DIABETES MELLITUS

Danish Mahmud; 24/07/2015

Some Aspects of treatment

Diagnostic Criteria

Type 1 vs Type 2 vs LADA

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

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

Therapeutic Options

Metformin Sulfonylueas Thiazolidinediones (glitazones) Acarbose DPP 4 Inhibitors GLP 1 Agonists SGLT2 inhibitors Insulin

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

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

Thiazolidinediones (glitazones)

Pioglitazone Decrease Insulin resistance Weight gain; fluid retention Heart failure worsening Macular edema Bladder cancer Increased fracture risk (postmenopausal

women)

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)

GLP-1 Agonists

Exenetide; Liraglutide More potent and efficacious SC injection Decreased appetite Pancreatitis

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)

Acarbose

Alpha glucosidase inhibitor Not used frequently Causes bloating and flatulence Not tolerated well

Insulin

Sir Fredrick Banting- Nobel Prize 1923

Insulin

Geyelin et al 1922

Insulin types

Triple Combinations

All Oral Metformin + Sulphonylurea + Thiozolidinedione Metformin + Sulphonylurea + Acarbose Metformin + Sulphonylurea + DPP4 inhibitor Metformin + Sulphonyurea + SGLT2 inhibitor

With Injections Metformin + Sulphonylurea + Exenetide

CSII

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

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

An overview of Insulin pump therapy: Medicine Today December 2010

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

Inpatient Management

Causes of Hypoglycemia:

Decreased oral intake Decreased renal clearance Sepsis / liver dysfunction Inadequate treatment strategy

Inpatient Management

Issues: Metformin

Renal failure Lactic acidosis

Sulphonylureas Hypoglycemia

GLP1 agonists and DPP4 Inhibitors Hypoglycemia

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

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!

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-

MJA August 2012