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7/31/2019 Guidelines of Management of Type 2 DM
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DIABETES .An Overview
ByDr.Hala Aly Gamal El Din
Professor Of Diabetes & EndocrinologyFaculty of Medicine- Cairo University
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Diabetes in the 21st century
One of the most challenging health problemsfacing the world
246 million people worldwide diagnosed in 2007
5th leading cause of death in developed countries
Complications heart attacks, stroke, kidney
failure, amputations and blindness
380 million people worldwide projected to bediagnosed by 2025
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Facts
Diabetes is a chronic, debilitating and costly diseaseassociated withsevere complications, which poses
severe risksfor families, Member States and theentireworld.
UN Resolution 61/225. World Diabetes Day
Every 5 seconds 1 person develops diabetes
Every 10 seconds 1 person dies of diabetes
Every 30 seconds a limb is lost due to diabetes
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Natural History of DM-2
0
100
200
300
-10 -5 0 5 10 15 20 25 30
50
150
250
350
At risk forDiabetes
Glucose
RelativeFunction
Post Meal Glucose
Fasting Glucose
Insulin Resistance
Insulin LevelBeta Cell Failure
Years of Diabetes
Bergenstal, 2000 International Diabetes CenterUsed with permission.
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Criteria for the Diagnosis of Diabetes
A1C 6.5%
OR
Fasting plasma glucose (FPG)
126 mg/dl (7.0 mmol/l)OR
Two-hour plasma glucose 200 mg/dl (11.1
mmol/l) during an OGTT
OR
A random plasma glucose 200 mg/dl (11.1
mmol/l)
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
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Criteria for the Diagnosis of Diabetes
A1C 6.5%
The test should be performed in a laboratory
using an NGSP-certified method standardizedto the DCCT assay*
*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
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Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG)
126 mg/dl (7.0 mmol/l)
Fasting: no caloric intake forat least 8 h*
*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
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Criteria for the Diagnosis of Diabetes
Two-hour plasma glucose 200 mg/dl (11.1
mmol/l) during an OGTT
The test should be performed as described bythe World Health Organization, using a
glucose load containing the equivalent of 75 g
anhydrous glucose dissolved in water*
*n the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
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Prediabetes: IFG, IGT, Increased A1C
Categories of increased risk for diabetes
(Prediabetes)*
FPG 100-125 mg/dl (5.6-6.9 mmol/l): IFG
or
2-h plasma glucose in the 75-g OGTT
140-199 mg/dl (7.8-11.0 mmol/l): IGT
or
A1C 5.7-6.4%
*For all three tests, risk is continuous, extending below the lower limit of a range and becomingdisproportionately greater at higher ends of the range.
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 3.
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Two thirds of individuals do not
achieve target HbA1c
Saydah SH, et al. JAMA 2004; 291:335342.
Liebl A, et al.Diabetologia2002; 45:S23S28.
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Why?
The major limiting factor to achieving
intensive glycemic control for peoplewith type 2 diabetes is Hypoglycaemia
Briscoe VJ, et al. Clin Diab2006;24:115-121.
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CVD=cardiovascular; HbA1c=haemoglobin A1c; T2DM=type 2 diabetes mellitus.
American Diabetes Association. Diabetes Care.2011; 34 (Suppl 1): S4S10.
More stringent HbA1c goals may be suitable for
selected patients with early stage disease, if this canbe achieved without significant hypoglycaemiaorother adverse effects
Less stringent HbA1c goals may beappropriate for patients with a history ofhypoglycaemia, CVD or late-stage disease
Normal Controlled T2DM Uncontrolled T2DM
7%6.16.9%HbA1c
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Glycemic targets
- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9mmol/l])
- Pre-prandial PG
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It is time to say...
Our goal is early controlof hyperglycemia
to preventthe short and long-term
complications of diabetes
with low risk of
hypoglycemia
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Tips to get control
Lifestyle should be used in all patients but only as part ofthe treatment
Start aggressively and back off
Assume each medication will improve HbA1c 1%
Never substitute medsAlways add new agent first
Titrate to get control
Then stop first agent
Ask the patient what they want Shots may be better than more pills
Develop a plan that prevents hypoglycemia
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ADASummary of Recommendations forAdults with Diabetes
Goals
Glycemic control:
A1C* < 7%
Preprandial BG 90
130 mg/dl
Peak postprandial BG
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Screening For Diabetes
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Screening For Diabetes
A1C or FPG or 75 g oral GTT Testing should be considered in all adults who are
overweight (BMI >25 kg/m2)
And
Have the following additional risk factors.
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Risk Factors for Screening
Physical inactivity
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African American,
Latino, Native American, Asian American, Pacific
Islander) Women who delivered a baby weighing 9 lb or were
diagnosed with GDM
Diabetes Care 34:Supplement 1, 2011
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Risk Factors for Screening(contd)
Hypertension (140/90 mmHg or on therapy forhypertension)
HDL 250mg/dl
Women with polycystic ovarian syndrome (PCOS)
A1C >5.7%, IGT, or IFG on previous testing
Other clinical conditions associated with insulin
resistance (e.g., severe obesity, acanthosis nigricans)
History of CVD
Diabetes Care 34:Supplement 1, 2011
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Risk Factors for Screening
In the absence of the previous criteria, testing beginsat age 45
Normal results, repeat at least at 3-year intervals
Consider more frequent testing depending on resultsand risk status
Diabetes Care 34:Supplement 1, 2011
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23
A A
C
E
A CE
Robard HW, et al. Endocr Pract. 2009; 15: 540559.
AACE / ACE Di b t Al ith f
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DPP-4TZDMET AGI
MET
Dual therapy Dual therapy
TZD
Glinide or SU
MET +GLP-1orDPP-4
AACE / ACE Diabetes Algorithm for
%*6.5
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25
NATIONAL INSTITUTEFOR HEALTH AND
CLINICAL EXCELLENCE
NICE Guidelines for the Management of
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NICE Guidelines for the Management of
Type 2 Diabetes
*Avoid aggressive targets (6.5%) and individually agree target with patient; **With active dose titration;
***If at significant risk of hypoglycemia or its consequences, or if SU not tolerated / contraindicated;#If insulin is unacceptable (eg personal reasons or obesity); ##If weight is an issue. NICE, Clinical Guideline 87, 2009.
If HbA1c targetnot reached*
Increase insulin doseand intensify regimenover time. Consider
pioglitazone
Metformin + SU(or glinides)
Metformin + SU
+ insulin Start insulin
Metformin + SU+ sitagliptin or
metformin + SU + TZD#
or metformin +SU + exenatide##
SU + DPP-4inhibitor or TZD
Metformin + DPP-4inhibitor or TZD***
If HbA1c target
not reached*
If HbA1c targetnot reached*
If HbA1c target
not reached*
If HbA1c targetnot reached*
OR
OR
OR
Metformin**(mainly overweight /
obese patients)
Lifestyle intervention
If HbA1ctarget not
reached*
If HbA1c
target notreached*
Ste
p
1
Step
2
Step
3
Ste
p
4
SU if not overweight,metformin not tolerated, or
rapid response required
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27
Canadian Diabetes
AssociationAlgorithm
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Clinical assessment
Lifestyle intervention (initiation of nutrition therapy and physical activity)
A1C < 9% A1C 9% Symptomatic hyperglycemia with
metabolic decompensation
Initiate metformin
Initiating pharmacotherapy immediately without waiting effect from
lifestyle intervention
Consider initiating metformin with another agent from different classor
initiate insulin
Initiate insulin
metformin
If not at target
Add on agent best suited to the individual based on the advantage/disadvantage listed below
Class A1C Hypoglycemia Other advantage Other disadvantage
Alpha glucosidase inhibitors Rare Improved postprandial control, weight neutral GI side effects
Incretin DPP4 inhibitors to Rare Improved postprandial control,weight neutral
New agent (unknownlong term safety)
Insulin Yes No dose ceiling, f lexible regimens, many
types
Weight gain
Insulin secretogogus
Meglitinides
Sulhonylurea
to
Yes*
Yes
Improved postprandial control
Newer sulphonylurea (gliclazide &
glimeperide) are associated with less
hypoglycemia than glyburide
RequiresTid or QiDWeight gain
TZD Rare Durable monotherapy Weight gain, requires 6-12weeks to
Weight loss agent none Weight loss Increased heart rate/BPGI side effects
if not at target
Add another drug from a different classAdd bedtime basal insulin to another agent
Or intensify insulin regimen
*less hypoglycemia in the
context of missed meals
: 2% decrease in HBA1C
DPP4: Dipeptidyl peptidase-4
TZD: Thiazolidnedione
GI: gastrointestinalCHF: congestive heart failure
BP: blood pressure
A1C:glycated hemoglobin
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29
I
DF
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P ti f Di b t
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Prevention of DiabetesKey Messages As safe and effective preventive therapies for type 1
diabetes have not yet been identified, any attempts toprevent type 1 diabetes should be undertaken only within theconfines of formal research protocols.
Intensive and structured lifestyle modification that results inloss of approximately 5% of initial body weight can reducethe risk of progression from impaired glucose tolerance totype 2 diabetes by almost 60%.
Progression from prediabetes to type 2 diabetes can also bereduced by pharmacologic therapy with metformin (~30%reduction), acarbose (~30% reduction) and thiazolidinedione(~60% reduction).
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Recommendations:Medical Nutrition Therapy (MNT)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S22.
Individuals who have prediabetes or diabetesshould receive individualized MNT as needed to
achieve treatment goals (A)
For people with diabetes, it is unlikely one optimal mixof macronutrients for meal plans exists
The best mix of carbohydrate, protein, and fat
appears to vary depending on individual
circumstances
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Recommendations: Physical Activity
Advise people with diabetes to perform at least150 min/week of moderate-intensity aerobic
physical activity (50-70% of maximum heart rate)
(A)
In absence of contraindications, people with type
2 diabetes should be encouraged to perform
resistance training three times per week (A)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S24.
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Recommendations: Hypoglycemia
Glucose (15-20 g) is preferred treatment for
conscious individual with hypoglycemia (E)
Glucagon should be prescribed for all individuals
at significant risk of severe hypoglycemia, and
caregivers/family members instructed inadministration (E)
Those with hypoglycemia unawareness or one
or more episodes of severe hypoglycemia
should raise glycemic targets to reduce risk offuture episodes (B)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S25.
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Recommendations: Bariatric Surgery
Consider bariatric surgery for adults with BMI
>35 kg/m2 and type 2 diabetes (B)
After surgery, life-long lifestyle support and
medical monitoring is necessary (E)
Insufficient evidence to recommend surgery inpatients with BMI
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Recommendations: Immunization
Provide an influenza vaccine annually to all
diabetic patients 6 months of age (C)
Administer pneumococcal polysaccharide
vaccine to all diabetic patients 2 years
One-time revaccination recommended for those>64 years previously immunized at 5 years ago
Other indications for repeat vaccination:
nephrotic syndrome, chronic renal disease,immunocompromised states (C)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S27.
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Male patient 78 years old , diabetic for 5 years uncontrolled ,
hypertensive with IHD. Our Hb A1c goal is
1. 6.5%2. 6.5 - 7%
3. 7 7.5%
4. 7.5 - 8%
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Female patient 45 years old , BMI 33 kg/m2 ,with sedentary
life newly discovered diabetes . FBS is 350mg/dl , PPS
460 mg/dl , HbA1c 10% .Our ideal treatment will be :
1. Life style modification LSM
2. LSM & Metformin
3. Insulin therapy only
4. Insulin therapy & SU
5. Insulin therapy & Metformin
6. Insulin therapy & DPP4Is
7. Metformin & TDZs8. Metformin & DPP4Is
9. Metformin & GLP1
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Q&A
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