Download DIABETES MELLITUS

DIABETES MELLITUS
Management
IMPORTANT POINTS:
IN HISTORY, EXAMINATION,
INVESTIGATIONS AND TREATMENT
– Control: good / poor? Treatment?
– Complications
– Cardiovascular risk factors
HISTORY: special points
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Introduction: ethnic group and age
Presenting complaint
– E.g. admitted for control of diabetes
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History of presenting complaint
– Polyuria, polydypsia……blood glucose values, also indicates
control, screening
Complications – systemic review esp. CVS, Neuro, Eye, Renal, Skin,
 Drug history – What medication? Duration, Side effects? Compliance?
 P/H/O complications esp. CVS, wound infections
 F/H/O type 2 DM, IHD, CVA, HBP
 Social history: smoking, diet, exercise, financial aspects
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EXAMINATION: special points
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General examination
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CVS –
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Fatty liver, ascites with nephrotic syndrome
CNS
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Infections - TB
Abdomen
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BP, postural hypotension, JVP, cardiomegaly
peripheral pulses, bruits
RS
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skin infections, edema, waist
Ophthalmoscopy and cranial nerves
Mononeuritis
Amyotrophy
Autonomic (postural hypotension)
Peripheral neuropathy
• Muscle wasting
• Early sensory signs: vibration sense, absent jerks
• Romberg’s test
FEET
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Skin, bact / fungal infections, gangrene, pulses, neuropathy, ulcers, osteomyelitis ,
INVESTIGATIONS
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Assess glycemic control
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Extent of complications
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Risk factors for CAD
INVESTIGATIONS
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Assess glycemic control: blood glc levels, HbA1c,
fructosamine
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Extent of complications: ECG, A/B, Renal, CXR, ECHO,
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Risk factors for CAD: BP, lipids, metabolic syndrome
PRINCIPLES OF TREATMENT

Good glycemic control
 Prevent or treat complications
 Manage risk factors for CAD
PRINCIPLES OF TREATMENT
TYPE 2 DM

Good glycemic control
 Prevent or treat complications
 Manage risk factors for CAD
GLYCAEMIC CONTROL
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A healthy lifestyle
 OHD
 Insulin
HEALTHY LIFE STYLE
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Healthy eating
 Weight control
 Exercise
 Smoking and alcohol
HEALTHY LIFE STYLE
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Healthy diet
 Exercise
 Weight control: BMI <23 kg / m2
 Smoking and alcohol
DIET
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Carbohydrates
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60% of calories
Low glycaemic foods preferred
Restrict refined sugars and high fiber
Non-nutrient sweeteners
Avoid alcohol
Fats
– <30% of calories
– <7% saturated
– <200 g of cholesterol
– Avoid trans-fats
Eat fish twice a week
EXERCISE
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Control of blood sugar
Increases insulin sensitivity (danger of hypo)
Weight loss
Reduces body fat and maintains muscle bulk
Lowers blood pressure
Cardiovascular fitness
DRUGS
Decreased absorption
Decreased hepatic glc output
Increased peripheral glc uptake
Stimulate insulin release
OHD
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Decreased absorption
Acarbose
Decreased hepatic glc output
Increased peripheral glc uptake
Metformin
Pioglitazon
Stimulate insulin release
Sulphonyluria,
Repaglinide
OHD
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Biguanides: metformin
Sulphonyluria: glyclazide, glipizide
Thiozolidinediones: pioglitazone
Alpha glucosidase inhibitor: acarbose
Non-sulphonyluria secretagogues: repaglinide
DRUG THERAPY
Asymptomatic
Life-style modification
Drugs
DRUG THERAPY
Asymptomatic
Life-style modification
Metformin
Drugs
DRUG THERAPY
Asymptomatic
Symptomatic
High HbA1C
High FPG
High RPG
Life-style modification
Drugs
DRUG THERAPY
TYPE 2 D M
 Asymptomatic Type 2 DM ? Metformin
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Symptomatic Type 2 DM
 HbA1c >8%
 FBS > 11.1
 RBG > 14.0
TYPE 1 DM
 Insulin
TYPE 2 DM
Obese T2DM:
 Metformin
 If intolerant give acarbose or TZD
 HbA1C >10%: combination of metformin and
gliclazide (sulphonyluria)
Non-obese T2DM:
 Metformin or sulphonyluria
(gliclazide)
GOALS OF GLYCEMIC CONTROL
– FBS
– Non-fasting
– HbA1C
4.4-6.1
4.4-8.0
<6.5%
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Mono-therapy
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Combination of metformin + gliclazide
OR metformin + acarbose / TZDs (esp in obese)
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Then add third drug
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Add insulin
ADD INSULIN
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If not reaching target after 3 months of
optimum combination therapy (metformin,
gliclazide, acarbose, pioglitazone)
 FBG> 7.0 mmol/L
 HbA1c>6.5%
 Maximum doses of OHD
INSULIN
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Rapid-acting analogues
Fast-acting insulin (short-acting)
Intermediate-acting insulin
Long-acting insulin
Very long-acting analogues
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Lancet 2006;367:847
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INSULINS
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Rapid-acting analogues: insulin lispro, Humalog (4-6 hours)
Fast-acting: soluble insulin, Actrapid, Humulin R (6-10 hours)
Intermediate-acting: (10-16 hours)
– isophane; NPH, Humulin N
– Humulin L (Lente insulin)
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Long-acting insulin: Ultralente 24 hours
Very long-acting analogues: (24 hours)
– Insulin glargine (Lantus)
– Insulin detemir (Levemir)
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Lancet 2006;367:847
INSULIN REGIMES
Premixed (Mixtard) b.d.
(30% soluble + 70% isophane)
 Before meals rapid or short, with
bedtime intermediate or long acting
analog
 Bedtime Long-acting or intermediate
insulin, day time sulphonyluria +
metformin
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INSULIN REGIMES
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Basal-bolus (T1DM)
Insulin pumps (continuous subcutaneous)
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Twice daily mixtard (Often for T2DM)
– 2/3 of total dose in morning (2/3 long acting = e.g. 30:70
Mixtard)
– 1/3 of total dose in evening (1/2 long acting = e.g. 50;50
Mixtard)
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Lancet 2006;367:847
INSULIN PUMP
COMPLICATIONS OF TREATMENT
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Hypoglycaemia
 Hypoglycaemia unawareness
NEWER DRUGS IN TYPE 2 DM
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Exenatide
– Stimulates insulin secretion
– Glucagon-like-peptide
– Given S.C
PREVENT COMPLICATIONS OF DIABETES
PREVENT COMPLICATIONS OF DIABETES
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Nephropathy
Neuropathy
Retinopathy
Cardiovascular: IHD, CVA/TIA. PVD
Diabetic foot
PREVENT COMPLICATIONS OF DIABETES
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Good glycaemic control
 Screen for complications
 Action to prevent specific complications
PREVENT COMPLICATIONS OF DIABETES
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Good glycaemic control
Screen: regular BP, lipids, eye and renal check up
Action to prevent specific complications:
– ACEI or ARBs in early renal involvement
– Aspirin if IHD, or high risk of IHD (microalbuminuria, metabolic
syndrome, >35, high-risk ethnic groups, family history)
– Control hypertension (macrovascular, retinopathy and
nephropathy)
– Treat hyperlipidaemia (macrovascular and nephropathy)
– Stop smoking (IHD, CVA, TIA, PVD)
– Diabetic foot
CONTROL HBP AND HYPERLIPIDAEMIA
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LDL
<2.6
TG
<1.7
HDL
>1.1
BP
<130/80
BP
<120/75 (with renal impairment or gross
proteinuria)
COMPLICATIONS: DIABETIC FOOT
Wash, touch and look at
feet every day
Diabetic neuropathy
Foot education
Curriculum Module III-7c
Slide 8 of 34
• Do not soak feet
• Test water temperature
• Wash and dry between toes
• Avoid herbs and ointments
• Examine feet in good light
Slides current until 2008
COMPLICATIONS: DIABETIC FOOT
How to care for toenails
Diabetic neuropathy
Foot education
Curriculum Module III-7c
Slide 15 of 34
• Do not to let nail grow too
long
• Cut straight across
• File sharp edges
• Ask a friend or relative
Slides current until 2008
COMPLICATIONS
Learn to look for:
Hammer toe
Diabetic neuropathy
Foot education
Curriculum Module III-7c
Slide 11 of 34
Clawed toes
Slides current until 2008