Management of a New Diabetes Patient
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The document discusses the management of newly detected diabetes, emphasizing the importance of diagnosis, diet, exercise, and treatment with insulin and oral hypoglycemic agents. It outlines the types of diabetes, symptoms, diagnosis criteria, complications, and monitoring of glycemic control. Additionally, it covers dietary recommendations and the role of medication, including newer classes like DPP-4 inhibitors, for maintaining optimal blood sugar levels.
Management of a New Diabetes Patient
- 1. Dr. S. Aswini Kumar. MDProfessor of MedicineMedical College HospitalThiruvananthapuram1Management of NewlyDetected Diabetes
- 2. Learning Objectives ImportanceDiagnosisDietExerciseOHAsInsulinWhat is newSummarize2
- 3. importance3
- 4. Diabetes MellitusPancreatic insulin deficiency statePoor cells of the body crying for more insulin4
- 5. The Role of InsulinInsulin is the key that opens the door of the cellWithout insulin glucose can not enter the cells5
- 7. Type 2 DiabetesIt’s a Nightmare! Chronic Kidney DiseasePeripheral Occlusive Vascular DiseaseAutonomicNeuropathy StrokeSuddenBlindnessHeart AttackPeripheral Neuropathy 7Aswini Kumar. MD7Microvascular and Macrovascular Complications of Diabetes
- 8. Why control diabetes?Tight control of DM and maintaining blood sugar values within normal range has proved to prevent long term micro-vascular and macro-vascular complications of diabetes8
- 9. Symptoms of diabetesPolyuriaPolydypsiaPolyphagiaWeight loss in spite of adequate foodTingling and numbness in extremitiesGeneralized pruritusPruritus vulva, BalanoposthitisImpotency, loss of libido Premature cataract9
- 10. Diagnosis of DiabetesMUST be based on blood glucose estimationNOT urine glucose testingFasting venous glucose > 126mg% (Normal 70-110)2Hr PP venous glucose > 200mg% (Normal 110-140)RBS value not diagnosticTo be confirmed on repeat testing with FBS PPBSIn presence of symptoms of DM - diagnosticGTT is not needed in a confirmed diabetic10
- 11. Monitoring Glycemic ControlUrine sugar testingWidely used. Depends on renal thresholdOf value if threshold is normal & stableWhat if the urine sugar is absent?What if the urine sugar is high?Blood sugar estimation:Gives prevailing blood glucoseDoes not assess the overall controlPeriodic check up necessary- monthlyDiet and medicines should be continued on the day11
- 12. Self Monitoring of Blood GlucoseSMBG using test stripsAcucheckActivaUse within a monthCosts 30 rupees per stripAccuracy questionIndications:Wide fluctuationsProneness for ketosisNeed for tight control - pregnancyAcute illness: peri-operative period12
- 13. Hb A1cExcellent test to judge overall glycemic controlGives idea of average blood sugar Over a period of previous 120 daysBecause RBC Life Span is 121 daysIdeally done every 3-4 monthsNormal < 6.5 Good <7.0 Fair <8.0 Poor<9.0 Bad >10Disadvantages:Costly – Rs. 250 per test Falsely high values – Renal failureFalsely low values – RBC life span13
- 14. What are the goals?ADA and ACE/ AACE differ from each otherADA GoalsFBS - 70-130 PPBS - <180HbA1c - <7.0ACE/AACE GoalsFBS - <110PPBS - <140HbA1c - ≤6.514
- 15. diet15
- 16. Medical Nutrition Therapy Dietprescription Main stay of treatmentShall be individualized, realistic flexible & suitable to patients life style preferably Indian dietPatient educatedand at regular intervals compliance judged16
- 17. Weight Management17Record height - Record weight - Calculate BMI
- 18. Read against ready made charts – To get BMI
- 20. Above 25 – Overweight
- 21. Above 30 – Obese.
- 22. Diet ControlPrinciple less food – Better insulin actionNo sugars sweets tubers Otherwise eat normal food18
- 23. Which Food To Avoid19
- 24. Avoid all fried foods20
- 25. What for Breakfast?2 idli or 2 Dosa or ½ Puttu No Appam or Poori masalaWestern Style Breakfast Tea, Milk and Eggs21
- 26. What is for lunch?Ordinary Indian meals It is the ideal choiceFish 2-3 pieces everyday Chicken once a week22
- 27. Which Fruit To Eat?23
- 28. What for Evening and Dinner?3 Arrow root biscuits Tea with out sugarGreen Salad 2 Chappathi + Veg Kuruma24
- 29. exercise25
- 30. 26
- 31. 27
- 32. 28
- 34. ExerciseRegular ExerciseDaily at least 5 days/wk Isotonic Exercise - YesIsometric - No30
- 35. What prevents one from WalkingTraffic, heavy rain or dogs on the streetChoose Vellayambalam Museum or Gandhi Park31
- 36. PrecautionsCorrect foot wearComfortable loose clothesClose inspection of feet every dayCarry snacks as protection from hypoglycemiaHow it should be:Patient should be able to carry out a normal conversation while exercising without getting breathless32
- 38. DruG treatment34
- 39. 35Causes of Hyperglycemia in DM1 Intestine: glucose absorption2 Muscle and adipose tissue:decreased glucose uptake5 Insulin resistanceBlood glucose4 Liver: increased hepaticglucose output5 Insulinresistance3 Pancreas: impaired insulin secretion
- 40. BiguanidesMode Of Action:Decreases hepatic glucose productionIncreases peripheral glucose uptakeIncreases insulin sensitivityNo effect on insulin releaseDoes not cause hypoglycemiaFirst line choice in DM2 – Ideal in over weightMetformin 250 to 1500mg Phenformin no longer used36
- 41. SulphonylureasStimulates Pancreatic B cells to produce MORESecond line choice after Metformin First line in lean diabeticsMost effective in Type 2 DM of recent onsetGlibenglamide 2.5 to 10mgGlipizide2.5 to 10mgGlipride 1 to 4mg Glyclazide 40 to160mg37
- 42. ThiazolidinedionesAdd on druguseful for reducing PPBSReduce insulin resistance by binding to PPAR receptorFacilitates insulin’s effect on GLUT-4Promote adipocyte differentiationEnhance fatty acid storagePioglitazone 15-30mg OD Rosiglitazone 2-4mg ODModest weight gain Fluid retention, edema SGPT screening is advisable38
- 43. Glucosidase InhibitorsFor Big Eaters who can’t stop eatingMOA: inhibition of pancreatic alpha amylase in the gut lumen which hydrolyses complex starches to oligosaccharides.Delay absorption, when taken with meals Thus reduces PPBSDo not influence insulin secretionDo not affect glucose utilizationAcarbose 25-50mg BID Voglibose 0.2 -0.3mg BID39
- 44. Role of Incretins in Glucose HomoeostasisBlood glucose in fasting and postprandial statesGlucose production by liverIngestion of foodGlucose-dependent Insulin from β cells(GLP-1 and GIP)Glucose uptake by musclesRelease of gut hormones — incretins*PancreasGI tractβ cellsα cellsActiveGLP-1 & GIPGlucose dependent Glucagon fromα cells(GLP-1)DPP-4 enzymeInactiveGIPInactiveGLP-1*Incretins are also released throughout the day at basal levels.40
- 45. DPP-4 InhibitorsNew class of oral agentsIncrease endogenous GLP-1 activityPromote insulin secretionPreferential effect on PPBSFDA approved first moleculeSitagliptin – For use with diet and exerciseOr with metformin or thiozolidinediones41
- 46. Sitagliptin in clinical practiceDose: 100mg orally once dailyReduced doseCreatinine clearance 30-50ml/min – 50mg/dayCreatinine clearance <30ml/min – 25mg /dayRFT done initially and repeated there after42
- 48. 44
- 49. 45Intensifying of Oral Therapiesmetformin &/or glitazonesulfonylurea/repaglinide+&/or glucosidase inhsulfonylurea/repaglinide+and/or glucosidase inhibitorsmetformin and/or glitazoneFPG < 120 mg/dl A1C < 6.5%FPG > 120 mg/dl A1C >6.5%ContinueAdd Insulin
- 50. Insulin46
- 51. 47
- 52. 48
- 53. 49Insulin secretionYears from diagnosis010515-10-5OnsetDiagnosisInsulin resistancePostprandial glucoseFasting glucoseMicrovascular complicationsMacrovascular complicationsPre-diabetesType 2 diabetes
- 54. 50
- 55. 51Hyperglycaemia(glucose toxicity)Insulin resistanceb-cell(genetic background)“lipotoxicity”elevated FFA,TGProteinglycationAmyloiddeposition
- 56. 52
- 57. 53
- 59. 55Short acting Insulin Lispro and aspartLong acting Insulin Glargine and DetemirFull biological activityLess tendency for self aggregation
- 60. 56
- 61. 57Peak Time = 40-50 minPeak Time = 80-120 min InsulinAspart orLisproSubcutaneous TissueCapillaryMembraneRegularHuman Insulin
- 62. C14 fatty acid chain (Myristicacid)PheGlyPheArgGluTyrThrGlyProCysLysValThrLysCysAsnA21B29LeuTyrGlyA1AsnTyrIleGluLeuValLeuAlaGluGluGlnGlnTyrValCysLeuLeuCysSerSerThrCysIleHisSerGlyCysLeuGlnHisAsnValPheB158
- 63. 59
- 64. 60
- 65. Guidelines61
- 66. 62MetforminSulfonylureasTZDs Other oral agents InsulinLifestyle only60%45%15%6%12%15%Patients currently taking medication (%)
- 67. 63A1C < 9%A1C ≥ 9%Initiate insulin2 oral agents1 oral agentIf not at targetIf not at targetIf not at target Add an oral agent ORInitiate insulin alone or in combination with an oral agent Intensify insulin ORadd an oral agentAdd insulin ORan oral agentTimely adjustments of chosen therapy shall made to attain target A1C within 6 to 12 months.Adapted from the CDA 2003 Clinical Practice Guidelines.
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- 69. What is new65
- 70. 66
- 71. 6775Basal exogenous insulin is essential for regulating glycogen breakdown, gluconeogenesis lipolysis and ketogenesisFor normal glucose utilization and storageBreakfastLunchDinner50Plasma insulin (µU/ml) 254:008:0012:0016:0020:00 24:004:00Time
- 72. 68Impressive benefitsBreakfastLunchDinnerAspart Aspart AspartorororPersonal financial costLispro Lispro LisproPlasma insulinDetemir or Glargine4:0016:0020:00 24:004:0012:008:008:00Time
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- 78. Thank You For The Patient Listening74