Download The management of diabetes mellitus (DM)

Management
of diabetes mellitus (DM)
WORKSHOP
Dimitris Karanasios
• The Importance of DM Management in
Primary Care
• The role of the GP / FM in everyday
practice
• Diagnosis and management of DM
• Major complications resulting from DM
• Strategies for a patient-centred care
approach to achieving intensive glycemic
control
• Patients’ empowerment through education
about DM self-management
“Despite the same objectives, these
guidelines are substantially different
in content.”
Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD
consensus more clinically relevant than the IDF recommendations?
Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25
“ADA/EASD guidelines offer practical algorithms to
help initiate and modify pharmacological therapy for
diabetes with detailed descriptions of treatment
options.
IDF document, however, concentrates on the role of
postprandial hyperglycemia and calls for a lower
HbA1c target value of 6.5% as opposed to ADA/EASD
guidelines advocating a value of 7%.’’
Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more clinically
relevant than the IDF recommendations?
Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25
“Careful analysis of the guidelines’ contents
suggests that an ADA/EASD consensus might
be more useful in everyday clinical practice than
IDF recommendations, which do not offer a
particular treatment algorithm”.
Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more
clinically relevant than the IDF recommendations?
Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25
“For example, having been developed by
endocrinologists, ACE/AACE guidelines set
more aggressive target A1C levels than the
ADA/EASD guidelines(≤ 6.5% vs < 7%); they
also stratify patients into treatment-nave and
treated groups.
In contrast, ADA/EASD guidelines are
unstratified and more general.”
Robertson C. Translating Guidelines into Primary Care of Patients With Type 2 Diabetes: What's New
About ADA/EASD Guidelines and the ACE/AACE Road Maps? Journal for Nurse Practitioners 2008; 4(9):
661-671.
Complications: Macrovascular
– Atherosclerotic Heart Disease
– Myocardial Infarction
– Peripheral Vascular Disease
– Cerebrovascular Disease
– Renal Artery Stenosis
Complications: Microvascular
– Diabetic Retinopathy
– Diabetic Nephropathy
• Occurs in 40% of Type I Diabetes Mellitus
• Occurs in 20% of Type II Diabetes Mellitus
–
–
–
–
Peripheral Neuropathy
Autonomic Neuropathy
Gastroparesis
Impotence
Family Practice Notebook, LLC, 2008
Major complications of DM are:
• Cardiovascular Disease
• Diabetic Nephropathy
• Diabetic Retinopathy
Family Practice Notebook, LLC, 2008
• A 58-year-old man, referred by his cardiologist, is feeling
very tired and fears that his heart disease has worsened.
There are no indicators of a new coronary disease event.
• History:
–
–
–
–
Stopped smoking 10 years ago (40p/y)
Drinks 1 glass of red wine per night
Underwent angioplasty 10 months previously
Current medication: Statin, beta-blocker, aspirin, ACE inhibitor
and a diuretic
• Physical examination:
– BP 130/78 mmHg
PULSE 88/min
– WEIGHT 120 kg
BMI 38.3 kg/m2
Examinations:
– Fasting Glu 220 mg/dl, HbA1c 8.4%
– TC 212 mg/Dl, LDL 124 mg/dL, HDL 24 mg/dL and TG 320
mg/dL
Design a plan for:
• Diagnosis, additional examinations
(using current diagnostic criteria)
• Lifestyle modifications – Medication (using
current guidelines – treatment algorithms)
• Patient education / self-management (use
current guidelines)
• DM management plan – group
presentations
• Discussion
• Goals of the workshop
• Challenges in chronic disease
management
CRITERIA FOR DIABETES DIAGNOSIS
1. A1C ≥ 6.5%. The test should be performed in a laboratory using a
method that is NGSP certified and standardized to the DCCT assay.
2. FPG ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake
for at least 8 h.
3. 2-h plasma glucose ≥ 200 mg/dl (11.1 mmol/l) during an OGTT. The
test should be performed as described by the World Health
Organization, using a glucose load containing the equivalent of 75 g of
anhydrous glucose dissolved in water.
4. In a patient with classic symptoms of hyperglycemia or
hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dl (11.1
mmol/l).
5. Any of 4 but 1-3 should be confirmed by repeat testing.
AMERICAN DIABETES ASSOCIATION
Diabetes Care January 2010 vol. 33 no. Supplement 1 S62-S69
•
•
•
•
Weight loss of 10% of BW in 6 months
Lowering the daily calorie intake (500 kcal-1000 kcal)
Moderate exercise 30 min. daily
Stress control, social and family support, smoking
cessation
• Medication lowering lipid levels in case of an inability to
reach target levels within 6 months
http: // www.nhlbi.nih.gov
Copy for trainee
Agent
α Glucosidase inhibitors
Pramlintide
Mechanism
Target organ or tissue
Inhibition or delay of glucose aborption
Simulation of glucagon-like peptide
secretion*
Slowing of gastric emptying (not dipeptidyl
peptidase 4 inhibitors)
Gastrointestinal tract
Inhibition of glucagon relase
Sulfonylureas adn meglitinides
Acute stimulation of insulin secrection
Stimulation of insulin biosynthesis
Glucagon-like peptide and
dipeptidyl peptidase 4
inhibitors
Pancreatic β Cell
Antiapoptotic effects*
β Cell differentiation or neogenesis*
Modulation of appetite or autonomic
nervous system function*
α Glucosidase inhibitors
Central nervous
system
Inhibition of hepatic gluconeogenesis
Increase in hepatic insulin sensivity
Liver
Reduction of lipotoxicity
Increase in muscle insulin sensivity
Muscle
α Glucosidase inhibitors
Stimulation of favourable fat redistribution
Suppression of free fatty acid relase
Adipose tissue
Modulation of adipokine secrection
Heine RJ, Diamant M, Mbanya J-C, Nathan DM. Management of hyperglycaemia in type 2 diabetes: the end of
recurrent failure?
BMJ 2006; 333: 1200-1204
Recommendations:
• People with diabetes should receive DSME according to national
standards when their diabetes is diagnosed and as needed
thereafter. (B)
• Self-management behaviour change is the key outcome of DSME
and should be measured and monitored as part of care. (E)
• DSME should address psychosocial issues since emotional wellbeing is strongly associated with positive diabetes outcomes. (C)
• DSME should be reimbursed by third-party payers. (E)
Standards of Medical Care in Diabetes—2009.
Diabetes Care 2009 Jan; 32: S13–S61. doi: 10.2337/dc09-S013.
Reducing Risk
• What type 2 diabetes mellitus is: (a) insulin deficiency and resistance; (b) progression
of the disease
• The long-term effect of high blood sugar, emphasizing the importance of lowering
blood sugar levels in order to prevent complications
• What insulin is and why it is important
• How lifestyle modification affects long-term complications
Healthy Eating and Activity
• How lifestyle (diet and exercise) modification affects blood sugar, i.e., foods that raise
blood sugar and the impact of activity on blood sugar
Monitoring
• The importance of rigorous management of blood sugar levels—achieving desired
blood sugar levels
• The difference between fasting and postprandial sugar levels
Taking Medications
• How various oral anti-diabetic agents affect blood sugar levels
• Postprandial medications
• When and why insulin should be administered
• Which insulin?
Carolyn Robertson, Journal for Nurse Practitioners 2008; 4(9): 661-671
“Treatment involves control of hyperglycemia to
improve symptoms and prevent complications
while minimizing hypoglycemic episodes.”
Goals for glycemic control are:
• Blood glucose between 80 and 120 mg/dl during
the day
• Blood glucose between 100 and 140 mg/dL
at bedtime
• HbA1c levels < 7%
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