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
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