Diabetes

Management Annie Hung

BPT 3

Diabetes

Type 1

Type 2

Gestational

Latent autoimmune diabetes of adults

(LADA)

Mature onset diabetes of the young

(MODY)

Diagnostic Criteria

WHO and American Diabetes Association

HbA1c ≥ 6.5%

Fasting plasma glucose ≥ 7.0 mmol/L

2-hr plasma glucose post OGTT ≥ 11.1mmol/L

Random glucose level ≥ 11.1mmol/L plus

symptoms

21 year old female

presenting with hirsutism

oligomenorrhoea, obese

SHx: university student studying

accounting, smoker, supportive family

PMHx: Family history of T2DM

What would you do?

35 year old male

Referred from GP with abnormal sugars, Fasting glucose of 9, HbA1c 7.0, OGTT x 2 positive

SHx: patient works as a truck driver, smoker of 5 cigs per day for 10 years, supportive wife

Diet: mainly take-away foods, nil exercise

PMHx: Obesity, OSA, HTN

What would you do?

67 year old male Presenting with infective exacerbation of CCF

PMHx: T2DM, HTN, Hyperlipidaemia, Obesity, COPD

SHx: lives at home alone, current smoker, no family supports

Medications: Metformin 1g TDS plus insulin (Novomix 30/70 – 15/20 units), etc.

HbA1c 10.0

What do you do? What would you change/add?

Management 1. Diabetes

What would you start, switch to? Are there any other considerations?

2. Complications Microvascular

Retinopathy

Nephropathy

Neuropathy, Vascular complications

Macrovascular Stroke

Ischaemic heart disease

3. Comorbidities Hypertension

UKPDS 33 + 34

Newly diagnosed T2DM (mean age 53) followed up for 10 years

Intensive control of HbA1c – 7.0% vs conventional treatment with average HbA1c 7.9%

Reduced overall microvascular complication rate by 25%

American Diabetes Association to recommend HbA1c goal of <7%

UKPDS: Improving HbA1c Control

Reduced Diabetes-Related Complications

UKPDS=United Kingdom Prospective Diabetes Study.

Data adjusted for age, sex, and ethnic group, expressed for white men aged 50–54 years

at diagnosis and with mean duration of diabetes of 10 years.

Stratton IM et al. UKPDS 35. BMJ 2000;321:405–412.

EVERY 1%

reduction in HbA1c

REDUCED RISK (P<.0001)

1%

Diabetes-

related deaths

Myocardial infarctions

Microvascular

complications

Amputations or deaths from peripheral vascular disorders

Relative Risk N=3642

ADA and IDF Guidelines:

Treatment Goals for HbA1c, FPG, and PPG

<6.5%a <7%* 4% – 6% HbA1c

<7.8

<10.0 <7.8 PPG

mmol/L

<5.5

3.9–7.2 <5.6 FPG

mmol/L

IDF

Goal

ADA

Goal Normal

Level Parameter

aReference to a nondiabetic range of 4.0% to 6.0% using a DCCT-based assay.

ADA=American Diabetes Association; IDF=International Diabetes Federation.

American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S13–S61; International Diabetes Federation. 2007:1–32.

Buse JB et al. In: Williams Textbook of Endocrinology,11th ed. Philadelphia: Saunders; 2008:1329–1389.;

Harris P et al. RACGP/DA Diabetes management in general practice, fourteenth edition 2008/9. Canberra: Diabetes Australia, 2008.

DA

Goal

4–6

4-7.7

≤7%*

Intense therapy vs. ?

What is optimal HbA1c?

Intense for the young, but less so for the

older population?

One drug is better than another?

Hypoglycaemia

Mechanisms of Action of Major Oral

Monotherapies Do Not Target 3 Core Defects in

Type 2 Diabetes Oral Monotherapies

SUs

Meglitinides

TZDs

Metformin

α-Glucosidase

Inhibitors

DPP-4

Inhibitors

Improves insulin secretion

Improves insulin resistance

Lowers hepatic glucose production

SUs=sulfonylureas; TZD=thiazolidinediones; DPP-4=dipeptidyl peptidase 4.

Inzucchi SE. JAMA 2002;287:360–372; Gallwitz B. Minerva Endocrinol. 2006;31:133–147.

Ke

y D

efe

cts

Insulin secretory response

Tailor the Treatment

Diabetes Care

References http://www.diabetesaustralia.com.au

https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ext_2_ext_0002.pdf

http://www.racgp.org.au/your-practice/guidelines/diabetes/

ADVANCE trial. N Engl J Med 2008;358:2560-72.

UK PDS 34. The Lancet;1998; 352, 9131. 854 - 865

UK PDS 33. The Lancet;1998; 352, 9131. 837 – 853

ACCORD trial. The Lancet 2010; 376: 419–30.

Intensive Glycemic Control and the Prevention of Cardiovascular Events: Implications of the ACCORD, ADVANCE, and VA Diabetes TrialsJACC; Vol. 53, No. 3, 2009