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Diabetes in Special Populations
UEDA Diabetes Mini-Course
Aswan Feb 2016
INDIVIDUALIZE DIABETES THERAPYTREATING THE PATIENT NOT THE DISEASE
Diabetes in Special Populations
Agenda
1 Diabetes in Childhood and Adolescence + DKA
2 Diabetes in Pregnancy
3 Diabetes in Older People
4 Diabetes in Ramadan
5 Diabetes in Renal Insufficiency
6 Diabetes in Hepatic Insufficiency
Diabetes in Childhood and Adolescence in Under-Resourced Countries
UEDA Diabetes Mini-Course
Aswan Feb 2016
Type1 Diabetes in Childhood and Adolescence
Most diabetes in children is type 1 diabetes resulting in lifelong insulin dependency Type 2 diabetes can also occur in children (mainly in adolescents) Other rarer types can also occur even in neonates
Onset can be at any age after the neonatal period but it is most common in childhood and adolescence
Clinical presentation can vary from non-urgent presentation to severe presentation with dehydration shock and DKA
Newly diagnosed children should be transferred to a centre that has expertise in paediatric diabetes if this is possible
Treatment of diabetes consists of
lifelong insulin dependency with multiple injections per day
a healthy eating plan
regular physical activity
Type1 Diabetes in Childhood and Adolescence
It is increasingly being seen in older children particularly adolescents who are overweight and inactive have a family history of type 2 diabetes or in those who are of particular ethnic backgrounds where type 2 diabetes in adults is more prevalent
bull People with type 2 diabetes produce insulin but the insulin produced does not work effectively (ldquoinsulin resistancerdquo)
bull Type 2 diabetes often responds initially to a healthy eating plan appropriate exercise and weight reduction
bull However metformin is frequently needed (+- an insulin sensitizer) and later insulin may be required
Type2 Diabetes in Childhood and Adolescence
Some forms of diabetes do not neatly fit type 1 or type 2 ldquoatypical diabetesrdquo
Neonatal Diabetes (presenting in the first six months of life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes) If this is suspected genetic testing should be undertaken because it may influence management
Monogenic diabetes outside the neonatal period This was previously known as MODY ndash Maturity Onset Diabetes in the Young These cases generally have a strong family history of diabetes
Diabetes associated with syndromes such as Down Syndrome Prader-Willi Syndrome
Other Types of Diabetes in Childhood and Adolescence
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in Special Populations
Agenda
1 Diabetes in Childhood and Adolescence + DKA
2 Diabetes in Pregnancy
3 Diabetes in Older People
4 Diabetes in Ramadan
5 Diabetes in Renal Insufficiency
6 Diabetes in Hepatic Insufficiency
Diabetes in Childhood and Adolescence in Under-Resourced Countries
UEDA Diabetes Mini-Course
Aswan Feb 2016
Type1 Diabetes in Childhood and Adolescence
Most diabetes in children is type 1 diabetes resulting in lifelong insulin dependency Type 2 diabetes can also occur in children (mainly in adolescents) Other rarer types can also occur even in neonates
Onset can be at any age after the neonatal period but it is most common in childhood and adolescence
Clinical presentation can vary from non-urgent presentation to severe presentation with dehydration shock and DKA
Newly diagnosed children should be transferred to a centre that has expertise in paediatric diabetes if this is possible
Treatment of diabetes consists of
lifelong insulin dependency with multiple injections per day
a healthy eating plan
regular physical activity
Type1 Diabetes in Childhood and Adolescence
It is increasingly being seen in older children particularly adolescents who are overweight and inactive have a family history of type 2 diabetes or in those who are of particular ethnic backgrounds where type 2 diabetes in adults is more prevalent
bull People with type 2 diabetes produce insulin but the insulin produced does not work effectively (ldquoinsulin resistancerdquo)
bull Type 2 diabetes often responds initially to a healthy eating plan appropriate exercise and weight reduction
bull However metformin is frequently needed (+- an insulin sensitizer) and later insulin may be required
Type2 Diabetes in Childhood and Adolescence
Some forms of diabetes do not neatly fit type 1 or type 2 ldquoatypical diabetesrdquo
Neonatal Diabetes (presenting in the first six months of life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes) If this is suspected genetic testing should be undertaken because it may influence management
Monogenic diabetes outside the neonatal period This was previously known as MODY ndash Maturity Onset Diabetes in the Young These cases generally have a strong family history of diabetes
Diabetes associated with syndromes such as Down Syndrome Prader-Willi Syndrome
Other Types of Diabetes in Childhood and Adolescence
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in Childhood and Adolescence in Under-Resourced Countries
UEDA Diabetes Mini-Course
Aswan Feb 2016
Type1 Diabetes in Childhood and Adolescence
Most diabetes in children is type 1 diabetes resulting in lifelong insulin dependency Type 2 diabetes can also occur in children (mainly in adolescents) Other rarer types can also occur even in neonates
Onset can be at any age after the neonatal period but it is most common in childhood and adolescence
Clinical presentation can vary from non-urgent presentation to severe presentation with dehydration shock and DKA
Newly diagnosed children should be transferred to a centre that has expertise in paediatric diabetes if this is possible
Treatment of diabetes consists of
lifelong insulin dependency with multiple injections per day
a healthy eating plan
regular physical activity
Type1 Diabetes in Childhood and Adolescence
It is increasingly being seen in older children particularly adolescents who are overweight and inactive have a family history of type 2 diabetes or in those who are of particular ethnic backgrounds where type 2 diabetes in adults is more prevalent
bull People with type 2 diabetes produce insulin but the insulin produced does not work effectively (ldquoinsulin resistancerdquo)
bull Type 2 diabetes often responds initially to a healthy eating plan appropriate exercise and weight reduction
bull However metformin is frequently needed (+- an insulin sensitizer) and later insulin may be required
Type2 Diabetes in Childhood and Adolescence
Some forms of diabetes do not neatly fit type 1 or type 2 ldquoatypical diabetesrdquo
Neonatal Diabetes (presenting in the first six months of life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes) If this is suspected genetic testing should be undertaken because it may influence management
Monogenic diabetes outside the neonatal period This was previously known as MODY ndash Maturity Onset Diabetes in the Young These cases generally have a strong family history of diabetes
Diabetes associated with syndromes such as Down Syndrome Prader-Willi Syndrome
Other Types of Diabetes in Childhood and Adolescence
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Type1 Diabetes in Childhood and Adolescence
Most diabetes in children is type 1 diabetes resulting in lifelong insulin dependency Type 2 diabetes can also occur in children (mainly in adolescents) Other rarer types can also occur even in neonates
Onset can be at any age after the neonatal period but it is most common in childhood and adolescence
Clinical presentation can vary from non-urgent presentation to severe presentation with dehydration shock and DKA
Newly diagnosed children should be transferred to a centre that has expertise in paediatric diabetes if this is possible
Treatment of diabetes consists of
lifelong insulin dependency with multiple injections per day
a healthy eating plan
regular physical activity
Type1 Diabetes in Childhood and Adolescence
It is increasingly being seen in older children particularly adolescents who are overweight and inactive have a family history of type 2 diabetes or in those who are of particular ethnic backgrounds where type 2 diabetes in adults is more prevalent
bull People with type 2 diabetes produce insulin but the insulin produced does not work effectively (ldquoinsulin resistancerdquo)
bull Type 2 diabetes often responds initially to a healthy eating plan appropriate exercise and weight reduction
bull However metformin is frequently needed (+- an insulin sensitizer) and later insulin may be required
Type2 Diabetes in Childhood and Adolescence
Some forms of diabetes do not neatly fit type 1 or type 2 ldquoatypical diabetesrdquo
Neonatal Diabetes (presenting in the first six months of life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes) If this is suspected genetic testing should be undertaken because it may influence management
Monogenic diabetes outside the neonatal period This was previously known as MODY ndash Maturity Onset Diabetes in the Young These cases generally have a strong family history of diabetes
Diabetes associated with syndromes such as Down Syndrome Prader-Willi Syndrome
Other Types of Diabetes in Childhood and Adolescence
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Newly diagnosed children should be transferred to a centre that has expertise in paediatric diabetes if this is possible
Treatment of diabetes consists of
lifelong insulin dependency with multiple injections per day
a healthy eating plan
regular physical activity
Type1 Diabetes in Childhood and Adolescence
It is increasingly being seen in older children particularly adolescents who are overweight and inactive have a family history of type 2 diabetes or in those who are of particular ethnic backgrounds where type 2 diabetes in adults is more prevalent
bull People with type 2 diabetes produce insulin but the insulin produced does not work effectively (ldquoinsulin resistancerdquo)
bull Type 2 diabetes often responds initially to a healthy eating plan appropriate exercise and weight reduction
bull However metformin is frequently needed (+- an insulin sensitizer) and later insulin may be required
Type2 Diabetes in Childhood and Adolescence
Some forms of diabetes do not neatly fit type 1 or type 2 ldquoatypical diabetesrdquo
Neonatal Diabetes (presenting in the first six months of life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes) If this is suspected genetic testing should be undertaken because it may influence management
Monogenic diabetes outside the neonatal period This was previously known as MODY ndash Maturity Onset Diabetes in the Young These cases generally have a strong family history of diabetes
Diabetes associated with syndromes such as Down Syndrome Prader-Willi Syndrome
Other Types of Diabetes in Childhood and Adolescence
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
It is increasingly being seen in older children particularly adolescents who are overweight and inactive have a family history of type 2 diabetes or in those who are of particular ethnic backgrounds where type 2 diabetes in adults is more prevalent
bull People with type 2 diabetes produce insulin but the insulin produced does not work effectively (ldquoinsulin resistancerdquo)
bull Type 2 diabetes often responds initially to a healthy eating plan appropriate exercise and weight reduction
bull However metformin is frequently needed (+- an insulin sensitizer) and later insulin may be required
Type2 Diabetes in Childhood and Adolescence
Some forms of diabetes do not neatly fit type 1 or type 2 ldquoatypical diabetesrdquo
Neonatal Diabetes (presenting in the first six months of life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes) If this is suspected genetic testing should be undertaken because it may influence management
Monogenic diabetes outside the neonatal period This was previously known as MODY ndash Maturity Onset Diabetes in the Young These cases generally have a strong family history of diabetes
Diabetes associated with syndromes such as Down Syndrome Prader-Willi Syndrome
Other Types of Diabetes in Childhood and Adolescence
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Some forms of diabetes do not neatly fit type 1 or type 2 ldquoatypical diabetesrdquo
Neonatal Diabetes (presenting in the first six months of life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes) If this is suspected genetic testing should be undertaken because it may influence management
Monogenic diabetes outside the neonatal period This was previously known as MODY ndash Maturity Onset Diabetes in the Young These cases generally have a strong family history of diabetes
Diabetes associated with syndromes such as Down Syndrome Prader-Willi Syndrome
Other Types of Diabetes in Childhood and Adolescence
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Goals of T1DM Management
bull Utilize intensive therapy aimed at near-normal BG and A1C levels
bull Prevent diabetic ketoacidosis and severe hypoglycemiabull Achieve the highest quality of life compatible with the
daily demands of diabetes managementbull In children achieve normal growth and physical
development and psychological maturationbull Establish realistic goals adapted to each individualrsquos
circumstances
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Treatment goals Juveniles (ADA Guidelines)
Plasma blood glucose goal range (mgdL)
Before Meals BedtimeOvernight
HbA1c Rationale
Toddlers and Preschoolers
lt6 years100-180 110-200
lt85 (gt75)
High risk and vulnerable to hypoglycemia
School Age
6 to12 years90-180 100-180 lt8
Risk of hypoglycemia and relatively low risk of complication before puberty
Adolescents and Young
Adults
13 to19 years
90-130 90-150 lt75
Risk of hypoglycemia Developmental
and psychological issues
Plasma blood glucose and HbA1c goals by age group
UKDBT00743 ndash February 2011
Copyright 2005 American Diabetes Association from 21 Diabetes Care Vol 28 2005 186-212 Reprinted with permission
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
INSULIN TREATMENT
All children with type 1 diabetes and some children with other forms of diabetes require insulin
The aim is to replace insulin as physiologically as possible so that blood glucose levels are within
the target range
avoiding hypoglycaemia
Avoiding sustained hyperglycaemia
Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth diabetes complications including diabetic ketoacidosis
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept
Basal insulin Controls glucose production between meals and overnight
Near-constant levels
Usually ~50 of daily needs
Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10 to 20 of total daily insulin requirement at each meal
For ideal insulin replacement therapy each component should come from a different insulin with a specific profile or via an insulin pump (with 1 insulin)
Handelsman Y et al Endocr Pract 201117(suppl 2)1-53
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
400 1600 2000 2400 400
Breakfast Lunch Dinner
8001200800
Glargine or
detemir
Pla
sm
a in
su
lin
BasalBolus Treatment Program With Rapid-Acting and Long-Acting Analogs
Bed
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
Rapid
(lispro
aspart
glulisine)
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
bull pH le73
bull Bicarbonate le15 mmolL
bull Anion gap gt12 mmolL
= (sodium + potassium) ndash (chloride + bicarbonate)
bull Positive serum or urine ketones
bull Plasma glucose ge14 mmolL (but may be lower)
bull Precipitating factor
Suspect DKA ifhelliphellip
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Fluids Potassium Acidosis are the Pillars of Treatment
IV fluids AcidosisSerum Potassium
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Replace Fluids with IV 09 NaCl until Euvolemic
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Once euvolemic consider plasma Na+ and glucose to determine IV fluid type
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Replace Potassium Hypokalemia is an avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis not
the glucose
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Identify and Treat the Precipitating Factor
bull Insulin omission ndash MOST COMMON CAUSE of DKA
bull New diagnosis of diabetes
bull Infection Sepsis
bull Myocardial infarction
ndash Small rise in troponin may occur without overt ischemia
ndash ECG changes may reflect hyperkalemia
bull Thyrotoxicosis
bull Drugs
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
PREVENTION of DKA HHS
bull Type 1 diabetes
ndash Education around sick day management
ndash Continuation of insulin even when not eating
ndash Frequent monitoring when ill
bull Type 2 diabetes
ndash Education around sick day management
ndash Frequent monitoring when ill
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Gestational Diabetes
One of the most challenging aspects of diabetes practice
Seemingly easy Practically difficult
Needs a lot of commitment on part of doctor patient and family
Success can be achieved if we try together
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Definition
Glucose intolerance with onset or first recognition during pregnancy
Characterized by β-cell function that is unable to meet the bodyrsquos insulin needs
Buchanan Wiang Kjos Watanabe 2007
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Pathophysiology of GDM
Insulin Resistance
Relative Insulin Deficiency
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Risk factors for GDM
High risk
Obesity
Age gt25ys
Diabetes in 1st degree relative
Previous history of GDM or glucose intolerance
Previous infant with macrosomiagt 35 kg
High risk ethnic group South Asian East Asian Indigenous American or Australian Hispanic
PCOS
Low risk
Age less than 25 years
No previous poor pregnancy outcomes
No diabetes in 1st degree relatives
Normal prepregnancyweight and weight gain during pregnancy
No history of abnormal glucose tolerance
Perkins Dunn Jagastia 2007
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in Pregnancy
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Why diagnose and treat GDM
No increase in congenital anomalies Short term risks for the baby
MacrosomiaNeonatal hypoglycemia JaundicePreterm birthBirth injuryHypocalcemia hypomagnesimiaRespiratory distress syndrome
Long term risks for the babyObesityType 2 diabetes
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
RecommendationsDetection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors using standard diagnostic criteria
Screen for GDM at 24ndash28 weeks of gestation in pregnant women not previously known to have diabetes
Screen women with GDM for persistent diabetes at 6ndash12 weeks postpartum using OGTT nonpregnancy diagnostic criteria
ADA III Detection and Diagnosis of GDM Diabetes Care 201437(suppl 1)S18
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
GDM Diagnosis
2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)
AACE- and ADA-recommended
1-step 75-g 2-hour oral glucose tolerance test (OGTT) 12
or
ACOG- recommended 2 steps a 50-g 1-hour glucose challenge test (GCT) followed by a 100-g 3-hour OGTT (if necessary)3
GDM Diagnostic Criteria for OGTT Testing
75-g 2-hourdagger 100-g 3-hour
Fasting plasma glucose (FPG)
ge92 mgdL (51 mmolL)2 ge95 mgdL (53 mmolL)2
1-hour post-challenge glucose
ge180 mgdL (100 mmolL)2 ge180 mgdL (100 mmolL)2
2-hour post-challenge glucose
ge153 mgdL (85 mmolL2 ge155 mgdL (86 mmolL)2
3-hour post-challenge glucose
ge140 mgdL (78 mmolL)2
daggerA positive diagnosis requires that test results satisfy any one of these criteriaA positive diagnosis requires that ge2 thresholds are met or exceeded
1AACE Endocr Pract 201117(2)1-53
2ADA Diabetes Care 201336(suppl 1)11-66
3Committee on Obstetric Practice ACOG 20115041-3
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diet
Exercise
Glucose monitoring
Insulin and other medications
Management
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Dietary Modifications
bull Decrease carbohydrate content 40
bull Frequent small feedings
bull Small breakfast meals
bull Bedtime snacks
bull No gt 10 hours overnight fast
bull NO JUICE
bull Adequate calorie intake
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Exercise improved cardiorespiratoryfitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for insulin therapy in overweight women with GDM
Exercise
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Target Blood Glucose Values for GDM
Glucose level
Fasting - 90-99 mgdL (50ndash55 mmolL)
1- hr PP - lt 140 mgdL (78 mmolL)
2- hr PP - lt 120-127 mgdL (67ndash71 mmolL)
Fifth International Workshop Conference on Gestational Diabetes
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes
bull Individualized insulin therapy with
close monitoring
ndash Bolus insulin May use aspart or lispro
instead of regular insulin
ndash Basal insulin May use detemir or glargine
as alternative to NPH
bull Encourage patients to SMBG pre- and
postprandially
Target glucose values
Fasting PG lt53 mmolL
1h postprandial PG lt78 mmolL
2h postprandial PG lt67 mmolL
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in Pregnancy Hypoglycemia
Pathophysiology
May be related to fetal
absorption of glucose from the maternal bloodstream
via the placenta
particularly during periods
of maternal fasting
Risk Factors
History of severe hypoglycemia
before pregnancy
Impaired hypoglycemia
awareness
Longer duration of diabetes
A1C le65 at first pregnancy visit
High daily insulin dosage1
Causes of Iatrogenic
Hypoglycemia
Administration of too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more than usual23
Clinical Consequences
Signs of hypoglycemia
anxiety confusion dizziness headache
hunger nausea palpitations
sweating tremors warmth weakness4
Risks of hypoglycemiacoma traffic
accidents death15
Severe hypoglycemia can lead to maternal
seizures or hypoxia
Management
Inform patients of increased risk of
severe hypoglycemia during early pregnancy4
Educate patients on hypoglycemia
prevention
Frequent SMBG
Regular meal timing
Accurate medication
administration
Careful management of
exercise programs4
1 Mathiesen ER et al Endocrinol Metab Clin N Am 201140727-738 2 Inturrisi M et al Endocrinol Metab Clin N Am 201140703-26
3 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 4 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
5 Hod M Jovanovic L Int J Clin Pract 201064(166)47-52
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in Pregnancy Hypoglycemia Treatment
Suspected or confirmed
hypoglycemia (blood glucose lt60 mgdL via
SMBG)
Severe hypoglycemia (patient cannot
swallow)
1 mg glucagon injected
subcutaneously request emergency
assistance1
Mild to moderate
hypoglycemia (patient can
swallow)
Preferred treatment 15-20 g glucose12
Alternative treatments include
fast-acting carbohydrates
(eg 8 oz nonfat milk 4 oz juice)1
15-minutes recheck SMBG
Hypoglycemia resolved (normal SMBG
confirmed)
Snack or meal should
be consumed to prevent
recurrence1
Hypoglycemia not resolved
Repeat treatment
1 Jovanovic L et al Mt Sinai J Med 200976(3)269-80 2 Kitzmiller JL et al Diabetes Care 200831(5)1060-79
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Gestational Diabetes Care In Upper Egypt
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Objectives
bull Establish 7 GDM care and control centres in 7uuniversity hospitals
bull The existing government healthcare centres will be involved and strengthened to perform GDM screening and care
bull Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby
bull Training of health care providersbull NGOs women self help groups will be involved
for their effective participationbull Raising the public awareness
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Screening and care
Assiut
GDM care and control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care center
Sohag-NaghHammady
GDM care center
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in Pregnancy Labor and Delivery
bull Counsel women on diabetes management during labor and
delivery1
bull During the 4-6 hours prior to delivery there is increased risk of
transient neonatal hypoglycemia1
bull Labor and delivery in women with insulin-dependent type 1
diabetes should be managed by an endocrinologist or a diabetes
specialist1
bull Blood glucose levels should be monitored closely during labor to
determine patientrsquos insulin requirements
ndash Most women with gestational diabetes mellitus who are receiving insulin
therapy will not require insulin once labor begins1
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in Pregnancy Postpartum and Lactation
bull Metformin and glyburide are secreted into breast milk and are
therefore contraindicated during lactation1
bull Breastfeeding plus insulin therapy may lead to severe
hypoglycemia1
ndash Greatest risk is in women with T1DM
ndash Preventive measures are reduce basal insulin dosage andor
carbohydrate intake prior to breastfeeding
bull Bovine-based infant formulas are linked to increased risk of T1DM1
ndash Avoid in offspring of women with a genetic predisposition for diabetes
ndash Soy-based products are a potential substitute
1 Castorino K Jovanovic L Clin Chem 201157(2)221-30
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Adapted from httpwwwindexmundicomegyptdemographics_profilehtml httpswwwciagovlibrarypublicationsthe-world-factbookgeoseghtml httpenworldstatinfoWorld accessed 22-2-2014
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
2013
ge60 helliple60 hellip
International Diabetes Federation Managing Older People with Type 2 Diabetes Global Guidelines httpwwwidforgsitesdefaultfilesIDF20Guideline20for20Older20Peoplepdf accessed 15-12-2013
2050
ge60 helliple60 hellip
These changes present significant challenges to welfare pension and healthcare systems in both developing and developed nations
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Factors specific to the management of diabetes in the elderly
bull Screening and diagnosis
bull Specific complications of type 2 diabetes in the elderly
ndashRisk of hypoglycaemic episodes
ndashFunctional disability
ndashDepression cognitive impairment and other geriatric syndromes such as fractures and falls
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Managing type 2 diabetes in the elderlySpecial considerations
ndash Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
ndash Their approach is influenced by a multitude of factors such as the higher frequency of medical comorbidities frailty and socioeconomic issues
ndash Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs Sinclair A Diabetes Spectrum 200619(4)229-33
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Management goals in the elderly
ndash The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
ndash However in frail elderly patients with diabetes avoidance of hypoglycaemia hypotension and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes12
ndash In addition management of coexisting medical conditions is important because it influences their ability to perform self-management2
1Brown AF 2003 51(5)S265-286 2Sinclair A Diabetes Spectrum 200619(4)229-33
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Treatment priority of the elderly prevention of hypoglycaemia
ndash The elderly patient with diabetes is often a frail patient1
ndash Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness12
ndash Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1 Sinclair A Diabetes Spectrum 200619(4)229-332 ADA Diabetes Care201235(1)S11-S63
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
EASDADA recommendations for managing hyperglycaemia in the elderly (2012)
ndash Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger healthier individuals
ndash If lower targets cannot be achieved with simple interventions an HbA1c of lt75ndash80 may be acceptable transitioning upward as age increases and capacity for self-care cognitive psychological and economic status and support systems decline
ndash In the aged the choice of anti-hyperglycaemic agent should focus on drug safety especially protecting against hypoglycaemia heart failure renal dysfunction bone fractures and drugndashdrug interactions Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE et al Diabetes Care 201255(56)1577-96
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ et al Diabetes Metab 201137 Suppl 3S27-38
3minus6 months dietaryand lifestyle advice
Not achieving agreedglucose targets
Metformin
Metformin + DPP-IVinhibitor
Metformin + insulin
Metformin contraindicated inrenalhepatic dysfunctionrespiratoryheart failureanorexia gastrointestinal disease
Alternative treatmentsDPP-IV inhibitors or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatmentsMetformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk caution when using insulin or sulphonylurea therapy
Alternative treatmentsLow risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targetsFasting glucose range = 76minus90 mmollHbA1c range = 76minus85
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
guidelinesdiabetesca | 1-800-BANTING (226-8464) | diabetesca
Copyright copy 2013 Canadian Diabetes Association
bull CAUTION in the elderly
bull Initial doses = HALF of usual dose
bull Avoid glyburide
bull Use gliclazide gliclazide MR glimepiride
nateglinide or repaglinide instead
bull CAUTION in the elderly
bull Increased risk of fractures
bull Increased risk of heart failure
bull May use detemir or glargine instead of NPH or
human 3070 for less hypos
bull Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing
errors
bull CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)
INDIVIDUALIZE glycemic targets based on the above (A1C le85 for frail elderly) but if otherwise healthy use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinedionesBasal analogues instead of NPH or human 3070
insulinPremixed insulins instead of mixing insulins separately
GIVE regular diets instead of ldquodiabetic dietsrdquo or nutritional formulas in nursing homes
2015
Canadian D A Guidelines 2015
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes amp Ramadan
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Fasting Diabetics in figures
bull Islam has 157 billion adherent according to 2009 demographic studies
bull According to high global prevalence studies among adults age 20-79 years 66 type 2 diabetes
bull According to EPIDIAR Study
( 12243 patients 13 Islamic countries )
43 of patients of type 1 fast during Ramadan
79 of patients of type 2 fast during Ramadan
bull These figures lead to an estimate of more than 50 million people with diabetes fast during Ramadan
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Diabetes amp Ramadan
Fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers
Frequent monitoring of glycemia is essential multiple times daily
Structured education for patients fasting Ramadan is very important not only during Ramadan but also throughout the year for better management of diabetes
This structured education should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Fasting in Ramadan
Safe Fasting in Ramadan depends on multiple factors
These factors classify Diabetics to 4 categories -
Very High Risk
High Risk
Moderate Risk
Low Risk
The Decision to fasting or not is based on this categorization
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Very high risk
Severe hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness Hyperosmolar hyperglycemic coma within the previous 3
months Patients who perform intense physical labor Pregnancy Patients on chronic dialysis
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
High Risk
Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mgdl A1C 75ndash90)
Patients with renal insufficiency
Patients with advanced macrovascular complications
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with comorbid conditions that present additional risk factors
Old age with ill health
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Moderate risk
Well-controlled patients treated with short-acting insulin secretagogues such as repaglinideor nateglinide
Well-controlled patients treated with diet alone metformin or a thiazolidinedione who are otherwise healthy
Low risk
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Major risks associated with fasting in patients with Diabetes
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A Recommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Dehydration and thrombosis
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
bullThe ADA advise that all patients wishing to fast should undertake a medical assessment with their HCP at least one month before Ramadan 1
bullDuring Ramadan it is important for the patient to monitor their condition specifically looking at 1
bull Patients should be encouraged to schedule a follow-up consultation after Ramadan to discuss any necessary readjustment of medicine
Treatment
Certain diabetes medications may increase risk of hypoglycaemiawhile fasting therefore the treatment regimen may need to be altered to ensure blood sugar levels are effectively managed during Ramadan
Monitoring Blood sugar levels should be monitored frequently during the day FBS 9H afterSohour2 hours before breakfast2 hours after breakfastWhenever Hypo glycemicsymptoms
Diet
Diet during Ramadan should be healthy and balanced and high saturated fat foods such as ghee sambosas and pakoras should be avoided
Exercise Patients should try to maintain usual physical activity when fasting however it is best to avoid rigorous exercise Regular Tarawih (obligatory prayers) should be considered as part of daily exercise regime
Breaking the fastPatients should break their fast immediately and seek advice from their HCP if they experience any of the following symptomsHypoglycaemia ndashblood glucose less than 60 mgdl (33 mmoll)Hyperglycaemia ndashblood glucose higher than 300mgdl (167 mmoll)
Al Arouj et al Recommendations for the Management of Diabetes During Ramadan Diabetes Care 2010338Date of preparation January 2012 EX-2012-01-16T150104
16
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
SU are unsuitable and may be used with caution
bull It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia
bull Additional studies on the use of sulfonylureas in patients who fast during Ramadan are needed before strong recommendations on their utility can be made
These agents may be used in Ramadan though with caution
Al Arouj M Assaad-Khalil S Buse J Fahdil I Fahmy M Hafez S Hassanein M Ibrahim M Kendall D Kishawi SAl-Madini A Nakhi A Tayeb K Thomas A R ecommendations for the Management of Diabetes During Ramadan Diabetes Care August 2010338
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
BGSM IS MANDATORY FOR SAFE FASTING
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Management of type2 DM in Hepatic patients
bull Hepatogenous diabetes has particular clinical characteristics
bull (1) unlike the hereditary type 2 DM it is less frequently associatedwith risk factors such as age body mass index and family history ofdiabetes
bull (2) it is less frequently associated with retinopathy and cardiovascularand renal complications
bull (3) it is more frequently associated with hypoglycemic episodes as aresult of impaired liver function
bull The treatment of DM of cirrhotic patients has particularcharacteristics that make it different from type 2 DM without liverdisease
bull (1) about half the patients have malnutrition
bull (2) when clinical DM is diagnosed the patient has advanced liverdisease
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
bull As for the management of diabetes in patients with liver disease lifestylemodification plays an important role
bull Oral diabetic medications are contraindicated in patients with advanced liverdiseases with associated cirrhosis ascites or encephalopathy
bull As for stable liver disease metformin and thiazolenediones have shown mixedresults with some showing them to be effective in improving liver transaminasesin addition to histological improvement in steatosis and inflammation α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy
bull Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possiblepathogenetic mechanism for HCV-related insulin resistance and treatment withDPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liverdisease
bull Patients with impaired liver function with associated insulin resistance may needincreased insulin requirements On the other hand patients with altered livermetabolism might need decreased insulin requirements
bull Hala etalDiabetes research February 03 2014bull
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
DM Management in Hepatic Patients
bull Medical therapy for patients with type 2 diabetes and liver diseasemay be the same for patients without liver disease
bull Altered drug metabolism is primarily a concern in patients who haveliver failure and associated ascites coagulopathy orencephalopathy Metformin is an appropriate first-line therapy formost patients except those with advanced liver disease who have anincreased risk of lactic acidosis
bull Thiazolidinediones enhance insulin sensitivity and may be useful inpatients with NAFLD However the current recommendation is toevaluate ALT levels and other liver function test results and initiateTZD therapy only if the serum ALTlt25 times the upper limit ofnormal with no evidence of active liver disease
bull Khan R1 Foster GR Chowdhury TA Postgrad Med 2012 Jul124(4)130-7 doi 103810pgm2012072574
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Management of type2 DM in Hepatic patients
bull Other drugs are also appropriate for use in patients with liver diseaseSulfonylureas are considered safe in patients with hepatic disease and drugswith short half-lives such as glipizide are often appropriate choices
bull Acarbose an α-glucosidase inhibitor works directly in the gastrointestinal tractto decrease carbohydrate metabolism and glucose absorption
bull Although the prescribing information for acarbose contains a warning forpatients with liver disease it appears to be safe and effective in patients withhepatic encephalopathy and type 2 diabetes
bull Insulin can be used successfully in patients with liver disease but higher dosesmay be required due to increased insulin resistanceLater on withdecompensation insulin metabolism decreased so therapy with insulin must bepreferably performed in hospitalized patients with close monitoring of bloodglucose levels for development of hypoglycemia
bull Jonathan G Marquess PharmD Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Per 100000
httpwwwworldlifeexpectancycomcause-of-deathkidney-
diseaseby-country accessed 2012 Oct
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Management of CKD in Diabetes
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
NICE Diabetes with Kidney Disease Key Facts MARCH 2011
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Management of Type2 DM in CKD
Am J Kidney Dis 2007 50(5)865-79
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
bull Certain drugs including exenatide metformin sitagliptin and saxagliptin are either contraindicated or must be carefully monitored and their dosages adjusted in patients with moderate severe or end-stage renal disease
bull Glimepiride 1 mgday may be used cautiously to avoid hypoglycemia in patients with renal disease as they are more sensitive to the glucose-lowering effects of this agentInaddition because glimepiride is cleared by the kidneys the duration of action of insulin may be extended
bull Insulin have been found to be relatively safe in patients with renal disease although the dosages of insulin glargine and insulin detemir may need to be adjusted
bull Jonathan G Marquess PharmD
bull Pharmacotherapy 201131(12)65S-72S
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Russo E et al Diabetes Metab Syndr Obes 2013 6 161ndash170
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
SUs=sulfonylureas T2DM=type 2 diabetes melllitus Requiring medical assistance or hospital admission
UK Prospective Diabetes Study Group Diabetes1995441249ndash1258
Cumulative Incidence of Hypoglycemia in T2DM over 6 Years in UKPDS
45
33
76
112
0
10
20
30
40
50
60
70
80
Sulfonylurea (n=922)Insulin (n=689)
Sulfonylurea Insulin Sulfonylurea Insulin
Pat
ien
ts (
)
Any hypoglycema Major hypoglycemia
HbA1c = 71 in all groups
70 increased risk
40 increased risk
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
25 mg od 125 mg od 625 mg
od
Sitagliptin1
DPP-4 inhibitors
100 mg od 50 mg od 25 mg od
Saxagliptin2
Alogliptin3
5 mg odLinagliptin4
Vildagliptin5 50 mg od50 mg bid
Creatinine
clearance
(mLmin)
Serum
creatinine Male
(mgdL)
Serum
creatinine
Female (mgdL)
30
30
25
Mild RI Moderate RI Severe RI
50
17
15
1 Available at httpwwwmerckcomproductusapi_circularsjjanuviajanuvia_pipdf 2 Available at httpwww1astrazeneca-uscompipi_onglyzapdfpage=13 Available at httpgeneraltakedapharmcomcontentfileaspxFileTypeCode=NESINAPIampcacheRandomizer=7236cffb-eb6c-4b0a-ac79-26810425c89e4 Available at httpbidocsboehringer-ingelheimcomBIWebAccessViewServletserdocBase=renetntampfolderPath=Prescribing+InformationPIsTradjentaTradjentapdf5 Available at httpwwwemaeuropaeudocsen_GBdocument_libraryEPAR_-_Product_Informationhuman000771WC500020327pdf
25 or 5 mg od 25 mg od
od = once daily
bid= twice daily
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
New era in management of CKD patients with diabetes
Better glycemic and blood pressure control
Older oral hypoglycemic agents is either contraindicated or requires dosage adjustment in CKD
New medications for diabetes have been approved recently and many can be used safely in patients with CKD
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb 2016
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