Management of diabetes mellitus(ADA Guidelines)

Dr. Faisal Al Hadad

Consultant of Family Medicine & Occupational Health

PSMMC

Introduction

DM is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both

DM is a common health problem in Saudi Arabia

The overall prevalence of DM in adults in KSA is 23.7% according to Al Nozha et al (Saudi Med J 2004; Vol. 25 (11): 1603-1610)

Criteria for the diagnosis of diabetes

1. Classic symptoms of diabetes and a casual plasma glucose ≥200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.

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 WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.

*Each (1, 2 and 3) must be confirmed on a subsequent day

IFG/IGT

Recently, IFG and IGT have been officially termed “pre-diabetes.”

IFG and IGT are risk factors for future diabetes and CVD.

IFG = FPG 100-125 mg/dl (5.6-6.9 mmol/l)

● IGT = 2-h plasma glucose 140-199 mg/dl (7.8-11.0 mmol/l)

* These criteria should be confirmed by repeat testing on a different day.

Gestational DM

Diagnostic criteria for the 100-g OGTT are as follows:

≥95 mg/dl fasting ≥180 mg/dl at 1 h ≥155 mg/dl at 2 h ≥140 mg/dl at 3 h

Two or more values must be met or exceeded for a positive diagnosis. OGTT should be done in the morning after an overnight fast of 8–14 h.

Self-monitoring of blood glucose

SMBG should be carried out three or more times daily for patients using multiple insulin injections.

● For patients using less frequent insulin injections or oral agents or medical nutrition therapy alone, SMBG is useful in achieving glycemic goals.

● Instruct the patient in SMBG and routinely evaluate the patient’s technique and ability to use data to adjust therapy.

Glycemic goals

● Perform the A1C test at least two times a year in patients who are meeting glycemic goals and quarterly in patients whose therapy has changed or who are not meeting glycemic goals.

● The A1C goal for patients in general is an A1C goal of <7%.

● The A1C goal for the individual patient is an A1C as close to normal (<6%) as possible without significant hypoglycemia.

● Less strict treatment goals (A1C <7%) may be appropriate for patients with a history of severe hypoglycemia, patients with limited life expectancies, very young children or older adults, and individuals with comorbid conditions.

Management

Medical Nutrition Therapy (MNT)

Oral hypoglycemic agents

Insulin therapy

Prevention of diabetes complications (e.g. aspirin, statin, ACEI or ARB)

Medical Nutrition Therapy

Weight loss is recommended for all overweight or obese individuals who have diabetes.

Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss.

Low-fat diets

Low-carbohydrate diets

Drug Dose Side effects

Tolbutamide

Restinon ®

500-2000mg

OD-BID

Weight gain

hypoglycemia

Glibenclamide

Daonil ® 5mg

15-20 mg

OD-BID

Gliclazide

Diamicron ® 80mg

40-320mg

OD-BID

Glipizide

Minidiab ® 5mg

2.5-20mg

OD

Glimerpiride

Amaryl ® 1,2,4 mg

1-8mg

OD

Sulfonylureas

Drug Dose Side effectsDrug class

Metformin

Glocophage ®

500-850mg

1000-2550mg

BID-TID

Dyspepsia, diarrhea, lactic

acidosis

Biguanides

Acrobose

Glucobay ®

50-100 mg

150-300 mgTID

Gas, abdominal pain, diarrhea

α –Glucosidase inhibitors

Rosiglitazone

Avandia ® 2,4,8 mg

4-8mg

OD-BID

Oedema, weight gain, hepatic

failureThiazolidinediones

Repaglinide

Novonorm ® 0.5,1,2 mg

1.5-16mg

TID-QID

Weight gain

hypoglycemia

Meglitinides

HTN and DM

BP should be measured at every routine diabetes visit. Patients found to have systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg should have BP confirmed on a separate day.

Patients with a systolic BP of 130–139 mmHg or a diastolic BP of 80–89 mmHg should be given lifestyle and behavioral therapy alone for a maximum of 3 months and then, if targets are not achieved, in addition, be treated with ACEI or ARB.

Patients with hypertension (systolic BP ≥140 or diastolic BP ≥90 mmHg) should receive drug therapy (ACEI/ARB± thiazide diuretic) in addition to lifestyle and behavioral therapy.

Dyslipidemia and DM

● In adult patients, test for lipid disorders at least annually.

In adults with low-risk lipid values (LDL<100 mg/dl, HDL >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years.

● Lifestyle modification (reduction of fat and cholesterol intake, weight loss and increased physical activity) has been shown to improve the lipid profile in patients with diabetes.

Dyslipidemia and DM

In individuals without overt CVD

● The primary goal is an LDL <100 mg/dl (2.6 mmol/l).

● > 40 years, statin therapy is recommended.

● < 40 years but at increased risk of CVD who do not achieve lipid goals with lifestyle modifications alone, the addition of statin therapy is appropriate.

In individuals with overt CVD

● All patients should be treated with a statin.

● A lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option.

Dyslipidemia and DM

Lower TG to<150 mg/dl (1.7 mmol/l).

Raise HDL cholesterol to >40 mg/dl (1.0 mmol/l) in men and >50 mg/dl (1.25 mmol/l) in women.

● Combination therapy using statins and other lipid-lowering agents may be necessary to achieve lipid targets.

● Statin therapy is contraindicated in pregnancy.

Antiplatelet agents

As a secondary prevention strategy in those with diabetes with a history of CVD.

As a primary prevention strategy in those with diabetes and at increased CV risk (> 40 years of age or additional risk factors)

Combination therapy using other antiplatelet agents such as clopidrogel in addition to aspirin should be used in patients with severe and progressive CVD.

Diabetic Nephropathy

● To reduce the risk and/or slow the progression of nephropathy, optimize glucose control and BP control.

● Perform an annual test for the presence of microalbuminuria in type 1 diabetic patients with diabetes duration of ≥5 years and in all type 2 diabetic patients, starting at diagnosis and during pregnancy.

In the treatment of both micro- and macroalbuminuria, either ACEI or ARBs should be used except during pregnancy.

Diabetic Nephropathy

Serum creatinine should be measured at least annually for the estimation of GFR in all adults with diabetes regardless of the degree of urine albumin excretion

Consider referral to a physician experienced in the care of diabetic renal disease when the estimated GFR has fallen to <60 ml/min per 1.73 m2.

● Reduction of protein intake is recommended

Diabetic retinopathy

Optimal glycemic and BP control can substantially reduce the risk and progression of Diabetic retinopathy .

Annual comprehensive eye examination by an ophthalmologist is recommended in type 1 diabetic patients with diabetes duration of ≥5 years and in all type 2 diabetic patients.

● Women who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and should be counseled on the risk of development and/or progression of diabetic retinopathy.

Diabetic neuropathy

● All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests.

● Once the diagnosis of DPN is established, special foot care is appropriate for insensate feet to decrease the risk of amputation.

● Simple inspection of insensate feet should be performed at 3- to 6-month intervals. An abnormality should trigger referral for special footwear, preventive specialist, or podiatric care.

Thank you