Treatment & Prevention 6

DIABETES

TREATMENT AND PREVENTION

LAVANYA.K ROLL NO.39

Goals of therapyGoals of therapyTo eliminate the symptoms

related to hyperglycemiaTo reduce or eliminate the long

term microvascular and macrovascular complications

To allow the patient to achieve as normal a lifestyle as

possible

Healthcare TeamHealthcare Team

Members of the team include1. Primary care provider2. Endocrinologist/ Diabetologist3. Certified diabetes educator4. Nutritionist5. Sub specialists

Treatment GoalsTreatment GoalsINDEX GOAL

Glycemic controlA1CPreprandial plasma glucosePeak post prandial plasma glucose

<7

90-130 mg/dl

<180 mg/dl

Blood pressure <130/80

LipidsLDLHDLTriglycerides

<100mg/dl

>40mg/dl

<150mg/dl

Diabetes educationDiabetes education

◦Diabetes educator is healthcare professional (nurse, dietician or pharmacist)

◦Education topics include diet • Self monitoring of blood glucose• Urine sugar monitoring• diet• Insulin administration• Management of hypoglycemia• Foot & skin care• Diabetes mgmt. before, during & after

exercise• Risk factor modifying activities

EXERCISEEXERCISEPositive benefits

◦Reduces cardiovascular risks, BP, body fat, weight

◦Maintenance of muscle mass◦Lowers blood glucose◦Increases insulin sensitivity

Time◦150 min per week ( 3 days)◦In type 2 DM, resistance training

Problems◦either hypo/ hyperglycemia

Guidelines to avoid these problems◦Monitor blood glucose before, during &

after exercise◦Delay exercise if bld. Glucose > 250 mg/

dl and Ketone bodies are present◦If bld. Glucose< 100 mg/ dl , ingest

carbohydrate before exercise

Assesment of long term Assesment of long term glycemic controlglycemic control

Glycated Hb/ A1CFructose amine acid1,5 anhydroglucitol

Treatment of type 1 Treatment of type 1 DiabetesDiabetes

Preparation Onset (hr) Peak (hr) Eff.duration(hr)

Short acting s.c.

•Lispro

•Aspart

•Glulisine

•Regular

<0.25

“

“

0.5- 1.0

0.5- 1.5

“

“

2-3

3-4

“

“

4-6

Short acting-inhaled

• Regular

<0.25 0.5-1.5 4-6

Long acting

• NPH

•Detemir

•Glargine

1-4

“

“

6-10

Dual peak

Dual peak

10-16

12-20

24

Insulin CombinationsInsulin Combinations

75 / 25 - Protamine lispro+ Lispro50 / 50 - “ + “70 / 30 - Protamine aspart +

Aspart70 / 30 - NPH + Reg. Insulin50 / 50 - “ + “

INSULIN REGIMENS

INSULIN PREPARATIONSINSULIN PREPARATIONS

AVAILABLE AS U-40 & U-100 REGULAR INSULIN U-500

GUIDELINES FOR MIXING OF GUIDELINES FOR MIXING OF INSULININSULIN

Mix the different insulin formulations in the syringe immediately before injection &inject within 2 min after mixing

Do not store insulin as mixtureStandardize the responseDo not mix insulin glargine or

detemir with other insulins

CALCULATION OF INSULIN CALCULATION OF INSULIN DOSEDOSEMeal component

Based on insulin carbohydrate ratio1 to 1.5 U/10gm of carbohydrate

Pre prandial blood glucose level- 1 U of insulin for every 50

mg/dl- (Body weight in kg)×

(blood glucose-desired glucose)/1500

Advantage of having long acting insulin before night meal

Dawn phenomenon

METHODS OF INSULIN DELIVEYMETHODS OF INSULIN DELIVEY Insulin syringe insulin pen injectors Insulin jet injectors Insulin pumps Insulin inhalers

INSULIN SYRINGEINSULIN SYRINGE

ROTATION SITESROTATION SITES

INULIN PENINULIN PEN

Has cartridge for insulin-dialContains needle & plungerMore convenient to use in schools,public places or at work

Insulin jet injectorsInsulin jet injectors

Sprays insulin→directly passes through the skin

CostlyBruishing→thin individuals

BLOOD GLUCOSE MONITORINGBLOOD GLUCOSE MONITORING

Visually read test strips ex.Betachek diabetes test strips pamphlet chemical test strips

TREATMENT OF TYPE II TREATMENT OF TYPE II DIABETESDIABETES

MANAGEMENT OF TYPE II DIABETES

GLYCEMIC CONTROL•Diet•Exercise•Medication

ASSOCIATED CONDITIONS•Dyslipidemia•Hypertension•Obesity•CHD

SCREENING•Retinopathy•Cardiovascular disease•Nephropathy•Neuropathy

Treatment of type 2 diabetes mellitusOral

Biguanides Metformin

Alpha glucosidase inhibitors

Acarbose , meglitol

DPP 4 inhibtors sitagliptin

Insulin secretagogues

sulfonyl ureas

first generation chlorpropamide,tolbutamide

second generation Glimepiride , glipizide

non sulfonyl ureas Repaglinide , nateglinide

–Thiazolidinedidones roseglitazone, pioglitazone

Parenteral

Insulin

GLP1 agonist exenatide

Amylin agonist pramlintide

drugs advantages Disadvantages

biguanides Weight loss Lactic acidosis,GI dysfunctions

Alpha glucosidase inhibitor

Reduce postprandial glycaemia

Liver & GI dysfunctions

DPP4 inhibitors No hypoglcaemia ---

sulfonylureas Lowers fasting blood glucose

Weight gain,hypoglyacemia

Nonsulfonylureas

thiazolidinediones

Shorter onset of actionLowers postprandial glycaemia

Lowera insulin requirements

Hypoglycaemia

CHF,weight gain ,fractures

Glycaemic management of type 2 diabetes mellitus patient with type 2 diabetes

medical, nutrition therapy,increased physical Activity and weight loss + metformin

Reasses A1CCombination therapy metformin+second agent

Reasses A1CCombination therapy metformin+2 agents metformin +insuln

Fall in insulin requirements Dialysis associated

complications -hypotension,progression

of retinopathy,atherosclerosis & hyperlipidemia

Treatment for diabetic nephropathy

• Transplantation-combined pancreas and kidney

TREATMENT FOR DIABETIC TREATMENT FOR DIABETIC NEUROPATHYNEUROPATHYRisk factors -> hypertension and

hypertriglyceridemiaAvoidance of neurotoxins -

>alcohol,smokingVit.supp(B12,folate)Symptomatic treatmentShould check their feet daily & take precaution

Chronic painful-antidepressants and anticonvulsants

Orthostatic hypotension-clonidine,fludrocortisone,ocreotide

TREATMENT FOR GI TREATMENT FOR GI DYSFUNCTIONDYSFUNCTION

Smaller and more frequent meals(liquids)

Low in fat contentDrugs metoclopramide 5-10 mg domperidone 10-20 mgDiabetic diarrhoea loperamide or ocreotide(50-70µg

TDS)Antibiotics

TREATMENT FOR GENITOURINARY TREATMENT FOR GENITOURINARY DYSFUNCTIONDYSFUNCTION

Diabetic cystopathy-timed voiding and self catheterisation

Erectile dysfunction-type 5 PDE inhibitors

Women-lubricants,treatment of infections & estrogen replacement(systemic/local)

TREATMENT FOR CARDIOVASCULAR TREATMENT FOR CARDIOVASCULAR DYSFUNCTIONDYSFUNCTION

Revascularisation procedures PCI & CABGProblem-restenosisImproved outcomes-stents/

GP 2b 3a platelet inhibitorsDrugs -ß blockers,ACE inh/ARBsSecondary prevention-Aspirin

New technologies in treatment of New technologies in treatment of diabetesdiabetesIslet cell transplantationGene therapyVaccine-peptideFoot ulcer-dermograftArtificial pancreas

PREVENTION•Primary prevention population strategy high risk strategy

•Secondary prevention glycosylated Hb self care home blood glucose monitoring

•Tertiary prevention

Thank

you