management of diabetes
TRANSCRIPT
![Page 1: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/1.jpg)
Management Of Diabetes
Presenters: Otaalo Brian Nalukenge Caroline
![Page 2: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/2.jpg)
Outline
• Definition• Epidemiology • Classification• Clinical Features• Treatment
![Page 3: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/3.jpg)
Diabetes Mellitus
DefinitionA chronic disorder of metabolism resulting from lack or reduced effectiveness of endogenous insulin, characterized by hyperglycemia.
![Page 4: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/4.jpg)
Epidemiology
• >380 million people worldwide have DM• >90% have type 2 DM• In Uganda in 2014 (adults 20-79yr);- Approx 1.56 million pple have DM (est. 98,000 in yr 2000)- Prevalence of 4.4%- 693,200 cases were registered, 17,570 deaths- Cost per person with DM = $ 84.9 ( Ugshs=257,247)- Estimated undiagnosed DM= 520,500
![Page 5: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/5.jpg)
![Page 6: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/6.jpg)
Did you know?
![Page 7: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/7.jpg)
Classification
• Type 1 DM• Type 2 DM• Gestational diabetes• Diabetes due to other causes
![Page 8: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/8.jpg)
Type 1 DM
• Usually diagnosed in childhood but can occur at any age• Insulin deficiency from autoimmune destruction of pancreatic B cells• Concordance among identical twins approx 30%• >90% carry HLA DR3 +/- DR4• Environmental factors have a role in disease;-infection: mumps, cox sackie, CMV, EBV, rubella(in utero)-diet: bovine serum antigen (BSA)• Atleast 70-90% of pancreatic B cells destroyed • Latent Autoimmune Diabetes of Adults(LADA)
![Page 9: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/9.jpg)
Type 1 cont…
• LADA• Latent Autoimmune Diabetes in Adults (LADA) is a form of type 1
DM which is diagnosed in individuals who are older than the usual age of onset of type 1 diabetes.
• Aka "Slow Onset Type 1" diabetes, and sometimes also Type 1.5• Often, patients with LADA are mistakenly thought to have type 2
dm, based on their age at the time of diagnosis.
![Page 10: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/10.jpg)
Type 2 DM
• Common in adults > 40yrs • Teenagers are now also increasingly being diagnosed• Associated with obesity, lack of exercise, calorie & alcohol excess• Concordance in identical twins approx. 80%• Have B cell dysfunction and insulin resistance• Typically progresses from IGT or IFG• Maturity onset Diabetes of the Young (MODY)- Form of DM type 2
![Page 11: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/11.jpg)
Gestational diabetes
• Diabetes occurring during pregnancy without prior hx of diabetes• Usually resolves after pregnancy• Occurrs in 4% of pregnancies• Risk : >25yrs, +ve family hx, obesity• Approx. 5-10% are found to have DM type 2 after pregnancy• Have 20-50% chance of developing type 2 DM in the next 5-10yrs
![Page 12: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/12.jpg)
![Page 13: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/13.jpg)
Clinical Features
• Polyuria, polydipsia & polyphagia• Weight loss• Fatigue • Dehydration • DKA• Eyes- Retinopathy/ cataract - ask for visual blurring or blindness. - check for visual acuity, do fundoscopy
![Page 14: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/14.jpg)
Clinical features cont….
• Head : CN palsy• Cvs- hypertension,MI - take appropriate history, - take bp• GUT- nephropathy, erectile dysfunction, uti• MSS- peripheral neuropathy, slow wound healing, foot ulcers,
wasting, obesity• Skin- pigmentation, acathosis nigricans
![Page 15: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/15.jpg)
Diagnosis of Diabetes Mellitus• Symptoms of diabetes or testing urine for glucose and
ketones.• random blood sugar(RBS) ≥ 11.1 mmol/L (200
mg/dL)• Fasting plasma sugar(FBS) ≥ 7.0 mmol/L (126 mg/dL)
NB: FBS is the most reliable & convenient test for identifying D.M in asymptomatic individuals.
![Page 16: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/16.jpg)
• Random is defined as without regard to time since the last meal.
• Fasting is defined as no caloric intake for at least 8 h preceded by unrestricted carbohydrate diet for 3 days before the test.
Indications for Oral Glucose Tolerance test(OGTT)RBS: 7.8-11.0mmol/l (140-199 mg/dl)FBS: 6.1-7.0mmol/l (110-126 mg/dl)
• The OGTT should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
![Page 17: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/17.jpg)
•
Normal glucose tolerance
Prediabetes Diabetes Mellitus
Fasting blood sugar
<5.6mmol/l (100mg/dl)
6.1-6.9 mmol/l (100-125mg/dl)
≥7.0mmol (126mg/dl)
2Hr Plasma glucose
<7.8mmol/l (140mg/dl)
7.8-11.1 mmol/l (140-199 mg/dl)
≥11.1 mmol/l (200 mg/dl)
![Page 18: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/18.jpg)
Management of Diabetes
![Page 19: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/19.jpg)
Approach to the Patient
• Proper history; DM risk factors, symptoms and complications.
• Physical Examination; weight or BMI, retinal examination, orthostatic blood pressure, foot examination, peripheral pulses, and insulin injection sites.
![Page 20: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/20.jpg)
Investigations Urinalysis; glucose, protein, ketones. Blood glucose; RBS (4-7mmol/l is normal), FBS HBA 1C (normal; <6.5%) Blood lipids; total cholestrol, LDL, HDL, triglycerides. CBC LFTs RFTs
![Page 21: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/21.jpg)
Treatment• The major components of the treatment of diabetes
are:
• Diet and ExerciseA
• Oral hypoglycaemic therapyB
• Insulin TherapyC
![Page 22: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/22.jpg)
Basic Principles• Correct diagnosis is essential.
• lowering the blood glucose level but also correction of any associated CVD risk factors such as smoking,hyperlipidemias, and obesity
• Management of non-insulin-dependent diabetes mellitus (NIDDM) requires teamwork.
• Self-care is an essential strategy. People with diabetes should be encouraged and enabled to participate actively in managing and monitoring their condition.
• Good control is important
![Page 23: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/23.jpg)
A. DietDiet is a basic part of management in every case.
Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition.
Dietary treatment should aim at:◦ensuring weight control◦providing nutritional requirements◦allowing good glycaemic control with blood
glucose levels as close to normal as possible◦correcting any associated blood lipid
abnormalities
![Page 24: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/24.jpg)
A. Diet (cont.)• Dietary fat should provide 25-35% of total intake of
calories. Cholesterol consumption should be restricted and limited to 300 mg or less daily.
• Protein intake can range between 10-15% total energy (0.8-1 g/kg of desirable body weight). Requirements increase for children and during pregnancy
• Carbohydrates provide 50-60% of total caloric content of the diet. Carbohydrates should be low glycemic index and high in fibre.
![Page 25: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/25.jpg)
Exercise• Physical activity promotes weight reduction and
improves insulin sensitivity, thus lowering blood glucose levels.
• Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness.
• People should, however, be educated about the potential risk of hypoglycaemia and how to avoid it.
![Page 26: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/26.jpg)
B. Oral Anti-Diabetic Agents• There are currently four classes of oral anti-diabetic
agents:
i. Biguanidesii. Insulin Secretagogues – Sulphonylureasiii. Insulin Secretagogues – Non-sulphonylureasiv. α-glucosidase inhibitorsv. Thiazolidinediones (TZDs)
![Page 27: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/27.jpg)
B.1 Oral Agent MonotherapyIf glycaemic control is not achieved (HbA1c > 6.5%
and/or; FPS > 7.0 mmol/L or; RPS >11.0mmol/L) with lifestyle modification within 1 –3 months, ORAL ANTI-DIABETIC AGENT should be initiated.
In the presence of marked hyperglycaemia in newly diagnosed symptomatic type 2 diabetes (HbA1c > 8%, FPS > 11.1 mmol/L, or RPS > 14 mmol/L), oral anti-diabetic agents can be considered at the outset together with lifestyle modification.
![Page 28: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/28.jpg)
B.1 Oral Agent Monotherapy (cont.)As first line therapy:
Obese type 2 patients, consider use of metformin, acarbose or TZD.
Non-obese type 2 patients, consider the use of metformin or insulin secretagogues
Metformin is the drug of choice in overweight/obese patients. TZDs and acarbose are acceptable alternatives in those who are intolerant to metformin.
If monotherapy fails, a combination of TZDs, acarbose and metformin is recommended. If targets are still not achieved, insulin secretagogues may be added
![Page 29: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/29.jpg)
B.3 Combination Oral Agents and Insulin If targets have not been reached after optimal dose of
combination therapy for 3 months, consider adding intermediate-acting/long-acting insulin (BIDS).
Combining insulin and the following oral anti-diabetic agents has been shown to be effective in people with type 2 diabetes:◦ Biguanide (metformin)◦ Insulin secretagogues (sulphonylureas)◦ Insulin sensitizers (TZDs)(the combination of a TZD plus insulin
is not an approved indication)◦ α-glucosidase inhibitor (acarbose)
Insulin dose can be increased until target FPS is achieved
![Page 30: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/30.jpg)
Diabetes Management
Algorithm
![Page 31: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/31.jpg)
Oral Hypoglycaemic Medications
![Page 32: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/32.jpg)
General Guidelines for Use of Oral Anti-Diabetic Agent inDiabetes
• Oral anti-diabetic agent s are not recommended for diabetes in pregnancy
• Oral anti-diabetic agents are usually not the first line therapy in diabetes diagnosed during stress, such as infections. Insulin therapy is recommended for both the above
• When indicated, start with a minimal dose of oral anti-diabetic agent, while reemphasizing diet and physical activity.
![Page 33: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/33.jpg)
C. Insulin TherapyShort-term use: Acute illness, surgery, stress and emergencies Pregnancy Breast-feeding Type 1 in marked hyperglycaemia
Long-term use: If targets have not been reached after optimal dose of
combination therapy or BIDS, consider change to multi-dose insulin therapy. When initiating this,insulin secretagogues should be stopped and insulin sensitisers e.g. Metformin or TZDs, can be continued.
![Page 34: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/34.jpg)
Insulin regimensThe majority of patients will require more than one daily
injection if good glycaemic control is to be achieved. However, a once-daily injection of an intermediate acting preparation may be effectively used in some patients.
Twice-daily mixtures of short- and intermediate-acting insulin is a commonly used regimen.
In some cases, a mixture of short- and intermediate-acting insulin may be given in the morning. Further doses of short-acting insulin are given before lunch and the evening meal and an evening dose of intermediate-acting insulin is given at bedtime.
Other regimens based on the same principles may be used.
![Page 35: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/35.jpg)
![Page 36: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/36.jpg)
Monitoring of glycemic control• Self-monitoring of blood sugar by the patient.• Measurement of glycated hemoglobin(HB1AC)Rep. glycemic hx in previous 2-3 months; preceding
month contributes 50%1% rise in HB1AC translates in 2.0mmol/l (35mg/dl)
increase in mean glucose
Frequency; Good glycemic control; atleast twice a year. Poor glycemic control or when therapy is changed or
most pts with type 1 DM; every 3 months
![Page 37: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/37.jpg)
Self-CarePatients should be educated to practice self-care.
This allows the patient to assume responsibility and control of his / her own diabetes management. Self-care should include:
◦ Blood glucose monitoring◦ Body weight monitoring◦ Foot-care◦ Personal hygiene◦ Healthy lifestyle/diet or physical activity◦ Identify targets for control◦ Stopping smoking
![Page 38: Management of diabetes](https://reader030.vdocuments.site/reader030/viewer/2022032620/55ce5405bb61eb29188b4735/html5/thumbnails/38.jpg)
THANK YOU!