Presentation 1

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Current Management
of Diabetes
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
2
Aim
• having information on assessing symptoms and
signs.
• developing management plans for diabetes.
3
Objectives
At the end of this session, the trainees should be
able to:– list diagnostic criteria for DM
– describe how to differentiate Type I & II DM
– explain symptoms and signs of diabetes
– discuss the evidence for lifestyle changes
– describe the indications, contraindications, and
side effects of antidiabetic agents
DM in Saudi Arabia
Lifestyle Changes :
Social & cultural changes
Prevalence :
• Diabetes mellitus as a health problem in Saudi
Arabia
• prevalence of DM is 23.7 % according to Dr. Al
Nozha study (SMJ 2004)
– 1 / 4 of adults > 30 yr are diabetics.
– 36 Foot Amputation / day, at Riyadh.
D.M in Saudi Arabia
Cost & Impacts .
•
•
•
•
•
•
Psychological impact.
Family & Social impact .
Decreased Productivity .
Sick leaves.
Work Absence .
Economical Costs .
cont…..
I- Type 1 diabetes:
Etiologic
classification
II- Type 2 diabetes.
of
diabetes
mellitus
III- Other specific types.
IV- Gestational diabetes mellitus.
Etiologic Classification of Diabetes
Mellitus
 Type 1:
 b-cell destruction with lack of insulin .
 has absolute insulin deficiency
 predisposed to develop ketoacidosis
 insulin is required for survival.
Etiologic Classification of
Diabetes Mellitus
 Type 2
 has relative insulin deficiency combined with
defects in insulin action.
 is the most common form of diabetes,
accounting for 90–95% of the disease
 is most often found in overweight individuals.
Narayan K, Boyle J, Thompson T, Sorensen S, Williamson D (2003). "Lifetime risk for diabetes mellitus in the United
States". JAMA 290 (14): 1884–90. doi:10.1001/jama.290.14.1884.
Risk Factors for Type 2 DM
• Modifiable
– Overweight and obesity
– Sedentary lifestyle
– Previously identified
IGT and IFG
– Metabolic syndrome
– Diatery factors
– Intrauterine
environment
– Inflamation
• Non- Modifiable
–
–
–
–
–
Family history
Age
Gender
History of GDM
Polycystic ovary
syndrome (PCO)
10
Symptoms & Signs
• Classical symptoms
– Unusual thirst (Polydipsia)
– Frequent urination (Polyuria)
– Unusual weight loss
• Other symptoms
–
–
–
–
–
–
–
–
Extreme fatigue or lack of energy
Unusually hungry
Moody & irritable
Blurred vision
Have recurrent infections
Wounds and bruises that are slow to heal
Get a lot of yeast infections
Have tingling or numbness in the hands and/or feet
• Patients may present with a variety of symptoms or even
symptomless
Criteria to diagnosis diabetes
• FPG >126 mg/dl (7.0 mmol/l)
( Fasting is defined as no caloric intake for at least 8 h) OR
• Symptoms of diabetes and a casual plasma
glucose > 200 mg/dl (11.1 mmol/l) OR
• 2-h plasma glucose > 200 mg/dl (11.1 mmol/l)
during an OGTT.
( The test should be performed as described by the W H O (using a glucose load
containing the equivalent of 75g anhydrous glucose dissolved in water)).
Diagnosis of Diabetes :
Plasma Glucose Cutoff Points
mg/ dl
2- Hour BS on
OGTT
mg/dl
< 100
< 140
> 100 and < 126
_
_
> 140 and < 200
> 126
> 200
FBS
categories
Normal
IFG
IGT
Diabetes
* If. without symptoms, there should be more than one measurement in
order to diagnose.
Diagnosis of gestational DM
16
First visit evaluation
History taking and clinical assessment
Physical examination
• Height and weight measurement .
• Blood pressure determination .
• Fundoscopic examination
• Oral examination
• Thyroid palpation
• Cardiac examination
First visit evaluation
Physical examination







Abdominal examination (e.g., for hepatomegaly)
Evaluation of pulses by palpation
Hand/finger examination
Foot examination
Skin examination
Neurological examination
Signs of diseases that can cause secondary diabetes
(e.g., hemochromatosis, pancreatic disease)
First visit evaluation
Laboratory evaluation
• HBA1c
• Fasting lipid profile
• Test for microalbuminuria
• Serum creatinine in adults .
• Thyroid-stimulating hormone (if indicated)
• Electrocardiogram in adults (if indicated)
• Urinalysis for ketones and protein
Management Goals



Annual visits and examinations should be done
regularly
Eliminate symptoms and improve well-being
Prevent and retard microvascular complications



optimize glycemic control
target blood pressure levels
Reduce macrovascular events



optimize glycemic control
target blood pressure levels
target lipid levels
Summary of recommendations for adults with
Diabetes
Parameter
•
HbA1c
pre-prandial plasma glucose
post-prandial plasma glucose
Blood pressure
LDL- cholesterol
HDL- cholesterol
•
Triglycerides
•
•
•
•
•
Target Value
< 7%
70 - 130 mg/dL
< 180 mg/dL
< 130/80 mmHg
< 100 mg/dL (<2.6 mmol/l)
> 40 mg/dL (1 mmol/l) for men
> 50 mg/dL (1.3 mmol/l) for wom.
< 150 mg/dL (17 mmol/l)
ADA 2009
Key concepts in setting glycemic goals
Goals should be individualized based on:
● duration of diabetes
● pregnancy status
● age
● co-morbid conditions
● hypoglycemia unawareness
● individual patient considerations
Follow up
24
Things to keep in mind during
management of Diabetes

Type 2: Deterioration of beta cells over time

Increasing prevalence with increasing risk factors,
e.g obesity

Hyperglycemia affects morbidity, mortality and
resources

Tight glycemic control with insulin may reduce
costly complications

30% to 40% of patients ultimately require insulin
Non-pharmacologic Therapy for DM
Lifestyle therapeutic modifications

Diet





Improved food choices
Spacing meals
Individualized carbohydrate content
Moderate calorie restriction
Exercise
 improve blood glucose control
 reduce cardiovascular risk factors
 contribute to weight loss.
 improve well-being.
Nutritional recommendations for DM
patients
• Protein to provide 10-20% of kcal/day
• Saturated fat to provide < 10% of kcal/day (< 7 % for those with
elevated LDL).
• Polyunsaturated fat to provide < 10 % of kcal.
• Remaining calories to be divided between carbohydrate &
monounsaturated fat, based on medical needs & personal
tolerance.
• Use of caloric sweeteners is acceptable.
Considerations in Pharmacologic
Treatment of Diabetes
•
•
•
•
Complications/tolerability
Frequency of hypoglycemia
Compliance/complexity of regimen
Cost
Sulfonylureas
Drug
Dose
Side effects
Tolbutamide
Restinon®
500-2000mg
Od-Bid
Weight gain
hypoglycemia
Glibenclamide
15-20 mg
Od-Bid
Daonil ® 5mg
Weight gain
Hypoglycemia
40-320mg
Od-Bid
Weight gain
hypoglycemia
Glipizide
Minidiab ® 5mg
2.5-20mg
Od
Weight gain
hypoglycemia
Glimerpiride
Amaryl ® 1,2,4 mg
1-8mg
Od
Weight gain
hypoglycemia
Gliclazide
Diamicron ® 80mg
Drug
Dose
Side effects
Drug class
Metformin
Glocophage®
500-850mg
10002550mg
Bid-Tid
Diarrhea
Lactic acidosis
Biguanides
Acrobose
Glucobay ®
150-300 mg
Tid
Gas , Abdominal
pain, Diarrhea
Rosiglitazone
Avandia ®
4-8mg
Od-Bid
Oedema,weight
gain,hepatic
failure
50-100 mg
2,4,8 mg
Repaglinide
Novonorm ®
0.5,1,2 mg
↓ hepatic glucose production
α –Glucosidase
inhibitors
↓ intestinal absorption
Thiazolidinediones
↑ preipheral glucose
disposal
Meglitinides
1.5-16mg
Tid-Qid
Weight gain
hypoglycemia
↑ pancreatic insulin
secretion
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