10/3/18

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

DE LA SALLE UNIVERSITY MEDICAL CENTER
DE LA SALLE HEALTH SCIENCES INSTITUTE Objectives

§ To re-define Diabetes Mellitus (DM)

PHILIPPINE PRACTICE GUIDELINES
ON THE DIAGNOSIS AND MANAGEMENT OF § To be familiar with various guidelines commonly referenced
for DM
DIABETES MELLITUS
§ To classify, screen, and diagnose DM through UNITE
recommendations
(UNITE FOR DIABETES PHILIPPINES) § To be familiar with approach to Treatment for DM
Presented by:
Rei Fabbie Sierra, MD
3rd Year Resident, DFCM

Diabetes mellitus (DM) Guidelines

§ A group of common metabolic disorders sharing the § UNITE FOR Diabetes Philippines
phenotype of hyperglycemia § American Diabetes Association (ADA) 2017 Standards of Care
§ Hyperglycemia contributing factors: for Diabetes
ú Reduced insulin secretion § American Association of Clinical Endocrinologist (AACE)
ú Decreased glucose utilization Guidelines, 2017
ú Increased glucose production
§ Metabolic dysregulation associated with DM causes
secondary pathophysiologic changes in multiple organ
systems

CLASSIFICATION OF DIABETES

§ 4 MAJOR CLINICAL TYPES ACCORDING TO ETIOLOGY:

ú Type 1 DM
ú Type 2 DM
ú Gestational DM
ú Secondary Diabetes

CLASSIFICATION

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CLASSIFICATION OF DIABETES CLASSIFICATION OF DIABETES

§ TYPE 1 DIABETES MELLITUS § TYPE 2 DIABETES MELLITUS

ú Formerly known as IDDM or Juvenile diabetes mellitus ú Formerly NIDDM or adult onset DM

ú Results from a progressive insulin secretory defect on the

ú Results from auto-immune beta-cell destruction, leading to
background of insulin resistance
absolute insulin deficiency

ú Typically but not exclusively in children

§ GESTATIONAL DIABETES MELLITUS (GDM)
ú diabetes first diagnosed during pregnancy that is not clearly overt
diabetes

CLASSIFICATION OF DIABETES

§ SECONDARY DIABETES
ú genetic defects in beta cell function or insulin action,
ú diabetes of the exocrine pancreas (pancreatitis, cystic fibrosis),
ú drug or chemical induced diabetes (such as from the treatment of
AIDS, after organ transplantation, glucocorticoids),
ú other endocrine diseases (Cushing’s syndrome, hyperthyroidism)

SCREENING WHO SHOULD UNDERGO LABORATORY

TESTING FOR DIABETES/PREDIABETES?

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Demographic and clinical risk factors Demographic and clinical risk factors
for DM type 2 for dm type 2
Laboratory testing is recommended for individuals with any of the ú First degree relative with Type 2 diabetes
risk factors for Type 2 DM: ú Sedentary lifestyle
§ Testing should be considered in all adults > 40 years old ú Hypertension (BP > 140/90 mm Hg)
ú Diagnosis or history of any vascular diseases including stroke,
§ Consider earlier testing if with at least one other risk factor as peripheral arterial occlusive disease, coronary artery disease
follows: ú Acanthosis nigricans
ú Schizophrenia
ú *History of IGT or IFG ú Serum HDL < 35 mg/dL (0.9 mmol/L) and/or
ú *History of GDM or delivery of a baby weighing 8 lbs or above ú Serum Triglycerides > 250 mg/dL (2.82 mmol/L)
ú *Polycystic ovary syndrome (PCOS)
ú Overweight: BMI of > 23 kg/m2 or Obese: BMI of > 25 kg/m2 ,or
ú Waist circumference > 80 cm (females) and > 90 cm (males), or Waist-hip
ratio (WHR) of > 1 for males and > 0.85 for females *correlated strongly with DM occurrence

*correlated strongly with DM occurrence

DIAGNOSIS DIAGNOSIS OF PRE-DIABETES

Criteria for PRE- DIABETES

§ Impaired Fasting Glucose

ú FBS of 5.6 - 6.9 mmol/L (100-125 mg/dL)
ú HbA1C =5.7% to 6.4%
§ Impaired Glucose Tolerance:
ú RBS > 7.7 - 11.0mmol/L (140-199 mg/dL)
OR DIAGNOSIS OF DIABETES
ú 75g OGTT > 7.7 - 11.0 mmol/L (199 mg/dL)

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Case WHAT TESTS AND CRITERIA SHOULD BE USED

§ Junior Intern AB, 27 year old consulted due to
dizziness & difficulty sleeping. She claims that
she eat a lot, and visits the CR very often. Also is
experiencing weight loss for the past months
since she started internship.
§ Past Medical History: unremarkable
§ Family Medical History: (+) DM: Father
§ Menstrual history: (+) irregular menses
§ BMI: 29
§ PE: (+) darkening of nape area
TO DIAGNOSE DIABETES?
§ Among ASYMPTOMATIC individuals with positive results, any of
the three tests should be REPEATED within two weeks for
confirmation
§ FBS has a sensitivity ranging from 45 to 60% and a specificity of >
90%
§ Subjects with borderline fasting glucose need a confirmatory 75-
gram oral glucose tolerance test since the OGTT 2-hour post load
value would lead to greater detection of patients with diabetes at
a sensitivity of 90 to 93% and specificity of 100%

EVALUATION

§ Medical History
§ Physical Exam

EVALUATION

Medical History Medical History

§ Symptoms of Hyperglycemia § Family history of DM and its complications

ú Polyuria, polydipsia, polyphagia, weight loss § Exercise
ú Fatigue, weakness, blurring, § Smoking
ú Frequent superficial infections and slow-healing skin lesions
§ Presence of DM-related comorbidities (cardiovascular
diseases, hypertension, dyslipidemia)

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Medical History Physical Exam

§ For Previously diagnosed DM patients § Height and Weight, BMI

ú Type of therapy (Oral, Insulin therapy, or both) § Blood pressure, Heart rate, Respiratory rate, Temp. (Vital
ú Prior HbA1c levels signs)
ú Self-monitoring blood glucose results (CBG monitoring)
§ Fundoscopic examination
ú Frequency of hypoglycemia
§ Oral examination
ú Complications (CKD, Neuropathy, Retinopathy)
§ Thyroid palpation
ú Patient’s knowledge about diabetes
ú Exercise
ú Nutrition

Physical Exam CASE

§ Evaluation of pulses by palpation and with auscultation § P.A. is a 52-year old hypertensive woman who presented with a 2-
week history of polyuria, polydipsia, polyphagia, weight loss,
§ Hand/finger examination
fatigue, and blurred vision.
§ Foot examination § The patient denied any symptoms of numbness, tingling in hands
§ Skin examination (Acanthosis Nigricans and Insulin-injection or feet, dysuria, chest pain, cough or fevers.
sites) § He had no prior history of diabetes and no family history of
§ Neurological examination diabetes.
§ Pertinent PE: Acanthosis nigricans on the nape area, BP ranges
110-150/80-90 mmHg
§ WHAT TEST DO YOU RECOMMEND?

PA, ordered for the following

laboratory tests:
1. FBS: 6.1 3. RBS: 352 mg/dL
mmol/L

2. Hba1c: 5.9 4. 2hr PPG: 9

mmol/L

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MANAGEMENT

COMPREHENSIVE DIABETES CARE

FACTORS TO CONSIDER IN THE CHOICE OF
MANAGEMENT
OF ORAL HYPOGLYCEMIC AGENTS (OHA)
TYPE 2 DM § Patient § Drugs
ú Age ú Efficacy
TREAT
SCREEN / MANAGE
ú Weight ú Site of action
GLYCEMIC ASSOCIATED
CONTROL CONDITIONS COMPLICATIONS ú Severity of hyperglycemia ú Timing of Blood glucose
- Dyslipidemia - Retinopathy
- Diet/lifestyle
ú (+) Renal Disease lowering effect
- Hypertension - Cardiovascular
- Exercise
- Obesity
disease
ú (+) Liver Disease ú Adverse effects
- Medication
- Nephropathy
- Coronary heart
disease - Neuropathy
- Other complications

Medications Medications

Class Compound MOA Advantage Disadvantage Class Compound MOA Advantage Disadvantage

Biguanides Metformin Dec. hepatic 1st line GI side effects Sulfonylureas Gliclazide Inc. insulin Dec. Hypoglycemia
glucose Glimeperide secretion microvascular
production Cheap Vit. B12 risk Weight gain
deficiency
No Cheap
hypoglycemia Contraindicati
on: CKD
Dec. CVD
events

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Medications Medications

Class Compound MOA Advantage Disadvantage Class Compound MOA Advantage Disadvantage

Sulfonylureas Gliclazide Inc. insulin Dec. Hypoglycemia DPP4 Sitagliptin Inc. insulin No Dermatitis
Glimeperide secretion microvascular inhibitors Linagliptin secretion hypoglycemia
risk Weight gain Saxagliptin ? CVD risk
Vildaglitin Dec. glucagon
Cheap secretion ?Acute
Pancreatitis

Medications Medications

Class Compound MOA Advantage Disadvantage Class Compound MOA Advantage Disadvantage

Insulin Basal Insulin: Dec. hepatic Universal Hypoglycemia SGLT 2 Canagliflozin Blocks glucose No GU infection
Glargine glucose response inhibitors Dapagliflozin reabsorption hypoglycemia
production Weight gain Empagliflozin at proximal Polyuria
Intermediate: Unlimited tubule Weight loss
Human NPH Inc. glycolysis efficacy Training ?DKA
requirement Inc. glucosuria Dec.
Short acting: Dec. postprandial Expensive
Human Rapid microvascular Patient excursion
risk hesitance
Premix: 70/30
Injectable

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SAFETY OF OHA

§ Consider safety profile of drug

ú Contraindications
ú Side-effects
ú Drug precautions

EFFICACY OF OHA
• Choose an agent that can attain the desired level of blood glucose when
used as monotherapy.

• Choose an agent that has beneficial effects on other metabolic

parameters (weight, lipids)

STRATEGY OF EARLY COMBINATION

THERAPY WITH ORAL AGENTS INDICATIONS FOR INSULIN
§ To maximize efficacy § Pregnancy
§ To minimize the side effects (e.g. weight gain, GI discomfort, hypoglycemia) § Surgery
§ Ability to address both FBG and PPB § Allergy to OHA
§ Preserve B-cell function § Diabetic ketoacidosis (DKA)
§ Ability to address the other risk factors other than hyperglycemia § Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
§ Non-response to OHA

MEDICAL NUTRITION THERAPY MEDICAL NUTRITION THERAPY

§ People with diabetes should receive individualized MNT as needed to achieve
treatment goals
§ Amount (grams) of carbohydrate as well as the type of carbohydrate in a food
influence blood glucose level
§ Low carbohydrate diets (restricting total carbohydrate to <130 g/day) are not
recommended in the management of diabetes.
§ The primary approach for achieving weight loss is therapeutic lifestyle
change, which includes a reduction in energy intake and/or an increase in
physical activity.
§ Initial physical activity recommendations should be modest, based on the
patient’s willingness and ability, gradually increasing the duration and
frequency to 30–45 min of moderate aerobic activity 3–5 days per week, when
possible

§ Weight loss is recommended for all overweight or obese adults, who have, or
who are at risk for developing, type 2 diabetes

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FOLLOW-UP
GLYCEMIC CONTROL
A1C <6.5%*
Preprandial capillary plasma glucose 90–130 mg/dl (5.0–7.2 mmol/l)

Peak postprandial capillary plasma <180 mg/dl (<10.0 mmol/l)

glucose
Blood pressure
<130/80 mmHg

• *Young patients typically less than 60 yo.

CASE
§ P.A. is a 52-year old hypertensive man who presented with a
2-week history of polyuria, polydipsia, polyphagia, weight § A random glucose test performed 1 day before consult was
loss, fatigue, and blurred vision. 352 mg/dl.
§ The patient denied any symptoms of numbness, tingling in
hands or feet, dysuria, chest pain, cough or fevers.
§ He had no prior history of diabetes and no family history of
diabetes. What medication would u give?
§ Pertinent PE: Acanthosis nigricans on the nape area, BP
ranges 110-150/80-90 mmHg

summary summary

§ DM is a metabolic disorder § Investigate for family history of DM

§ There is NO “cure” § Screening/Diagnostic tests:
§ Lifestyle disease ú FBS

§ Screening should be done for early prevention ú RBS + symptoms

ú 40 yo and above ú 75g OGTT

ú Symptoms pertaining to DM (polyuria, polydipsia, weight loss)

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summary summary

§ HbA1c is NOT yet recommended for Philippine setting
§ Equivocal result maybe confirmed by re-testing after 2 weeks
§ Classify DM type for appropriate management
§ 1st line monotherapy is metformin
§ Watch Out For (WOF) adverse effects
§ Combination to insulin therapy maybe used for uncontrolled
sugar within 3 months of treatment
§ Individualize treatment based on patient profile, drug safety
and efficacy
§ Follow up 3-6 months depending on sugar control
§ Medical Nutritional Therapy and Education is as important as
medical management or even greater

Thank you for your

attention!!

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