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Current Management Current Management of Diabetesof Diabetes
Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847
Aim
• having information on assessing symptoms and signs.
• developing management plans for diabetes.
3
ObjectivesAt the end of this session, the trainees should be
able to:-
– list diagnostic criteria for DM– describe how to differentiate Type I & II DM– explain symptoms and signs of diabetes– discuss the evidence for lifestyle changes– describe the indications, contraindications, and
side effects of antidiabetic agents
DM in Saudi ArabiaDM in Saudi Arabia
Lifestyle Changes :
Social & cultural changes
Prevalence :• Diabetes mellitus as a health problem in Saudi
Arabia• prevalence of DM is 23.7 % according to Dr. Al
Nozha study (SMJ 2004)– 1 / 4 of adults > 30 yr are diabetics.
– 36 Foot Amputation / day, at Riyadh.
D.M in Saudi Arabia cont…..D.M in Saudi Arabia cont…..
Cost & Impacts .• Psychological impact.• Family & Social impact .• Decreased Productivity .• Sick leaves.• Work Absence .• Economical Costs .
Etiologicclassification
of
diabetesmellitus
II- Type 2 diabetes.
III- Other specific types.
IV- Gestational diabetes mellitus.
I- Type 1 diabetes:
Etiologic Classification of Diabetes Etiologic Classification of Diabetes MellitusMellitus
Type 1:Type 1: -cell destruction with lack of insulin .-cell destruction with lack of insulin . has absolute insulin deficiencyhas absolute insulin deficiency predisposed to develop ketoacidosispredisposed to develop ketoacidosis insulin is required for survival.insulin is required for survival.
Etiologic Classification of Etiologic Classification of Diabetes MellitusDiabetes Mellitus
Type 2Type 2 has relative insulin deficiency combined with has relative insulin deficiency combined with
defects in insulin action.defects in insulin action. is the most common form of diabetes, is the most common form of diabetes,
accounting for 90–95% of the diseaseaccounting for 90–95% of the disease is most often found in overweight individuals.is most often found in overweight individuals.
Narayan K, Boyle J, Thompson T, Sorensen S, Williamson D (2003). "Lifetime risk for diabetes mellitus in the United States". JAMA 290 (14): 1884–90. doi:10.1001/jama.290.14.1884.
Risk Factors for Type 2 DM
• Modifiable– Overweight and obesity– Sedentary lifestyle– Previously identified
IGT and IFG– Metabolic syndrome– Diatery factors– Intrauterine
environment– Inflamation 10
• Non- Modifiable– Family history– Age– Gender– History of GDM– Polycystic ovary
syndrome (PCO)
• Classical symptoms– Unusual thirst (Polydipsia)– Frequent urination (Polyuria)– Unusual weight loss
• Other symptoms– Extreme fatigue or lack of energy– Unusually hungry– Moody & irritable– Blurred vision– Have recurrent infections– Wounds and bruises that are slow to heal– Get a lot of yeast infections– Have tingling or numbness in the hands and/or feet
• Patients may present with a variety of symptoms or even symptomless
Symptoms & Signs
Criteria to diagnosis diabetesCriteria to diagnosis diabetes
• FPG FPG >>126 mg/dl (7.0 mmol/l) 126 mg/dl (7.0 mmol/l) ( Fasting is defined as no caloric intake for at least 8 h)) OROR
• Symptoms of diabetes and a casual plasma Symptoms of diabetes and a casual plasma
glucose glucose > > 200 mg/dl200 mg/dl ( (11.1 mmol/l) 11.1 mmol/l) OROR
• 2-h plasma glucose 2-h plasma glucose >> 200 mg/dl (11.1 mmol/l) 200 mg/dl (11.1 mmol/l)
during an OGTT. during an OGTT. ( The test should be performed as described by the W H O (using a glucose load
containing the equivalent of 75g anhydrous glucose dissolved in water)).
Diagnosis of Diabetes :Plasma Glucose Cutoff Points
.
FBS 2- Hour BS on OGTT
categories mg/ dl mg/dl
NormalNormal < 100< 100 < 140< 140
IFGIFG >> 100 and < 126 100 and < 126 __
IGTIGT __ >> 140 and < 200 140 and < 200
DiabetesDiabetes >> 126 126 >> 200 200
* If without symptoms, there should be more than one measurement in
order to diagnose.
Diagnosis of gestational DM
16
First visit evaluation
History taking and clinical assessmentHistory taking and clinical assessment
Physical examination Physical examination • Height and weight measurement .
• Blood pressure determination .
• Fundoscopic examination
• Oral examination
• Thyroid palpation
• Cardiac examination
First visit evaluation
Physical examination Physical examination Abdominal examination (e.g., for hepatomegaly) Evaluation of pulses by palpation Hand/finger examination Foot examination Skin examination Neurological examination Signs of diseases that can cause secondary diabetes
(e.g., hemochromatosis, pancreatic disease)
First visit evaluation
Laboratory evaluationLaboratory evaluation• HBA1c
• Fasting lipid profile
• Test for microalbuminuria
• Serum creatinine in adults .
• Thyroid-stimulating hormone (if indicated)
• Electrocardiogram in adults (if indicated)
• Urinalysis for ketones and protein
Management Goals
Annual visits and examinations should be done regularly
Eliminate symptoms and improve well-being Prevent and retard microvascular complications
optimize glycemic control target blood pressure levels
Reduce macrovascular events optimize glycemic control target blood pressure levels target lipid levels
Summary of recommendations for adults with Diabetes
Parameter Target Value
• HbA1c < 7%
• pre-prandial plasma glucose 70 - 130 mg/dL• post-prandial plasma glucose < 180 mg/dL • Blood pressure < 130/80 mmHg • LDL- cholesterol < 100 mg/dL (<2.6 mmol/l) • HDL- cholesterol > 40 mg/dL (1 mmol/l) for men
> 50 mg/dL (1.3 mmol/l) for wom.
• Triglycerides < 150 mg/dL (17 mmol/l)
ADA 2009
Goals should be individualized based on:
● duration of diabetes
● pregnancy status
● age
● co-morbid conditions
● hypoglycemia unawareness
● individual patient considerations
Key concepts in setting glycemic goals
Follow up
24
Things to keep in mind during management of Diabetes
Type 2: Deterioration of beta cells over time Increasing prevalence with increasing risk factors,
e.g obesity Hyperglycemia affects morbidity, mortality and
resources Tight glycemic control with insulin may reduce
costly complications 30% to 40% of patients ultimately require insulin
Non-pharmacologic Therapy for DM Lifestyle therapeutic modifications Diet
Improved food choices Spacing meals Individualized carbohydrate content Moderate calorie restriction
Exercise
improve blood glucose control
reduce cardiovascular risk factors
contribute to weight loss.
improve well-being..
Nutritional recommendations for DM patients
• Protein to provide 10-20% of kcal/day
• Saturated fat to provide < 10% of kcal/day (< 7 % for those with
elevated LDL).
• Polyunsaturated fat to provide < 10 % of kcal.
• Remaining calories to be divided between carbohydrate &
monounsaturated fat, based on medical needs & personal
tolerance.
• Use of caloric sweeteners is acceptable.
Considerations in Pharmacologic Treatment of Diabetes
• Complications/tolerability• Frequency of hypoglycemia• Compliance/complexity of regimen• Cost
SulfonylureasDrug Dose Side effects
TolbutamideRestinon®
500-2000mgOd-Bid
Weight gainhypoglycemia
Glibenclamide
Daonil ® 5mg
15-20 mgOd-Bid
Weight gainHypoglycemia
GliclazideDiamicron ® 80mg
40-320mgOd-Bid
Weight gainhypoglycemia
GlipizideMinidiab ® 5mg
2.5-20mgOd
Weight gainhypoglycemia
GlimerpirideAmaryl ® 1,2,4
mg
1-8mgOd
Weight gainhypoglycemia
Drug Dose Side
effectsDrug class
Metformin Glocophage
® 500-850mg
1000-2550mgBid-Tid
Diarrhea Lactic
acidosis
BiguanidesBiguanides↓ hepatic glucose
production
Acrobose
Glucobay ® 50-100 mg
150-300 mgTid
Gas , Abdominal
pain, Diarrhea
αα ––Glucosidase Glucosidase inhibitorsinhibitors
↓ intestinal absorption
Rosiglitazone
Avandia ® 2,4,8 mg
4-8mgOd-Bid
Oedema,weight
gain,hepatic failure
TThiazolidinedionhiazolidinedioneses
↑ preipheral glucose disposal
Repaglinide Novonorm ® 0.5,1,2 mg
1.5-16mgTid-Qid
Weight gainhypoglycemia
Meglitinides Meglitinides ↑ pancreatic insulin
secretion