Guidelines For Diabetes

Introduction
• 5.9% of Americans are diabetics
• Prevalence increases with age:
1.6% of individuals between age 20-39
20% 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
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
 Guidelines For Diabetes
Classification
• Type 2 DM:
- Formerly called NIDDM
- Strong genetic basis, monocygotic twins
approximately 90%.
- Insufficient insulin secretion and
Increased insulin resistance
- 92% have insulin resistance
 Guidelines For Diabetes
Diagnostic criteria
IMPAIRED FASTING
BLOOD SUGAR
• FBS 110 AND <126 on
DIABETES two occasions(noA1C hb)
• Presence of classic • 2h after 75 g >140 <200
symptoms and random or
postprandial  200 mg/dl. GESTATIONAL
• Fasting glucose  126 on DIABETES
more than one occasion • Fasting > 126 or
• Glucose  200 2hr after • Random > 200 or
after 75 g of oral glucose • Glucose challenge test:
load (n= <140) >130 1 hr after 50 g
• 75 g load test: >95 fasting,
>180 1 hr, >155 2 hrs.
 Guidelines For Diabetes
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.
Relationship Between Obesity
and
Insulin Resistance and
Dyslipidemia
 Guidelines For Diabetes
The Insulin Resistance Syndrome
• Synd. X., Dysmetabolic syndrome, Deadly
quartet.
• Clustering of metabolic abnormalities that
frequently occur together in patients who
are resistant to insulin.
• ICD9 code: 277.7
• Increased risk of develop. DM and
Cardiovascular disease.
 Guidelines For Diabetes
The Insulin Resistance Syndrome
Having 3 or more R. F.
RISK FACTOR DEFINING LEVEL
Abdominal obesity Waist Circumference
Men------------------------------ >102 cm (>40 in)
Women-------------------------- >88 cm (35 in)
Triglycerides------------------- >150 mg/dL
HDL
Men------------------------------ < 40 mg/dL
Women-------------------------- <50 mg/dL
Blood Pressure---------------- >130/85 mmHg
Fasting Glucose--------------- >110 mg/dL(110-125)
>140 ,<199 after 75g
Insulin Resistance: Associated
Conditions
 Guidelines For Diabetes
Treatment/ Goals
(As per ADA guidelines)

• The target HbA1C level is 7%. Check Q 3

months.
• FBS: 80-120.
• BS 2 hr postprandial or at bedtime: 100-140
 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 recurrent
vaginitis/balanitis.
• Decrease risk of development or progression of
retinopathy and other macro and microvascular
complications. ----Gastro paresis---
• Promote general well being.
 Guidelines For Diabetes
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
 Guidelines For Diabetes
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.
 Guidelines For Diabetes
Treatment/ Exercise
Benefits of regular aerobic
exercise:
-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 risk: BP, LDL,
HDL, triglycerides, blood glucose, improves
collateral flow in patient with ischemic arterial
disease,  max. O2 uptake.
 Guidelines For Diabetes
Treatment/ Exercise
Medical 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 <100= dehydration and hypoglycemia
- Type 1: may require to dec. dosage of reg. Insulin on the day of
exercise.
 2002 ADA Risk Stratification
Based on Lipoprotein Levels* in
Adults With Diabetes
The 4S Diabetes Substudy
 NCEP: Treatment
Recommendations for High TG
Levels
Veterans Affairs Cooperative
Studies Program HDL-C
Intervention Trial (VA-HIT)
Recommended Treatment Goals
for
Hypertension for Adults With
Diabetes
 UKPDS: Risk Reduction in
Diabetes-Related Complications
With Decrease in SBP
Hypertension Optimal Treatment
(HOT): Outcomes in Patients
With Diabetes
 Guidelines For Diabetes
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.
 Guidelines For Diabetes
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 1st 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.
 Guidelines For Diabetes
Treatment/ Type 2 DM
Oral Hypoglycemic Agents
• Diet and exercise alone:
-consider for stable patient with a mild increase of Blood
sugar. (fbs <200 or A1CHb <8%).
-Can give 3 moths trial and reassess A1CHB
• Consider Insulin as initial therapy in patients presenting
with rapid weight loss, dehydration, ketoacidosis, extreme
hyperglycemia. Then, make changes based on individual
clinical situation.
• Each patient is a different clinical scenario and the
medications chosen should fit the clinical profile of the
patient.
• Consider general efficacy lowering blood sugar, safety,
side effects, easy compliance and price of medications.
 Guidelines For Diabetes
Treatment/ Type 2 DM
Oral Hypoglycemic Agents
• Always start with one medication(the best for the patient’s
clinical profile) and optimize it up to the highest dosage
before introducing a second line medication.
• Stepwise treatment, adjusting medications usually after one
month of treatment, But can adjust insulin in a weekly
bases and sulfunylureas every 2 weeks at the beginning.
Don’t overdo…hypoglycemia is worse.
• Don’t make many changes in therapy at the same time in
order to asses the efficacy of each change.
• Before adjusting medications go back to diet compliance.
 Guidelines For Diabetes
Treatment/ Type 2 DM
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 LFT’S,
nausea, vomiting, skin rashes, leucopenia,thrombocytopenia,
cholestasis.
-D/C when creatinine >1.5 or 2 fold of LFT’S
-Not good for patients with night time hypoglycemia
and elderly(use glipizide).
• Combinations: O.k. with metformin, thiazolidinediones,
not recommended with insulin.
 Guidelines For Diabetes
Treatment/ Type 2 DM
Metformin(biguanide)
• Mech. Of Action:Decreases hepatic glucose production
and in a minor way also increases glucose utilization. May
increase insulin action by inc. glucose uptake in muscle
and 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.
 Guidelines For Diabetes
Treatment/ Type 2 DM
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 LFT’S
 Guidelines For Diabetes
Treatment/ Type 2 DM
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 with
insulin, sulfonylureas and glucophage.
-No risk of hypoglycemia alone
-Can use with renal insufficiency.
-dec. triglycerides, inc HDL, may help LDL too.
 Guidelines For Diabetes
Treatment/ Type 2 DM
Thiazolidinediones
• Side effects:
hepatotoxcity,CHF,edema(fluid
retention),dilutional anemia
• Monitor LFT’S q 2 months for the first
year, then periodically. Stop if >2.5 times
normal.
• Consider cost.
 Guidelines For Diabetes
Treatment/ Type 2 DM
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 high
fbs.
• 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 follow
accuchecks 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.
 Guidelines For Diabetes
Treatment/ Type 2 DM
Acarbose
• Mech of A:Inhibits the enzymes that breakdown
the 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 LFT’S
 Guidelines For Diabetes
Treatment/ Type 2 DM
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 renal
insufficiency.
• Not effective for fasting hyperglycemias(short
acting)
• Side effects: GI.
• Increased cost.
 Guidelines For Diabetes
Treatment/ IGT-Metabolic synd.

• Diet and Exercise.

• Strict control of hypertension and correction
of hyperlypidemia has shown to reduce
cardiovascular disease on this patients.
• If persistent insulin resistance can use
metformin or TZDs. May prevent onset of
diabetes(TRIPOD STUDY)
 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.
ADA Recommendations for
Aspirin Use
in People With Diabetes
 Guidelines For Diabetes
Clinical Case
• 38 y/o male with 10 year history of type 2
diabetes on maximal dosages of Metformin
and sulfonylurea. Patient’s A1CHB: 9%
 Guidelines For Diabetes
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.
 Guidelines For Diabetes
Clinical Case
• One month after increasing glipizide to
20mg/d fbs 160 and A1CHB 8.2%.
• After 5 mg of vasotec BP 120/80 and
negative for microalb.
 hGuidelines For Diabetes
Clinical Case
• Start on glucophage vrs actos/avandia
 Guidelines For Diabetes
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:288
HDL:41
Trigl:200
LDL: 160