Management of New Diabetic Patient

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Information about Management of New Diabetic Patient

Published on August 18, 2009

Author: draswinikumars


Slide 1: Dr. S. Aswini Kumar. MD Professor of Medicine Medical College Hospital Thiruvananthapuram 1 Management of Newly Detected Diabetes Learning Objectives : Learning Objectives Importance Diagnosis Diet Exercise OHAs Insulin What is new Summarize 2 importance : importance 3 Diabetes Mellitus : Diabetes Mellitus Pancreatic insulin deficiency state Poor cells of the body crying for more insulin 4 The Role of Insulin : The Role of Insulin Insulin is the key that opens the door of the cell Without insulin glucose can not enter the cells 5 Types of Diabetes : Types of Diabetes 6 <10% >90% IDDM NIDDM Slide 7: 7 Heart Attack Sudden Blindness Stroke Autonomic Neuropathy Chronic Kidney Disease Type 2 Diabetes Peripheral Neuropathy It’s a Nightmare! Aswini Kumar. MD Peripheral Occlusive Vascular Disease 7 Microvascular and Macrovascular Complications of Diabetes Why control diabetes? : 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 diabetes 8 Symptoms of diabetes : Symptoms of diabetes Polyuria Polydypsia Polyphagia Weight loss in spite of adequate food Tingling and numbness in extremities Generalized pruritus Pruritus vulva, Balanoposthitis Impotency, loss of libido Premature cataract 9 Diagnosis of Diabetes : Diagnosis of Diabetes MUST be based on blood glucose estimation NOT urine glucose testing Fasting venous glucose > 126mg% (Normal 70-110) 2Hr PP venous glucose > 200mg% (Normal 110-140) RBS value not diagnostic To be confirmed on repeat testing with FBS PPBS In presence of symptoms of DM - diagnostic GTT is not needed in a confirmed diabetic 10 Monitoring Glycemic Control : Monitoring Glycemic Control Urine sugar testing Widely used. Depends on renal threshold Of value if threshold is normal & stable What if the urine sugar is absent? What if the urine sugar is high? Blood sugar estimation: Gives prevailing blood glucose Does not assess the overall control Periodic check up necessary- monthly Diet and medicines should be continued on the day 11 Self Monitoring of Blood Glucose : Self Monitoring of Blood Glucose SMBG using test strips Acucheck Activa Use within a month Costs 30 rupees per strip Accuracy question Indications: Wide fluctuations Proneness for ketosis Need for tight control - pregnancy Acute illness: peri-operative period 12 Hb A1c : Hb A1c Excellent test to judge overall glycemic control Gives idea of average blood sugar Over a period of previous 120 days Because RBC Life Span is 121 days Ideally done every 3-4 months Normal < 6.5 Good <7.0 Fair <8.0 Poor<9.0 Bad >10 Disadvantages: Costly – Rs. 250 per test Falsely high values – Renal failure Falsely low values – RBC life span 13 What are the goals? : What are the goals? ADA and ACE/ AACE differ from each other ADA Goals FBS - 70-130 PPBS - <180 HbA1c - <7.0 ACE/AACE Goals FBS - <110 PPBS - <140 HbA1c - ≤6.5 14 diet : diet 15 Medical Nutrition Therapy : Medical Nutrition Therapy Diet prescription Main stay of treatment Shall be individualized, realistic flexible & suitable to patients life style preferably Indian diet Patient educated and at regular intervals compliance judged 16 Weight Management : Weight Management 17 . Record height - Record weight - Calculate BMI Read against ready made charts – To get BMI Healthy value 20-25 Above 25 – Overweight Above 30 – Obese Diet Control : Diet Control Principle less food – Better insulin action No sugars sweets tubers Otherwise eat normal food 18 Which Food To Avoid : Which Food To Avoid 19 Avoid all fried foods : Avoid all fried foods 20 What for Breakfast? : What for Breakfast? 2 idli or 2 Dosa or ½ Puttu No Appam or Poori masala Western Style Breakfast Tea, Milk and Eggs 21 What is for lunch? : What is for lunch? Ordinary Indian meals It is the ideal choice Fish 2-3 pieces everyday Chicken once a week 22 Which Fruit To Eat? : Which Fruit To Eat? 23 What for Evening and Dinner? : What for Evening and Dinner? 3 Arrow root biscuits Tea with out sugar Green Salad 2 Chappathi + Veg Kuruma 24 exercise : exercise 25 Slide 26: 26 Slide 27: 27 Slide 28: 28 Caloric equivalents: : Caloric equivalents: 29 Exercise : Exercise Regular Exercise Daily at least 5 days/wk Isotonic Exercise - Yes Isometric - No 30 What prevents one from Walking : What prevents one from Walking Traffic, heavy rain or dogs on the street Choose Vellayambalam Museum or Gandhi Park 31 Precautions : Precautions Correct foot wear Comfortable loose clothes Close inspection of feet every day Carry snacks as protection from hypoglycemia How it should be: Patient should be able to carry out a normal conversation while exercising without getting breathless 32 Physique Exercise Treadmill : Physique Exercise Treadmill 33 DruG treatment : DruG treatment 34 Causes of Hyperglycemia in DM : Causes of Hyperglycemia in DM 35 Blood glucose 5 Insulin resistance 1 Intestine: glucose absorption 2 Muscle and adipose tissue:decreased glucose uptake 4 Liver: increased hepaticglucose output 3 Pancreas: impaired insulin secretion 5 Insulinresistance Biguanides : Biguanides Mode Of Action: Decreases hepatic glucose production Increases peripheral glucose uptake Increases insulin sensitivity No effect on insulin release Does not cause hypoglycemia First line choice in DM2 – Ideal in over weight Metformin 250 to 1500mg Phenformin no longer used 36 Sulphonylureas : Sulphonylureas Stimulates Pancreatic B cells to produce MORE Second line choice after Metformin First line in lean diabetics Most effective in Type 2 DM of recent onset Glibenglamide 2.5 to 10mg Glipizide 2.5 to 10mg Glipride 1 to 4mg Glyclazide 40 to160mg 37 Thiazolidinediones : Thiazolidinediones Add on drug useful for reducing PPBS Reduce insulin resistance by binding to PPAR receptor Facilitates insulin’s effect on GLUT-4 Promote adipocyte differentiation Enhance fatty acid storage Pioglitazone 15-30mg OD Rosiglitazone 2-4mg OD Modest weight gain Fluid retention, edema SGPT screening is advisable 38  Glucosidase Inhibitors :  Glucosidase Inhibitors For Big Eaters who can’t stop eating MOA: inhibition of pancreatic alpha amylase in the gut lumen which hydrolyses complex starches to oligosaccharides. Delay absorption, when taken with meals Thus reduces PPBS Do not influence insulin secretion Do not affect glucose utilization Acarbose 25-50mg BID Voglibose 0.2 -0.3mg BID 39 Role of Incretins in Glucose Homoeostasis : Role of Incretins in Glucose Homoeostasis Ingestion of food β cells α cells Release of gut hormones — incretins* Pancreas Glucose-dependent  Insulin from β cells (GLP-1 and GIP) Glucose uptake by muscles Glucose dependent  Glucagon fromα cells (GLP-1) GI tract Active GLP-1 & GIP DPP-4 enzyme InactiveGIP InactiveGLP-1 *Incretins are also released throughout the day at basal levels. 40 DPP-4 Inhibitors : DPP-4 Inhibitors New class of oral agents Increase endogenous GLP-1 activity Promote insulin secretion Preferential effect on PPBS FDA approved first molecule Sitagliptin – For use with diet and exercise Or with metformin or thiozolidinediones 41 Sitagliptin in clinical practice : Sitagliptin in clinical practice Dose: 100mg orally once daily Reduced dose Creatinine clearance 30-50ml/min – 50mg/day Creatinine clearance <30ml/min – 25mg /day RFT done initially and repeated there after 42 Oral Hypoglycemic Agents : Oral Hypoglycemic Agents 43 Slide 44: 44 Slide 45: 45 Insulin : Insulin 46 Slide 47: 47 Slide 48: 48 Slide 49: 49 Type 2 diabetes Years from diagnosis 0 5 -10 -5 10 15 Pre-diabetes Onset Diagnosis Insulin resistance Postprandial glucose Macrovascular complications Fasting glucose Microvascular complications Slide 50: 50 Slide 51: 51 b-cell (genetic background) Hyperglycaemia (glucose toxicity) Protein glycation Amyloid deposition Insulin resistance “lipotoxicity” elevated FFA,TG Slide 52: 52 Slide 53: 53 Insulin analogues : Insulin analogues 54 Slide 55: 55 Full biological activity Less tendency for self aggregation Short acting Insulin Lispro and aspart Long acting Insulin Glargine and Detemir Slide 56: 56 Slide 57: 57 Insulin Aspart or Lispro RegularHuman Insulin CapillaryMembrane Subcutaneous Tissue Slide 58: 58 Slide 59: 59 Slide 60: 60 Guidelines : Guidelines 61 Slide 62: 62 Patients currently taking medication (%) 60% 45% 15% 6% 12% 15% Slide 63: 63 Adapted from the CDA 2003 Clinical Practice Guidelines. Timely adjustments of chosen therapy shall made to attain target A1C within 6 to 12 months. Add an oral agent OR Initiate insulin alone or in combination with an oral agent Add insulin OR an oral agent Intensify insulin OR add an oral agent 2 oral agents If not at target Initiate insulin If not at target 1 oral agent If not at target A1C < 9% A1C ≥ 9% Slide 64: 64 What is new : What is new 65 Slide 66: 66 Slide 67: 67 4:00 25 50 75 8:00 12:00 16:00 20:00 24:00 4:00 Breakfast Lunch Dinner Plasma insulin (µU/ml) Time Basal exogenous insulin is essential for regulating glycogen breakdown, gluconeogenesis lipolysis and ketogenesis For normal glucose utilization and storage Slide 68: 68 4:00 16:00 20:00 24:00 4:00 Breakfast Lunch Dinner 8:00 12:00 8:00 Time Detemir or Glargine Lispro Lispro Lispro Aspart Aspart Aspart or or or Plasma insulin Impressive benefits Personal financial cost Slide 69: 69 Slide 70: 70 Slide 71: 71 Slide 72: 72 Slide 73: 73 Slide 74: Thank You For The Patient Listening 74

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