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An introduction to diabetes
1.
2.
3. share our experiences of management
of diabetes in local perspective.
early identify the diabetic pts and
complications of DIABETES
motivate patients to achieve targets
understand the advantages of
treatment and disadvantages of not
achieving targets
attain Hb A1c less than 7%
4.
5. Principal Aims in Diabetes Care
Medical/Diabetes Care Team-orientated
( A)Promote overall well-being and a normal life expectancy
(B) Prevent/delay the onset of cardiovascular disease
(C)Manage diabetes-related complications early and aggressively as appropriate
(D) Minimize hypo glycaemia and adverse drug event rate
(E) Provide specialist care at optimal time points
Patient/Care-orientated
(1)To acquire the education and skills to self-manage
(2) Maintain an optimal level of physical and cognitive function
(3) To be confident of access to services and support where necessary to manage their
DIABETES
6. Definition
Diabetes mellitus is a
complex metabolic disorder
characterised by persistent
hyperglycaemia due to relative or
absolute deficiency of insulin or
insulin resistance
9. TYPES of DIABETES
Type 1 Diabetes: 5 to 10% patients
have type 1 diabetes.
Type 2 Diabetes: 90 to 95% patient
have type 2 diabetes.
Other Types.
GDM
IGT
IFG
10. Characteristic Type 1 ( 10% ) Type 2
Onset (Age) Usually < 30 Usually > 40
Type of onset Abrupt Gradual
Nutritional status Usually thin Usually obese
Clinical symptoms Polydipsia, polyphagia, Often asymptomatic
polyurea, Wt loss
Ketosis Frequent Usually absent
Endogenous insulin Absent Present, but relatively
ineffective (in. resistance)
Related lipid Hypercholesterolemia Cholesterol & triglycerides
abnormalities frequent, all lipid fractions often elevated; carb
elevated in ketosis induced hyper TG
common
Insulin therapy Required FOR WHOLE Required in only 20 - 30%
LIFE(DEPENDS ON INSULIN) of patients FOR CONTROL
Hypoglycemic drugs Should not be used Clinically indicated
Diet Mandatory with insulin Mandatory with or without
drug
COMPLICATIONS AFTER 5 40-50% AT DIAGNOSIS
YEARS(MAJORITY)
11. DIFFERENCE
TYPE 2 (TYPE II,
TYPE 1(TYPE I, IDDM) NIDDM)
YOUNGER AGE
OVER 35 , ANY AGE
ABRUPT ONSET
INSIDOUS ONSET
NO FAMILY HIST.
SIGNIFICANT FAMILY HIST.
VIRUS,TOXINS,
OVEREATING ATTITUDE
AUTOIMMUNITY
OVERWEIGHT
MINIMAL OR ABSENT INSULIN
DELAYED OR REDUCED INSULIN
THIN OR CATABOLIC STATE
OBESE OR NORMAL STATE
CLASSICAL SYMPTOMS
NONE OR MILD SYMPTOMS
KETOSIS PRONE
KETOSIS RESISTANT
DIET ESSENTIAL
DIET ESSENTIAL
INSULIN ESSENTIAL(FOR
INSULIN MAY BE REQUIRED
SURVIVAL) (20 – 30%) FOR CONTROL.
SU S NOT EFFICACIOUS
SU S EFFICACIOUS
Complications .AFTER 5 YRS IN
FREQUENT(35-50%) INITIALLY /
MAJORITY. at diagnosis/PC
12. Table 4—Criteria for testing for diabetes in
asymptomatic adult individuals
1. Testing should be considered in all adults who
are overweight (BMI 25 kg/m2*) and
have additional risk factors:
● physical inactivity
● first-degree relative with diabetes
● members of a high-risk ethnic population (e.g.,
African American, Latino, Native
American, Asian American, Pacific Islander)
● women who delivered a baby weighing 9 lb or
were diagnosed with GDM
● hypertension (140/90 mmHg or on therapy for
hypertension)
● HDL cholesterol level 35 mg/dl (0.90 mmol/l)
and/or a triglyceride level 250mg/dl (2.82 mmol/l)
13. ● women with polycystic ovary syndrome
● A1C 5.7%--6.4%, IGT, or IFG on previous
testing
● other clinical conditions associated with insulin
resistance (e.g., severe obesity,
acanthosis nigricans)
● history of CVD
2. In the absence of the above criteria, testing
diabetes should begin at age 45 years
3. If results are normal, testing should be
repeated at least at 3-year intervals, with
consideration of more frequent testing depending
on initial results and risk
status.
*At-risk BMI may be lower in some ethnic groups
14. The foundation of our current practices in
diabetes stems from large prospective
studies, such as the
UK Prospective Diabetes Study (UKPDS)
and the
Diabetes Control and Complications Trial
(DCCT),
which suggested that better control of
blood glucose reduces complications
15. Diabetes Mellitus:
Health Impact of the Disease
6th leading cause
of death
Renal Life expectancy
failure 5 to 10 yr
↑
↑
Blindness
Diabetes Cardiovascular
disease ↑ 2 to 4X
Nerve damage in
Amputation 60 to 70% of patients
e most common cause of renal failure, blindness, and nontraumatic amputations
16. UKPDS: decreased risk of diabetes-related complications
associated with a 1% decrease in A1C
Observational analysis from UKPDS study data
corresponding to a 1% decrease in HbA1C
Any
Percentage decrease in relative risk
diabetes- Diabetes- All Peripheral Micro-
related related cause Myocardial vascular vascular Cataract
endpoint death mortality infarction Stroke disease† disease extraction
12%
14% 14%
* 19%
21% 21% ** **
**
** **
37%
†
Lower extremity amputation or fatal peripheral vascular disease 43%
*P = 0.035; **P < 0.0001
**
**
Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412.
17.
18.
19.
20. Stages of Type 2 Diabetes—
UKPDS
100
75
β-Cell Function (%)
50
IGT Postprandial Type 2 Type 2 Diabetes
25 Hyperglycemia Diabetes
Type 2 Phase III
Phase I
Diabetes
Phase II
0
-12 -10 -6 -2 0 2 6 10 14
Years From Diagnosis
Lebovitz H. Diabetes Review. 1999;7:139.
21.
22. TABLE OF OHAS / OADS
SECRETOGOGUES INSULIN INHIBITORS OF
SENSITIZERS CHO
ABSORPTION
SULFONYLUREAS BIGUANIDES ALPHA
GLUCOSIDASE
INHIBITORS
GLICLAZIDE METFORMIN ACARBOSE
TZDS OTHERS-
GLIBENCLAMIDE NEW
GLIMEPIRIDE PIOGLITAZONE DI -PEPTIDYL
PEPTIDASE-4
INHIBITORS
NON ROSIGLITAZONE GLIPTINS
Black box warning
-SULFONYLUREAS
REPAGLINIDE
26. The Moral of the Tale
Aslong as we
reach the
objective
(TARGETS), it
doesn’t matter
how we get there
27. Tools to manage Diabetes
Whether it is pills,
insulin shots or both
GOAL IS CONTROL
HbA1c <7%
28.
29. The August 2006 guidelines from the
ADA
and the European Association for
the Study
of Diabetes recommends the
inclusion of
METFORMIN
in initial diabetes treatment,
AS PART OF TLC
31. Clinical implications
Algorithm encourages flexibility and clinical judgement in
Type 2 diabetes treatment
Algorithm is cautious in use of newer treatments
Lack of head-to-head trials continues to impede informed
comparisons of strategies
In severely uncontrolled diabetes, lifestyle + insulin is
preferred regimen
Long-term ability to control diabetes or reduce
cardiovascular complications still a concern
35. Advantages of Insulin Therapy
Most clinical experience
Most effective (lowering
glycemia)
Can decrease any level of elevated HbA1c
No maximum dose of insulin beyond
which a therapeutic effect will not occur
Beneficial effects on triglyceride
and HDL cholesterol levels
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
36.
37.
38. Why Aren’t Patients Achieving
Blood Glucose Goals?
Physicians not setting appropriate
glycemic targets
Type 2 diabetes is progressive -
what works now may not work in
the future
Type of medications used are not
appropriate
Insulin therapy only used as a
“threat”
39. Yikes! I have
5 minutes to
tell this
patient
everything
about
diabetes!!
40.
41.
42. (ABC )–ALPHABET STRETEGY)
JOINT BRITISH
SOCIETIES GUIDELINES- 2005
A ADVICE EDUCATION, COMPLIANCE, SMOKING
CESSATION, DIET,
PHYSICAL ACTIVITY,WEIGHT REDUCTION.
B BLOOD PRESSURE < 130/80, ACE/ARB, DIURETICS, CCB
C CHOLESTREROL < 160 MG/DL, LDL<100MG/DL, TG<160,
HDL>40 IN MALES >50 IN FEMALES
D DIABETES CONTROL HBA1C < 6.5% METFORMIN 1ST
CHOICE
E EYE CARE ANNUAL OPHTHALMOLOGICAL EXAM
F FOOT CARE ANNUAL EXAM
G GUARDIAN DRUGS ASPIRIN > 50 YRS, > 10 YRS DM,
HTN / PROTEINUREA( NEPHROPATHY)
ACE/ARB
STATINS(EVEN IF LIPID PROFILE
IS WITHIN NORMAL LIMITS)
43.
44. TAKE HOME
MESSAGE
“Insulin should not be the
treatment of last resort for many
of our patients, but should be the
treatment of best resort. Starting
insulin is always resisted. A lot
depends on the clinician to handle
the different situations in a tactful
way”
45. TAKE HOME
MESSAGE
DIABETES”S therapy should be
individualized
and adjusted according to the
changing needs of the patients
UKPDS 35 was a prospective observational study to determine the relationship between exposure to hyperglycemia over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes who were participants in the UKPDS. 3,642 white, Asian Indian and Afro-Caribbean UKPDS patients who had HbA 1c measured 3 months after their diabetes diagnosis and with complete data for potential confounders were included in the sub-analysis of relative risk. Reductions in the risk of microvascular and macrovascular complications that might be achieved by lowering HbA 1c by 1% were estimated. The incidence of clinical complications was found to be significantly associated with hyperglycemia. While any reduction in HbA 1c is likely to reduce the risk of complications, the lowest risk was observed in those with HbA 1c values in the normal range (< 6.0%). A 1% decrease in HbA 1c was estimated to correspond with significant reductions in any diabetes-related endpoint, diabetes-related death, all cause mortality, myocardial infarction, stroke, peripheral vascular disease, microvascular disease and cataract extraction. Stratton IM, et al. UKPDS 35. BMJ 2000; 321 :405–412.
This is Mr. M.C.’s left heel ulcer. Note the maggots infesting – but perhaps also debriding – this wound.
Slide 1-24 Stages of Type 2 Diabetes Epidemiological studies suggest that the onset of diabetes occurs 10 to 12 years before a clinical diagnosis is made. (Harris 1997) In the UKPDS study of type 2 diabetics, at least 50% of the patients had evidence of diabetic tissue damage when diabetes was first diagnosed. (UKPDS Study 16, 1995) In the earliest phase, when beta-cell function is not impaired, the ability of the beta-cells to hypersecrete insulin masks the impaired glucose tolerance, often for years. During the IGT phase, the FPG will be higher than the normal 110 mg/dL but lower than the 126 mg/dL that is indicative of diabetes. As beta-cell function continues to decline, mild postprandial hyperglycemia develops, reflecting the inability of the beta-cell to hypersecrete enough insulin to overcome insulin resistance. At the end of this prediabetic phase, the first phase of type 2 diabetes typically produces symptoms that lead to a diagnosis. During phase I, in the first 2 years after diagnosis of diabetes, beta-cell function decreases to between 70% and 40% of normal function. CORE
The classical approach to treating type 2 diabetes can be described as stepped management. The first step is to encourage the patient to reduce hyperglycemia through a combination of diet and exercise followed by support with an oral antidiabetic agent in monotherapy. If glycemic control continues to deteriorate, additional oral agents are added in a step-wise fashion followed by insulin where necessary. Slide 17
Published simultaneously in the August 2006 issues of Diabetes Care and Diabetologia , the new consensus statement takes into account the characteristics of individual interventions, their synergies, and expenses (Figure 1) to facilitate the management of hyperglycemia. “We have developed a step-by-step algorithm that simplifies how and when treatments should be administered [Figure 2],” says Dr. Nathan. “We want to achieve and maintain glycemic levels as close to the non-diabetic range as possible and to change interventions at as rapid a pace as titration of medications allows.”
Key Points Insulin is the oldest of the currently available medications for the management of hyperglycemia in type 2 diabetes and has the most clinical experience. It is the most effective of diabetes medications in lowering glycemia: when used in adequate doses it can decrease any level of elevated HbA 1c to, or close to, the therapeutic goal, and there appears to be no maximum dose beyond which a therapeutic effect will not occur. Insulin has also been shown to beneficially affect triglyceride and HDL cholesterol levels. Reference: Nathan DM et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 2006;29(8):1963-72 .
We as health care providers need to know blood glucose goals and develop strategies for our patients to reach these goals. However, it must be made clear that regardless of appropriate control, changes in blood glucose is part of the disease’s progressions. This may have a psychological impact on the patient. Insulin is used as a punishment, therefore, it is often used too late. Insulin must be presented as a wonderful tool to control blood glucose levels.
According to Dr. Nathan, there are several key points for physicians to remember when using the newly created algorithm. “First, physicians need to quickly and aggressively move onto the next step if A1C improvements do not occur. The earlier these new interventions are initiated, the better chance we have at preventing complications. Second, we must recognize that lifestyle interventions [eg, a healthy diet and regular exercise] and early administration of metformin are essential throughout treatment. Patients should receive these interventions as soon as a diabetes diagnosis is made and continue them. Third, physicians should not hesitate to initiate early and aggressive insulin therapy because it can further prevent diabetes-related complications. Lastly, each treatment goal will need to be individualized based on the patient’s characteristics. What may work for some patients will not work for all.”