overview of therapeutic options in diabetes mellitus
TRANSCRIPT
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DIABETES MELLITUS
Danish Mahmud; 24/07/2015
Some Aspects of treatment
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Diagnostic Criteria
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Type 1 vs Type 2 vs LADA
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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
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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
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Therapeutic Options
Metformin Sulfonylueas Thiazolidinediones (glitazones) Acarbose DPP 4 Inhibitors GLP 1 Agonists SGLT2 inhibitors Insulin
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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
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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
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Thiazolidinediones (glitazones)
Pioglitazone Decrease Insulin resistance Weight gain; fluid retention Heart failure worsening Macular edema Bladder cancer Increased fracture risk (postmenopausal
women)
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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)
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GLP-1 Agonists
Exenetide; Liraglutide More potent and efficacious SC injection Decreased appetite Pancreatitis
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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)
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Acarbose
Alpha glucosidase inhibitor Not used frequently Causes bloating and flatulence Not tolerated well
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Insulin
Sir Fredrick Banting- Nobel Prize 1923
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Insulin
Geyelin et al 1922
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Insulin types
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Triple Combinations
All Oral Metformin + Sulphonylurea + Thiozolidinedione Metformin + Sulphonylurea + Acarbose Metformin + Sulphonylurea + DPP4 inhibitor Metformin + Sulphonyurea + SGLT2 inhibitor
With Injections Metformin + Sulphonylurea + Exenetide
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CSII
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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
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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
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An overview of Insulin pump therapy: Medicine Today December 2010
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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
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Inpatient Management
Causes of Hypoglycemia:
Decreased oral intake Decreased renal clearance Sepsis / liver dysfunction Inadequate treatment strategy
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Inpatient Management
Issues: Metformin
Renal failure Lactic acidosis
Sulphonylureas Hypoglycemia
GLP1 agonists and DPP4 Inhibitors Hypoglycemia
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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
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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!
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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