guidelines for diabetes

8/14/2019 Guidelines for Diabetes

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5.9% of Americans are diabetics Prevalence increases with age:

1.6% of individuals between age 20-3920% of individuals of age > 60

1.6 times more prevalent among no Hispanic African-Americans

1.9 times more prevalent among Hispanic Americans. It is the leading cause of new blindness, end state renal

disease and nontraumatic amputations in adults.

Guidelines For Diabetes

Introduction


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Classification Type 1 D M:

- Formerly called IDDM

- Onset is predominantly in youth.- Genetic basis but only approximately 35%

monozygotic twins.-Autoimmune destruction of B-cells = low c

peptide.- Chance for first degree relative 5-10%- HLA alleles B8-B15-DR3-DR4


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Type 2 DM:- Formerly called NIDDM- Strong genetic basis, monocygotic twins

approximately 90%.

- Insufficient insulin secretion andIncreased insulin resistance

- 92% have insulin resistance


Classification


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Guidelines For Diabetes Diagnostic criteria

DIABETES

Presence of classicsymptoms and random or postprandial 200 mg/dl.

Fasting glucose 126 onmore than one occasion

Glucose 200 2hr after after 75 g of oral glucoseload (n= 200 or Glucose challenge test:

>130 1 hr after 50 g 75 g load test: >95 fasting,

>180 1 hr, >155 2 hrs.


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Screening Patients over 45 screening with fbs Q 3 years Younger patients with risk factors:

-Family history of diabetes-> 149% of ideal weight-Previous IFG or IGT

-A.A., Hispanics, American natives-Women with history of GDM-Patients with hypertension or dyslipidemia.


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Re at ons p Between O es tyand

Insulin Resistance andDyslipidemia


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The Insulin Resistance Syndrome Synd. X., Dysmetabolic syndrome, Deadly

quartet. Clustering of metabolic abnormalities that

frequently occur together in patients whoare resistant to insulin.

ICD9 code: 277.7 Increased risk of develop. DM and

Cardiovascular disease.


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Guidelines For Diabetes The Insulin Resistance Syndrome

Having 3 or more R. F.RISK FACTOR

Abdominal obesi ty

Men------------------------------Women--------------------------Triglycerides------------------- H DL

Men------------------------------Women--------------------------Blood Pr essur e---------------- F asting Glucose---------------

DEFINING LEVELWaist Cir cumference

>102 cm (>40 in)>88 cm (35 in)>150 mg/dL

< 40 mg/dL130/85 mmHg>110 mg/dL(110-125)>140 ,


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Insulin Resistance: AssociatedConditions


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Guidelines For Diabetes Treatment/ Goals

( As per ADA guidelines)

The target HbA1C level is 7%. Check Q 3months. FBS: 80-120.

BS 2 hr postprandial or at bedtime: 100-140


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Guidelines For Diabetes Treatment/ Goals

( As per ADA guidelines) Avoid acute metabolic decompensation due to

ketoacidosis or hyperosmolar state. Decrease General symptoms of hyperglycemia,

polyuria, polydipsia, fatigue,weight loss, polyphagia, blurred vision and recurrentvaginitis/balanitis.

Decrease risk of development or progression of retinopathy and other macro and microvascular complications. ----Gastro paresis---

Promote general well being.


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Treatment/ Education Refer patients to a Diabetes Educator Educate patients about the disease and its

complications. Ketoacidosis and hyperosmolar states Monitoring of blood sugar at home. Instruct them

about when to call you or when they should go to

E.R. Hypoglycemia symptoms and management. A1 C Hb. Dietary Referal: caloric restriction and

individualized meal plan


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Treatment/ Exercise An exercise program is an important part of

treatment of type 2 diabetes.(also type 1) Type: aerobic exercise has a direct effect in

reversing the insulin resistance and can delay or prevent type 2 diabetes in high risk populations.

Biking, swimming, jogging, etc. Time: Start with 20 min. with a goal of 30 to 40

minutes every other day or at least 3/week.


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Treatment/ ExerciseBenefits of regular aerobicexercise:-Increases tissue sensitivity to insulin.-Reduces dosage of insulin and oral agents. -Improves psychological well-being and quality of

life and reduces stress.- Reduces cardiovascular r isk: BP, LDL,

HDL, triglycerides, blood glucose, improvescollateral flow in patient with ischemic arterial

disease, max. O2 uptake.


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Treatment/ ExerciseMedical Precautions and diagnostic Evaluation:

-Blood pressure

-Peripheral pulses-Examination of carotid and femoral arteries

for bruits.-Sensory examination of the feet. No running if neuropathy.-Ophthalmoscopic evaluation(refer if proliferative retinopathy).

-ECG at rest.-Exercise stress test if previous hx of cardiovascular disease or poor

exercise tolerance.-Do not exercise if bs >300 or


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The 4S Diabetes Substudy


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NCEP: TreatmentRecommendations for High TG

Levels


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Veterans Affairs CooperativeStudies Program HDL-C

Intervention Trial (VA-HIT)

R T G


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Recommen e Treatment Goa sfor

Hypertension for Adults WithDiabetes


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UKPDS: Risk Reduction inDiabetes-Related Complications

With Decrease in SBP


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Hypertension Optimal Treatment(HOT): Outcomes in Patients

With Diabetes


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Treatment/ Hypertension BP control should be priority in management of patients with diabetes.

80% will develop macro vascular disease, also

nephropathy and retinopathy. Target BP < 120/80. First-line agents: Thiazide diuretic for A.A. and

ACE Inhibitor for the rest. Angiotensin-receptor blockers as an alternative,

specially if signs of LVH. B-Blockers if hx of CAD.

CCB 2nd

or 3rd

line agents.


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Treatment/ Type 1 DM Oral hypoglycemic are not effective Insulin is the only treatment.There is no standard way to treat IDDM

with insulin. 0.5-1 U/kg/d Split dose regimen with NPH or lente 2/3 in am and 1/3 in the pm. Insulin needs may vary during the course of the disease. Honeymoon effect: improvement of symptoms during 1 st year. Down Phenomenon:-Inc of BS from 4 to 7 am

- No symptoms of hypoglic.

-patient needs more insulin Somogyi:-Occurs at any time, but more at evening

and night. Is reactive hyperglicemia.-with symptoms: headaches and

nightmares(due to hypoglycemia's).

-Patient needs less insulin.


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Guidelines For Diabetes Treatment/ Type 2 DM

Oral Hypoglycemic Agents Diet and exercise alone:

-consider for stable patient with a mild increase of Bloodsugar. (fbs


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Oral Hypoglycemic Agents Always start with one medication(the best for the patients

clinical profile) and optimize it up to the highest dosage

before introducing a second line medication. Stepwise treatment, adjusting medications usually after onemonth of treatment, But can adjust insulin in a weekly

bases and sulfunylureas every 2 weeks at the beginning.Dont overdohypoglycemia is worse.

Dont make many changes in therapy at the same time inorder to asses the efficacy of each change.

Before adjusting medications go back to diet compliance.


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Sulfonylureas Mech. Action: increase release of insulin from B cells. Decrease A1C HB 1.5% to 2.5%. Clinical profile: good as a first line medication for the non obese patient

with new onset of DM, patients with no evidence of insulin resistance.

Good medication to decrease FBS but not for very high post-prandials. Start with low dosage and increase every 2 weeks. Side Effects:- Hypoglycemia,Wight gain, abnormal LFTS,

nausea, vomiting, skin rashes, leucopenia,thrombocytopenia,cholestasis.

-D/C when creatinine >1.5 or 2 fold of LFTS -Not good for patients with night time hypoglycemiaand elderly(use glipizide).

Combinations: O.k. with metformin, thiazolidinediones,not recommended with insulin.


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Metformin(biguanide) Mech. Of Action:Decreases hepatic glucose production

and in a minor way also increases glucose utilization. Mayincrease insulin action by inc. glucose uptake in muscleand fat.

Decreases A1C HB -------- Clinical profile: overweight patient , insulin resistance. Specific advantages: reduction of ins. Resistance, weight

loss, decrease of triglyceride levels and improvement of lipid profile.

No hypoglycemia when used alone.


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Metformin(biguanide) Side Effects: abdominal discomfort(pain),nausea

and diarrhea(10-30%),flatulence, Lactic acidosis,decreases levels of vit. B12(macrocitic anemia).

Stop if creat. >=1.5 males and >1.4 in females Stop if risk of hypoxia and renal insufficiency:

Acute MI,decompensated CHF, shock, severe

infection, major surgical procedure, ketoacidosis,use of iodinated contrast media. Monitor LFTS


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Thiazolidinediones Mec of action: decrease insulin resistance

inc. glucose utilization in peripheral tissues slower onset of action(allow 4 weeks to make changes) Dec. A1CHB 1-1.5% Clinical profile: patients with insulin resistance,

monotherapy for elderly and renal patients. Specific Advantages:

-can be used as monotherapy or in combination withinsulin, sulfonylureas and glucophage.-No risk of hypoglycemia alone-Can use with renal insufficiency.

-dec. triglycerides, inc HDL, may help LDL too.


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Thiazolidinediones Side effects:

hepatotoxcity,CHF,edema(fluid

retention),dilutional anemia Monitor LFTS q 2 months for the first

year, then periodically. Stop if >2.5 times

normal. Consider cost.


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Insulin Therapy Consider if ketonuria, ketoacidosis, hyperosmolar state and

progressive weight loss Mesurement of c- peptide? Is Not cost effective

Use evening dose of intermediate-acting if problem is highfbs.

Use NPH in AM and PM or single dosage of long acting if persistent hyperglycemia at daytime.

Start at a dosage of 0.2 to 0.5 U/Kg. Then followaccuchecks for 1 or 2 weeks to make adjustments. Can also combine with regular before breakfast and dinner

or use 70/30 if persistent high post-prandials. If patients experience late hypoglycemia(3 to 5 hrs after

meals), use lispro Insulin in place of regular.


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Acarbose

Mech of A:Inhibits the enzymes that breakdownthe carbohydrates in the intestines.

Decreases A1CHB by 0.5-1% Clinical Profile: patient with high postprandials. Needs frequent doses.

Side effects: Abdominal pain and diarrhea.-----decrease dosage and titrate as tolerated.Abnormal LFTS


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Other Insulin Secretagogues

Rapaglidine(prandin) and Nateglidine. Stimulate postprandial secretion of insulin by B

cells. Clinical profile: specific target is the postprandial

rise in the blood sugar. Also may be used in renalinsufficiency.

Not effective for fasting hyperglycemias(shortacting)

Side effects: GI.

Increased cost.


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Guidelines For Diabetes Treatment/ IGT-Metabolic synd.

Diet and Exercise. Strict control of hypertension and correction

of hyperlypidemia has shown to reducecardiovascular disease on this patients.

If persistent insulin resistance can use

metformin or TZDs. May prevent onset of diabetes(TRIPOD STUDY)


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Guidelines For Diabetes Treatment

Health Maintainace Strict control of HTN and Hyperlipidemias Annual referal to Ophtalmology. Foot care and referal to podiatry. Neurological exam focusing in possible neuropathy. Vaccination:Pneumonia every 5 years and flu every year. Screening for microalbuminuria annually:

Spot sample = 20-300mcg/mg or 30-300 mg/24hr If microalbuminuria persists after controlling blood sugar and having A1C HB of 7%, start on ACE inhibitors.

Smoking cessation.


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Clinical Case 38 y/o male with 10 year history of type 2

diabetes on maximal dosages of Metformin

and sulfonylurea. Patients A1CHB: 9%


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Clinical Case 68 y/o female with 3 year history of type 2

DM. Complains of vaginal itching and

whitish vaginal d/c. postprandial blood sugar 360.A1cHB 10.5%

BP 140/80 Normal renal function but pos. for microalb.meds: glipizide 10mg p.o. q.d.


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Clinical Case One month after increasing glipizide to

20mg/d fbs 160 and A1CHB 8.2%.

After 5 mg of vasotec BP 120/80 andnegative for microalb.


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hGuidelines For Diabetes

Clinical Case Start on glucophage vrs actos/avandia


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Clinical Case 35 y/o female with 6 year history of type 2 DM

complaining of polyuria and polydipsia. P.E.remarkable for overweight(235 lb). BP 130/80

Meds: glucophage 500mg bid Labs: A1CHB 10%

Cholest:288HDL:41Trigl:200LDL: 160

guidelines for diabetes

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