, A1C testing should be performed routinely in all patients with diabetes—at initial assessment and as part of continuing care. Measurement about every 3 months determines whether patients’ glycemic targets have been reached and maintained, though the frequency of A1C testing should depend on the clinical situation, the treatment regimen, and the clinician’s judgment. For your patients meeting treatment goals and with stable control, check the A1C at least twice a year, and for your patients whose therapy has changed or who aren’t meeting glycemic goals, test quarterly. You may also have patients who are unstable or highly intensively managed, such as pregnant women with type 1, whom you may wish to test more frequently than every 3 months. Point of care A1C testing can help accommodate more timely decisions, for example on when to change therapy. The A1C test is subject to certain limitations: conditions that affect erythrocyte turnover (e.g., hemolysis, blood loss) and hemoglobin variants must be considered, particularly when the A1C result does not correlate with the patient’s clinical situation;2 in addition, A1C does not provide a measure of glycemic variability or hypoglycemia For patients prone to glycemic variability (especially type 1 diabetic patients, or type 2 diabetic patients with severe insulin deficiency), glycemic control is best judged by the combination of result of self-monitoring of blood glucose (SMBG) testing and A1C The A1C may also confirm the accuracy of a patient’s meter (or the patient’s reported SMBG results) and the adequacy of the SMBG testing schedule [SLIDE]
- We’ll discuss glycemic goals in children and adolescents and in pregnant women in the sections specific to care of those populations. These slides are specific to nonpregnant adults. Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management; recommendations for glycemic goals in adults1 are reviewed on three slides. The concerning mortality findings in the ACCORD trial, discussed which we’ll get to shortly, and the relatively intense efforts required to achieve near-euglycemia should also be considered when setting glycemic targets. Glycemic control achieved using A1C targets of &lt;7% has been shown to reduce microvascular complications of diabetes and, in type 1 diabetes, mortality. If implemented soon after the diagnosis of diabetes this target is associated with long-term reduction in macrovascular disease. Providers might suggest more stringent A1C goals (such as &lt;6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. Less stringent A1C goals (such as &lt;8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. [SLIDE]
- We’ll discuss glycemic goals in children and adolescents and in pregnant women in the sections specific to care of those populations. These slides are specific to nonpregnant adults. Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management; recommendations for glycemic goals in adults1 are reviewed on three slides. The concerning mortality findings in the ACCORD trial, discussed which we’ll get to shortly, and the relatively intense efforts required to achieve near-euglycemia should also be considered when setting glycemic targets. Glycemic control achieved using A1C targets of &lt;7% has been shown to reduce microvascular complications of diabetes and, in type 1 diabetes, mortality. If implemented soon after the diagnosis of diabetes this target is associated with long-term reduction in macrovascular disease. Providers might suggest more stringent A1C goals (such as &lt;6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. Less stringent A1C goals (such as &lt;8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. [SLIDE]
- We’ll discuss glycemic goals in children and adolescents and in pregnant women in the sections specific to care of those populations. These slides are specific to nonpregnant adults. Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management; recommendations for glycemic goals in adults1 are reviewed on three slides. The concerning mortality findings in the ACCORD trial, discussed which we’ll get to shortly, and the relatively intense efforts required to achieve near-euglycemia should also be considered when setting glycemic targets. Glycemic control achieved using A1C targets of &lt;7% has been shown to reduce microvascular complications of diabetes and, in type 1 diabetes, mortality. If implemented soon after the diagnosis of diabetes this target is associated with long-term reduction in macrovascular disease. Providers might suggest more stringent A1C goals (such as &lt;6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. Less stringent A1C goals (such as &lt;8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. [SLIDE]
- We’ll discuss glycemic goals in children and adolescents and in pregnant women in the sections specific to care of those populations. These slides are specific to nonpregnant adults. Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management; recommendations for glycemic goals in adults1 are reviewed on three slides. The concerning mortality findings in the ACCORD trial, discussed which we’ll get to shortly, and the relatively intense efforts required to achieve near-euglycemia should also be considered when setting glycemic targets. Glycemic control achieved using A1C targets of &lt;7% has been shown to reduce microvascular complications of diabetes and, in type 1 diabetes, mortality. If implemented soon after the diagnosis of diabetes this target is associated with long-term reduction in macrovascular disease. Providers might suggest more stringent A1C goals (such as &lt;6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. Less stringent A1C goals (such as &lt;8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. [SLIDE]
- This slide, “Approach to Management of Hyperglycemia,” depicts the elements of decision making used to determine appropriate efforts to achieve glycemic targets1 (Adapted with permission from Inzucchi et al.) You may have seen this before, but in case not we’ll walk through it briefly. Going down the left side you see a series of patient or disease characteristics with a corresponding A1C impact scale on the right. The small end of the triangle aligns with a more stringent A1C and the fatter end aligns with less stringent A1C. So taking the first one, the red triangle, risks associated with hypoglycemia and other drug adverse effects…. Clearly the risks are lower with a more stringent A1C and higher with a less stringent A1C. These are grouped into two categories, the [CLICK] top set consists of factors that are usually not modifiable and [CLICK] the bottom set may be potentially modifiable. Where possible, such decisions should be made in conjunction with the patient, reflecting his or her preferences, needs, and values This “scale” is not designed to be applied rigidly but to be used as a broad construct to help guide clinical decisions Those with long duration of diabetes, known history of severe hypoglycemia, advanced atherosclerosis, and advanced age/frailty may benefit from less aggressive targets Providers should be vigilant in preventing severe hypoglycemia in patients with advanced disease and should not aggressively attempt to achieve near-normal A1C levels in patients in whom such targets cannot be safely and reasonably achieved Severe or frequent hypoglycemia is an absolute indication for the modification of treatment regimens, including setting higher glycemic goals [SLIDE]
- Shown here are the Association’s recommended glycemic goals for many nonpregnant adults. These recommendations are based on those for A1C values, with listed blood glucose levels that appear to correlate with achievement of an A1C of &lt;7% [SLIDE]
- • An A1C goal of &lt;7.5% is recommended across all pediatric age-groups. Current standards for diabetes management reflect the need to lower glucose as safely as possible. This should be done with stepwise goals. Special consideration should be given to the risk of hypoglycemia in young children (aged &lt;6 years) who are often unable to recognize, articulate, and/or manage their hypoglycemic symptoms. This “hypoglycemia unawareness” should be considered when establishing individualized glycemic targets. Although it was previously thought that young children were at risk for cognitive impairment after episodes of severe hypoglycemia, current data have not confirmed this notion. Furthermore, new therapeutic modalities, such as rapid- and long-acting insulin analogs, technological advances (e.g., continuous glucose monitors, low glucose suspend insulin pumps), and education, may mitigate the incidence of severe hypoglycemia [SLIDE]
- This is Table 11.1, Blood glucose and A1C goals for type 1 diabetes across all pediatric age-groups. With these goals it is essential to keep in mind three key concepts: [CLICK] Goals should be individualized, and lower goals may be reasonable based on benefit-risk assessment. [CLICK] Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness. [CLICK] Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and to help assess glycemia in those on basal–bolus regimens. [SLIDE]
- Approaches to Glycemic Treatment
- Starting off with type 1 diabetes, there are plenty of other resources out there on initiating and managing insulin therapy, so we won’t go into that here. Most of your patients with type 1 diabetes should be treated with multiple dose injections or insulin pump therapy. There are minimal differences between the two as far as hypoglycemia is concerned. Whichever one a patient chooses, intensive management and active patient or family participation should be strongly encouraged. [CLICK] Individuals who have been successfully using an insulin pump should have continued access after they turn 65. [SLIDE]
- Consider educating your patients with type 1 diabetes on matching prandial insulin doses to carbohydrate intake, premeal blood glucose, and anticipated activity. [CLICK] And finally, most individuals with type 1 should use insulin analogs to reduce the risk of hypoglycemia. [SLIDE]
- Pramlintide is an FDA approved amylin analog that delays gastric emptying, blunts pancreatic glucose secretion, and enhances satiety. It can induce weight loss and lower the insulin dose, but does require the concurrent reduction of prandial insulin to lower the risk of severe hypoglycemia. [SLIDE]
- A few words on transplantation. Pancreatic or islet cell transplantation can normalize glucose levels but require lifelong immunosuppression to prevent graft rejection and recurrence of islet destruction. Therefore, pancreas transplantation should be reserved for type 1 patients undergoing simultaneous renal transplantation, following renal transplantation, or for those with recurrent ketoacidosis or severe hypoglycemia despite aggressive glycemic management. Islet cell transplantation remains investigational. Auto-islet transplantation may be considered for patients requiring total pancreatectomy who meet eligibility criteria. {SLIDE]
- A few words on transplantation. Pancreatic or islet cell transplantation can normalize glucose levels but require lifelong immunosuppression to prevent graft rejection and recurrence of islet destruction. Therefore, pancreas transplantation should be reserved for type 1 patients undergoing simultaneous renal transplantation, following renal transplantation, or for those with recurrent ketoacidosis or severe hypoglycemia despite aggressive glycemic management. Islet cell transplantation remains investigational. Auto-islet transplantation may be considered for patients requiring total pancreatectomy who meet eligibility criteria. {SLIDE]
- Recommended pharmacological therapy for hyperglycemia in type 2 diabetes1 is summarized on the next two slides. First, metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes. Metformin has a long-standing evidence base for efficacy and safety, is inexpensive, and may reduce risk of cardiovascular events. [CLICK] In patients with newly diagnosed patients type 2 diabetes and markedly symptomatic or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset [SLIDE]
- The progressive nature of T2DM should be regularly & objectively explained to T2DM patients. Along those lines, for your patients who are not achieving glycemic goals, promptly initiate insulin therapy Avoid using insulin as a threat, describing it as a failure or punishment And do give patients a self-titration algorithm [SLIDE]
- Here we give the action profiles of NN brands including the newer introductions, NovoRapid & NovoMix 30 Note the difference in onset, peak & duration of action of NovoRapid & Actrapid & similarly NovoMix 30 & Mixtard 30
- Here we give the action profiles of NN brands including the newer introductions, NovoRapid & NovoMix 30 Note the difference in onset, peak & duration of action of NovoRapid & Actrapid & similarly NovoMix 30 & Mixtard 30
- Here we give the action profiles of NN brands including the newer introductions, NovoRapid & NovoMix 30 Note the difference in onset, peak & duration of action of NovoRapid & Actrapid & similarly NovoMix 30 & Mixtard 30
- In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day These two injections are given before breakfast & before bedtime. The proportion/dosage of insulins can be titrated based on BG profiles. This regimen has its own drawbacks which include Mixing insulins is tedious and problematic for the patient Inaccuracy of dose is common Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
- In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day These two injections are given before breakfast & before bedtime. The proportion/dosage of insulins can be titrated based on BG profiles. This regimen has its own drawbacks which include Mixing insulins is tedious and problematic for the patient Inaccuracy of dose is common Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
- In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day These two injections are given before breakfast & before bedtime. The proportion/dosage of insulins can be titrated based on BG profiles. This regimen has its own drawbacks which include Mixing insulins is tedious and problematic for the patient Inaccuracy of dose is common Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
- In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day These two injections are given before breakfast & before bedtime. The proportion/dosage of insulins can be titrated based on BG profiles. This regimen has its own drawbacks which include Mixing insulins is tedious and problematic for the patient Inaccuracy of dose is common Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
- HL Refs Aronoff_Diabetes_Spectrum_2004_p184,185,186,187,188.pdf Nielsen_Regul_Pept_2004_p77.pdf DISCUSSION Continuously infused GLP-1 has the following effects1,2 It enhances glucose-dependent insulin production It restores first-phase insulin response It decreases postprandial glucagon production, thus decreasing glucagon-stimulated hepatic glucose output It regulates gastric emptying, decreasing the rate of peak nutrient absorption from meals It decreases food intake REFERENCES 1. Aronoff SL, et al. Diabetes Spectrum. 2004;17:183-190 2. Nielsen LL, et al. Regul Pept. 2004;117:77-78
- Section 12: Management of Diabetes in Pregnancy This section will cover the management of diabetes in pregnancy; Guidelines related to the diagnosis of GDM were covered earlier, in Classification and Diagnosis of Diabetes.
- Recommendations for the preconception care of women with diabetes are summarized in two slides: Provide preconception counseling that addresses the importance of glycemic control as close to normal as is safely possible, ideally &lt;6.5%, to reduce the risk of congenital anomalies. Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. [SLIDE]
- Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examinations should occur before pregnancy or in the first trimester and then be monitored every trimiseter and for 1 year postpartum as indicated by degree of retinopathy. [SLIDE]
- Recommendations for care of women with gestational diabetes include the following: Lifestyle change is an essential part GDM mgmt. and may suffice for many women. Add medications if needed to achieve glycemic targets. Preferred medications in GDM are insulin and metformin; glyburide may be used but may have higher rate of neonatal hypoglycemia & macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta and all lack long-term safety data. [SLIDE]
- Recommendations for care of women with gestational diabetes include the following: Lifestyle change is an essential part GDM mgmt. and may suffice for many women. Add medications if needed to achieve glycemic targets. Preferred medications in GDM are insulin and metformin; glyburide may be used but may have higher rate of neonatal hypoglycemia & macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta and all lack long-term safety data. [SLIDE]
- And finally, recommendations on general principles for management of diabetes in pregnancy are summarized here and on the following slide: Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. Fasting, preprandial & postprandial SMBG are recommended in both gestational and pregestational diabetes in pregnancy to achieve glycemic control. [SLIDE]
- And finally, recommendations on general principles for management of diabetes in pregnancy are summarized here and on the following slide: Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. Fasting, preprandial & postprandial SMBG are recommended in both gestational and pregestational diabetes in pregnancy to achieve glycemic control. [SLIDE]
- Due to increased red blood cell turnover, A1C is lower in normal pregnancy than in normal nonpregnant women. The A1C target in pregnancy is 6 – 6.5%. Less than 6% may be optimal if you can achieve it without significant hypoglycemia, but the target may be relaxed to less than 7% if necessary to prevent hypoglycemia. [SLIDE]
- In women with pregestational, or pre-existing type 1 or type 2 diabetes, the American College of Obstetricians and Gynecologists recommends the following targets: Fasting ≤90 mg/dL One-hour postprandial ≤130–140mg/dL Two-hour postprandial ≤120 mg/dL [SLIDE]
- Key Points In conclusion: Insulin is the oldest, most studied and most effective antihyperglycemic agent but can cause weight gain (2-4 kg) and, in rare instances, hypoglycemia Insulin analogues with longer, non-peaking profiles may decrease the risk of hypoglycemia compared with NPH insulin Published studies have not demonstrated whether inhaled insulin can lower HbA1c to 7% or lower Premixed insulin is not recommended during dose adjustment
- Key Points In conclusion: Insulin is the oldest, most studied and most effective antihyperglycemic agent but can cause weight gain (2-4 kg) and, in rare instances, hypoglycemia Insulin analogues with longer, non-peaking profiles may decrease the risk of hypoglycemia compared with NPH insulin Published studies have not demonstrated whether inhaled insulin can lower HbA1c to 7% or lower Premixed insulin is not recommended during dose adjustment
- Key Points In conclusion: Insulin is the oldest, most studied and most effective antihyperglycemic agent but can cause weight gain (2-4 kg) and, in rare instances, hypoglycemia Insulin analogues with longer, non-peaking profiles may decrease the risk of hypoglycemia compared with NPH insulin Published studies have not demonstrated whether inhaled insulin can lower HbA1c to 7% or lower Premixed insulin is not recommended during dose adjustment
- Key Points (continued from previous): When initiating insulin, patients should start with bedtime intermediate-acting insulin, or bedtime or morning long-acting insulin After 2 to 3 months, if fasting blood glucose levels are in target range but HbA1c is 7% or higher, blood glucose levels should be checked before lunch, dinner and bed, and, depending on the results, a 2nd insulin injection should be added. After 2 to 3 months, if pre-meal blood glucose is out of range, a 3rd injection may be needed. If HbA1c is still 7% or higher, 2-hour postprandial levels should be checked and preprandial rapid-acting insulin adjusted accordingly.
- Key Points (continued from previous): When initiating insulin, patients should start with bedtime intermediate-acting insulin, or bedtime or morning long-acting insulin After 2 to 3 months, if fasting blood glucose levels are in target range but HbA1c is 7% or higher, blood glucose levels should be checked before lunch, dinner and bed, and, depending on the results, a 2nd insulin injection should be added. After 2 to 3 months, if pre-meal blood glucose is out of range, a 3rd injection may be needed. If HbA1c is still 7% or higher, 2-hour postprandial levels should be checked and preprandial rapid-acting insulin adjusted accordingly.