diabetes pssa presentation prof danie van zyl · metformin (biguanide) 1 –2 obese patients...
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Diabetes PSSA presentation
Prof Danie van Zyl
Number of people (20-79 years) with diabetes globally and by IDF Region
IDF diabetes atlas 2019
Diagnostic
Criteria for
DM2
Fasting plasma glucose (FPG) > 7.0 mmol/la
or
2-h plasma glucose (2PG) > 11.1 mmol/l during OGTTb
or
HbA1c > 6.5%c
or
Random plasma glucose (RPG) > 11.1 mmol/l
if classic symptoms or hyperglycaemic crisisd
Classification of Diabetes
Type 1
Destruction of beta cells
Autoimmune (ICA, anti-GAD, anti-Insulin)
Idiopathic
Absolute deficiency of insulin
Not all patients with late onset
of diabetes have type 2
diabetes. LADA diabetes looks
like type 2 but has antibodies
Type 2
Variable degrees of insulin
deficiency and resistance
No specific test for type 2
diabetes
Keto-acidosis does not
exclude type 2 diabetes
Insulin
Resistance
Syndrome
(Syndrome
X, Reaven’s
Syndrome,
Metabolic
Syndrome)
Constellation of abnormalities often seen together:
•Hyperinsulinaemia
• Impaired glucose tolerance
•Hypertension
• Increased plasma TGs
•Decreased HDL cholesterol
•Truncal obesity
Indicates an increased risk for DM2 and atherosclerotic disease
INSULIN RESISTANCE
RISK OF
DIABETES
IN
OBESITY
PROGRESSION OF TYPE 2 DIABETES
Graph adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.
Chronic
progressive
disease
Achieving Targets
SEMDSA 2017
Factors to consider when choosing
glucose lowering drugs
Glycaemic targets
Glycaemic efficacy
Hypoglycaemia risk
Weight gain
Adverse effects
Treatment complexity
Patient factors
Clinical Effects of Anti-hyperglycemic Agents
Name HbA1c
reduction
Patient best suited
α glycosidase inhibitor (Acarbose) 0.5 – 1 High postprandial glucose
Metformin (Biguanide) 1 – 2 Obese patients
Meglitinides (Rapa-, Nata-glinide) 1 – 2 High postprandial glucose
Sulphonylureas (Glimepiride, Gliclazide) 1 – 2 Recently Dx type 2 diabetes
Thiazolinediones (Pioglitazone) 0.8 – 1.0 Obese or insulin resistant
DPP4 inhibitors (Sita-, Vilda-, Saxa- and Lina-
gliptin)
0.7 Add-on therapy
GLP-1 receptor agonist (Exena-,Lira-glutide) 0.8 – 1.2 Injectable only
SGLT2 inhibitor (Empa-, Dapa,-Canaglifozin) 0.8 – 1.2
HBA1C vs Average blood glucose control
HBA1c (%) Average blood glucose (mmol/L)
6.5 7.7
7 8.5
8 10.1
10 13.3
12 16.5
14 19,7
16 22.9
Treatment strategy DOH EDL
Metformin
Metformin + Sulphonylurea
Metformin + Sulphonylurea + basal Insulin
Metformin + Intensified Insulin
SEMDSA 2017 strategy
The Importance of BP and Glucose Control
-45
-40
-35
-30
-25
-20
-15
-10
-5
0Stroke
Any DM2endpoint Death Microvasc Compl
% r
ed
uc
tio
n
Effects of tight glucose and BP control
TightGlucosecontrol
Tight BPcontrol42
32
37
UKPDS 33
Patient with optimal life expectancy and best quality of life,
lowest morbidity
Glu
co
se
co
ntro
l
BP
co
ntro
l
Lip
id c
on
trol
Ea
rly d
ete
ctio
n o
f
com
plic
atio
ns
Lifestyle intervention and support
What role
can the
Pharmacist
play?
Early diagnosis of diabetes – Identify at risk
individuals (FINDRISK score)
50% diabetic patients is undiagnosed
The delay in diagnosis is 2 to 12 years
25% of type 2 diabetic patients have complications
at diagnosis
Refer for diagnostic testing if needed
Avoid Fad diet advice but motivate patients to
follow a healthy balanced diet
Motivate compliance to medication
Be vigilant – depression is frequent among diabetic
patient