Overview of Therapeutic options in Diabetes Mellitus; Presented Friday 24/7/2015

1. DIABETES MELLITUS
Danish Mahmud; 24/07/2015
Some Aspects of treatment

2. Diagnostic Criteria

3. Type 1 vs Type 2 vs LADA

4. What else can help
 Elevated Antibodies
 Anti GAD antibodies (glutamic acid
decarboxylase)
 Anti islet cell antibodies
 Anti Insulin antibodies
 IA 2 antibodies
 C-peptide levels

7. Recommended Targets
 HBA1c:
 < 7% generally
 Younger patients: < 6.5%
 Older with comorbidities: < 8.0%
 BGLs:
 Fasting: 4-8mmol/L
 Postprandial: < 10mmol/L
 BP: < 130/80 mmHg
 Lipids:
 LDL: <2 mmol/L
 TG: <2mmol/L
 HDL: > 1mmol/L
 No smoking
 Aspirin for Microalbuminuria

8. Therapeutic Options
 Metformin
 Sulfonylueas
 Thiazolidinediones (glitazones)
 Acarbose
 DPP 4 Inhibitors
 GLP 1 Agonists
 SGLT2 inhibitors
 Insulin

10. Metformin
 First line
 Mortality benefits
 Weight neutral
 CI: Severe Renal, hepatic, and heart failure
 Renal failure:
 eGFR 30-60: Half dose
 eGFR < 30: CI
 GI adverse effects- dose related
 Start low and uptitrate to maximum tolerated dose
* NB: Vitamin B12 defeciency

11. Sulphonylureas
 Long track record
 Cheap and effective
 Hypoglycemia and weight gain
 Can be used as initial therapy if metformin not
tolerated/contraindicated
 Issues in Renal failure

12. Thiazolidinediones (glitazones)
 Pioglitazone
 Decrease Insulin resistance
 Weight gain; fluid retention
 Heart failure worsening
 Macular edema
 Bladder cancer
 Increased fracture risk (postmenopausal
women)

13. DPP 4 Inhibitors
 Incretin effect
 Decreased inactivation of GLP1
 GLP 1
 Promotes glucose dependent insulin release
 Inhibits glucagon
 Delay gastric emptying (decrease appetite)
 Pancreatitis rare
 Linagliptin; Saxagliptin; Sitagliptin; Vidagliptin
 Linagliptin (no dose adjustment for renal failure)

14. GLP-1Agonists
 Exenetide; Liraglutide
 More potent and efficacious
 SC injection
 Decreased appetite
 Pancreatitis

15. SGLT2 Inhibitors
 Canagliglozin and dapagliflozin
 Sodium glucose co-transporter in Proximal
tubules
 Weight loss secondary to glucose wasting
 Dehydration (adequate fluid intake)
 Genitourinary infections (meticulous hygiene)

16. Acarbose
 Alpha glucosidase inhibitor
 Not used frequently
 Causes bloating and flatulence
 Not tolerated well

17. Insulin
Sir Fredrick Banting- Nobel Prize 1923

18. Insulin
Geyelin et al 1922

20. Insulin types

22. Triple Combinations
 All Oral
 Metformin + Sulphonylurea + Thiozolidinedione
 Metformin + Sulphonylurea + Acarbose
 Metformin + Sulphonylurea + DPP4 inhibitor
 Metformin + Sulphonyurea + SGLT2 inhibitor
 With Injections
 Metformin + Sulphonylurea + Exenetide

23. CSII

24. CSII
 Indications:
 Type 1 DM
 ? Type 2 DM
 Inadequate control despite good compliance
 Frequent severe hypoglycemia
 Motivated, well educated and cognitively intact
patient
 Specialist centre management

25. CSII terminologies
• Basal rate
 Can be different at different times of the day
• Meal Bolus
 Immediate
 Prolonged (Square wave), combination
 Insulin to Carbohydrate ratio
 Carb counting
• Correction Factor
 Blood glucose range
 Correction / Insulin sensitivity factor

26. An overview of
Insulin pump
therapy:
MedicineToday
December 2010

27. Inpatient Management
 Acutely unwell but not critical:
 Causes of Hyperglycemia:
 Known DM or previously unrecognised
 Stress response (counter regulatory hormones)
 Use of systemic steroids
 Inadequate treatment strategy

28. Inpatient Management
 Causes of Hypoglycemia:
 Decreased oral intake
 Decreased renal clearance
 Sepsis / liver dysfunction
 Inadequate treatment strategy

29. Inpatient Management
 Issues:
 Metformin
 Renal failure
 Lactic acidosis
 Sulphonylureas
 Hypoglycemia
 GLP1 agonists and DPP4 Inhibitors
 Hypoglycemia

30. Inpatient Management
 Targets:
 6-10mmol/L (fasting and pre meal)
 Avoid hypoglycemia
 Need for Insulin
 Sliding scale only – NO
 Basal Bolus Insulin
 Basal (long acting)
 Mealtime bolus (short acting)
 Correction (short acting)
ADS guidelines

31. HbA1c on Hospital admission
 Should be done if not available from last 2-3
months
 Admission bloods HbA1c can avoid result
variation because of blood transfusion
 Provides indication of pre hospital glycemic
control
 Can guide management plan at time of
discharge
 Hospitalisation- moment of patient education
opportunity- please assess and intervene!

32. Recommended Readings
 A new blood glucose management algorithm for type 2 Diabetes- A
position statement of Australian Diabetes Society. MJA December
2014
 Position statement Australian Diabetes Society: Individualisation of
glycated haemoglobin targets for adults with Diabetes mellitus- MJA
September 2009
 Inpatient Management of Hyperglycemia and Diabetes- Clinical
Diabetes, 2011
 The past 200 years in Diabetes- NEJM October 2012
 An overview of Insulin pump therapy- Medicine Today December
2010
 The role of HbA1c in diagnosis of Diabetes Mellitus in Australia-
MJAAugust 2012