![• Less stringent A1C goals (such as ,8% [64 mmol/mol]) may be
appropriate for patients with a history of severe hypoglycemia,
limited life expectancy, advanced microvascular or macrovascular
complications, extensive comorbid conditions, or long-standing diabetes
in whom the goal is difficult to achieve despite diabetes self management
education, appropriate glucose monitoring, and effective doses of multiple
glucose lowering agents including insulin
• . Reassess glycemic targets over time based on the criteria](https://image.slidesharecdn.com/newerohasada2020guidelinesfordiabetescare-200911060655/85/NEWER-OHAs-ADA-2020-GUIDELINES-FOR-DIABETES-CARE-58-320.jpg)
NEWER OHAs & ADA 2020 GUIDELINES FOR DIABETES CARE
- 1. AZEEZIA MEDICAL COLLEGE DEPARTMENT OF GENERAL MEDICINE
- 2. NEWER OHAs & ADA 2020 GUIDELINES FOR DIABETES CARE Dr Mohammed Iqbal Junior resident Department of general medicine Azeezia medical college
- 3. India Diabetic Capital of the World
- 4. Magnitude of problem of DM • Major health problem • >10% of adult population affected • On the increase due to unhealthy life-style • About 50% may remain undiagnosed • Majority remain uncontrolled • Morbidity and mortality high
- 5. Continued…. • 40 million diabetes world wide • 6.3 million in india • 4.6 million deaths due to DM per year • Every 8 sec 2 people develop diabetes and 1 die due to diabetes
- 6. Definition of DM Non communicable metabolic disease characterised by hyperglycemia resulting from defect in insulin action, insulin secretion or both This may lead to abnormalities of carbohydrate, protein and fat metabolism with significant disturbance in water and electrolyte homeostasis
- 7. Continued…. The chronic hyperglycemia of DM is associated with long term damage, dysfunction and failure of various organs, especially the eyes,kidneys,nerves,heart and blood vessels.
- 8. Management of DM • Establishing the diagnosis of diabetes • Initial evaluation • Therapeutic measures • Follow-up and monitoring
- 9. Euglycemia • FPG <100 mg (<110 WHO) • 2 hr PPG <140 mg • 2 hr OGTT <140 mg • A1C <5.7 %
- 10. Diagnosis of DM
- 11. DIAGNOSTIC CRITERIA 1. Symptoms of DM + casual plasma glucose > 200mg % OR 2. FPG ( fasting plasma glucose ) > 126mg% ( fasting –no calorie intake for at least 8 hours) OR 3. Two hrs post glucose during OGTT (WHO) > 200mg/dl OR 4. HbA1C > 6.5 %
- 13. Oral Agents- General Principles • Most agents produce > 75% effect with 50% of maximum dose • Small dose of 2 agents- better effect than maximum dose of single agent • Combination of 2 agents with different mode of action may be considered early • Side effects dose related
- 14. AGENTS AVAILABLE • Insulin secretagogues • Sulphonylureas • meglitinides- Natiglinide and Repaglinide • Insulin sensitizers • Biguanides – Metformin • Thiazolidinediones (Glitazones)
- 15. Oral agents contd.. • glucosidase Inhibitors – Acarbose & Voglibose • DPP4 inhibitors (incretin modifiers ) • gliptins
- 16. Sulphonylureas Mode of Action • close K.ATP channels in β cell plasma membrane • Mainly Pancreatic : insulin secretion • Defect in early post prandial secretion not corrected • Work only with pancreatic insulin reserve
- 17. SU. INDICATIONS Non obese Type 2 Diabetes Mellitus • Can be combined with Metformin / Glitazones / Insulin • Give before food • Effective in obese also – but weight
- 18. SU • Potency next only to insulin • Protein bound- not removed by dialysis • Avoid glibenclamide in RF(GFR- <50ml) • May be avoided in elderly/old age
- 19. SU. Side effects + disadv. • Hypoglycemia – esp. Glibenclamide more in elderly & Renal Failure – avoid • Weight gain • ?blunts myocardial ischemic pre-conditioning
- 20. Non SU secretagogues- meglitinides REPAGLINIDE + NATEGLINIDE • Stimulate early meal media. insulin secretion • post prandial glucose • Duration of action –short • Hypoglycemia + weight gain less than SU • Needs frequent doses
- 22. Advantages of sensitizers • No Hypoglycemia – even with combination • IR – improved • Reduction in macro vascular complications.
- 23. METFORMIN • insulin activity at post receptor level in liver- decrease hepatic glucose output • appetite, helps weight reduction • Lipid favourable: TC, LDL ,TGL, HDL neutral • Reduce cardiovascular mortality
- 24. METFORMIN - INDICATIONS First line therapy in obese type 2 DM- especially overweight/obese Combination therapy - with SU glitazones incretin modifiers insulin
- 25. Metformin - advantages • Extensive experience of efficacy & safety • No weight gain ( weight neutral/decrease) • No hypoglycemia • Decrease CVD events
- 26. Metformin- side effects • GI upset- abd. Pain , vomiting , diarrhoea • Extreme tiredness- in some • Lactic acidosis- very rare(0.1/1000pt years) • Vit B12 malabsorbtion- in up to 30%
- 27. METFORMIN - CONTRAINDICATIONS • Hepatic/ renal/ respiratory failure • Acute cardiac failure (Stable CCF can be used) • Acute medical conditions like sepsis/AMI/stroke • Acute surgical (major surgery/trauma/burns) • Acute & C/c. metabolic acidosis • IV Radio contrast administration- stop before 48 hrs. Restart after 48 hrs.
- 28. Glitazones
- 29. Mode of Action • 70% more effective than Metformin • Primary site of action – Adipose tissue • Improve glycemic control • Preserve cell function • Activates nuclear transcription factor- PPAR γ
- 30. Glitazones and Lipids • HDL , TGL (pioglitazone) • Anti atherogenic effect • Rosiglitazone - banned • Pioglitazone – recently banned in india
- 31. Glitazones – Side Effects • Fluid Retention, Oedema • Precipitation of CHF • ? Bladder cancer with pioglitazone Monotherapy – No hypoglycemia
- 32. Glitazones - indications Type 2 DM – all stages 1. Monotherapy • Pioglitazone 7.5 to 30 mg daily 2. Combination with SU, Metformin
- 33. Glitazones - Cautions • Avoid glitazones in overt / occult CHF • Weight gain – be cautious • Obesity – do not combine Insulin & Glitazone
- 34. Incretin modifiers • Incretins- gut hormones Glucagon like peptide1 (GLP1) Glucose dependent insulinotropic peptide ( GIP) • Glucose dependent insulin secretion • Decreased glucagon secretion • Slows gastric emptying • Improve satiety
- 35. Incretins • In Type 2 DM- deficiency of GLP1- GLP1 inactivated by DPP-4 enzyme • GLP1 receptor agonist exenatide liraglutide • Expensive • Multiple injection needed- not commonly used
- 36. DPP-4 inhibitors- increase concn. Of GLP1 • Sitagliptin • Vidagliptin • Saxagliptin • Linagliptin • Teneligliptin
- 37. GLUCOSIDASE INHIBITORS • Acarbose and voglibose • Inhibit Glucosidase – an enzyme at brush border of small intestine breaking down oligosaccharides to monosaccharides • Slow intestinal digestion & absorbtion of CHO • Damp postprandial hyperglycemia • Due to CHO malabsorption – abdominal bloating, flatus, gassy diarrhea
- 38. SGLT 2 Inhibitors • Sodium glucose cotransport 2 inhibitor • Also called gliflozins • It inhibits reabsorption of glucose from the PCT • It promotes the excretion of glucose in the urine ( glucosuria) leads to UTI
- 42. • The American Diabetes Association/ European Association for the Study of Diabetes consensus report “Management of Hyperglycemia in Type 2 Diabetes, 2018” and the 2019 update recommend a patient- centered approach to choosing appropriate pharmacologic treatment of blood glucose. This includes consideration of efficacy and key patient factors: • 1) important comorbidities such as atherosclerotic cardiovascular disease (ASCVD) and indicators of high ASCVD risk, chronic kidney disease (CKD), and heart failure (HF)
- 43. • 2) hypoglycemia risk, • 3) effects on body weight, • 4) side effects, • 5) cost, and • 6) patient preferences.
- 46. • Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. • Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin. • Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure.
- 47. • The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% ) or blood glucose levels (>300 mg/dL) are very high. • A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include cardiovascular comorbidities, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences
- 48. • Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high risk, established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors.
- 49. • In patients with type 2 diabetes who need greater glucose lowering than can be obtained with oral agents, glucagon-like peptide 1 receptor agonists are preferred to insulin when possible. • Intensification of treatment for patients with type 2 diabetes not meeting treatment goals should not be delayed. • The medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6months) and adjusted as needed to incorporate specific factors that impact choice of treatment
- 50. HbA1C
- 51. A1C in the diagnosis of DM • Recommended by the international expert Committee * 2009 • ADA 2010 (non –pregnant adults) • DM > 6.5% (2 times ) • Performed by a method certified by the NGSP (national glycohemoglobin standardization program certified method)
- 52. Advantage of A1C over FPG,OGTT • Convenience –no fasting needed • Greater stability • Less variation due to acute illness /stress • Better index of overall glycaemic exposure and risk of long term complications
- 53. A1C - disadvantages • Higher cost • Non availability in many centers • Lack of properly standardized labs • Unreliable • Hemoglobinopathies • Change in red cell turn over –hemolytic anemia • Chronic malaria, major blood loss , blood transfusion • Rapidly developing type 1 DM
- 54. Sensitivity of FPG,HbA1c & 2 hr OGTT • 2 hour OGTT > FPG> A1C • A1c 30 % less early diabetes detected compared to FPG > 126 • 2 hr OGTT value detects max. numbers
- 55. Recommendations • Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). • Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. • Point-of-care testing for A1C provides the opportunity for more timely treatment changes.
- 57. A1C GOALS • An A1C goal for many nonpregnant adults of < 7% (53 mmol/mol) is appropriate. • On the basis of provider judgement and patient preference, achievement of lower A1C levels (such as ,6.5%) may be acceptable if this can be achieved safely without significant hypoglycemia or other adverse effects of treatment.
- 58. • Less stringent A1C goals (such as ,8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self management education, appropriate glucose monitoring, and effective doses of multiple glucose lowering agents including insulin • . Reassess glycemic targets over time based on the criteria
- 61. Thank you