Presentation 1
Download
Report
Transcript Presentation 1
Current Management
of Diabetes
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
2
Aim
• having information on assessing symptoms and
signs.
• developing management plans for diabetes.
3
Objectives
At the end of this session, the trainees should be
able to:– list diagnostic criteria for DM
– describe how to differentiate Type I & II DM
– explain symptoms and signs of diabetes
– discuss the evidence for lifestyle changes
– describe the indications, contraindications, and
side effects of antidiabetic agents
DM in Saudi Arabia
Lifestyle Changes :
Social & cultural changes
Prevalence :
• Diabetes mellitus as a health problem in Saudi
Arabia
• prevalence of DM is 23.7 % according to Dr. Al
Nozha study (SMJ 2004)
– 1 / 4 of adults > 30 yr are diabetics.
– 36 Foot Amputation / day, at Riyadh.
D.M in Saudi Arabia
Cost & Impacts .
•
•
•
•
•
•
Psychological impact.
Family & Social impact .
Decreased Productivity .
Sick leaves.
Work Absence .
Economical Costs .
cont…..
I- Type 1 diabetes:
Etiologic
classification
II- Type 2 diabetes.
of
diabetes
mellitus
III- Other specific types.
IV- Gestational diabetes mellitus.
Etiologic Classification of Diabetes
Mellitus
Type 1:
b-cell destruction with lack of insulin .
has absolute insulin deficiency
predisposed to develop ketoacidosis
insulin is required for survival.
Etiologic Classification of
Diabetes Mellitus
Type 2
has relative insulin deficiency combined with
defects in insulin action.
is the most common form of diabetes,
accounting for 90–95% of the disease
is most often found in overweight individuals.
Narayan K, Boyle J, Thompson T, Sorensen S, Williamson D (2003). "Lifetime risk for diabetes mellitus in the United
States". JAMA 290 (14): 1884–90. doi:10.1001/jama.290.14.1884.
Risk Factors for Type 2 DM
• Modifiable
– Overweight and obesity
– Sedentary lifestyle
– Previously identified
IGT and IFG
– Metabolic syndrome
– Diatery factors
– Intrauterine
environment
– Inflamation
• Non- Modifiable
–
–
–
–
–
Family history
Age
Gender
History of GDM
Polycystic ovary
syndrome (PCO)
10
Symptoms & Signs
• Classical symptoms
– Unusual thirst (Polydipsia)
– Frequent urination (Polyuria)
– Unusual weight loss
• Other symptoms
–
–
–
–
–
–
–
–
Extreme fatigue or lack of energy
Unusually hungry
Moody & irritable
Blurred vision
Have recurrent infections
Wounds and bruises that are slow to heal
Get a lot of yeast infections
Have tingling or numbness in the hands and/or feet
• Patients may present with a variety of symptoms or even
symptomless
Criteria to diagnosis diabetes
• FPG >126 mg/dl (7.0 mmol/l)
( Fasting is defined as no caloric intake for at least 8 h) OR
• Symptoms of diabetes and a casual plasma
glucose > 200 mg/dl (11.1 mmol/l) OR
• 2-h plasma glucose > 200 mg/dl (11.1 mmol/l)
during an OGTT.
( The test should be performed as described by the W H O (using a glucose load
containing the equivalent of 75g anhydrous glucose dissolved in water)).
Diagnosis of Diabetes :
Plasma Glucose Cutoff Points
mg/ dl
2- Hour BS on
OGTT
mg/dl
< 100
< 140
> 100 and < 126
_
_
> 140 and < 200
> 126
> 200
FBS
categories
Normal
IFG
IGT
Diabetes
* If. without symptoms, there should be more than one measurement in
order to diagnose.
Diagnosis of gestational DM
16
First visit evaluation
History taking and clinical assessment
Physical examination
• Height and weight measurement .
• Blood pressure determination .
• Fundoscopic examination
• Oral examination
• Thyroid palpation
• Cardiac examination
First visit evaluation
Physical examination
Abdominal examination (e.g., for hepatomegaly)
Evaluation of pulses by palpation
Hand/finger examination
Foot examination
Skin examination
Neurological examination
Signs of diseases that can cause secondary diabetes
(e.g., hemochromatosis, pancreatic disease)
First visit evaluation
Laboratory evaluation
• HBA1c
• Fasting lipid profile
• Test for microalbuminuria
• Serum creatinine in adults .
• Thyroid-stimulating hormone (if indicated)
• Electrocardiogram in adults (if indicated)
• Urinalysis for ketones and protein
Management Goals
Annual visits and examinations should be done
regularly
Eliminate symptoms and improve well-being
Prevent and retard microvascular complications
optimize glycemic control
target blood pressure levels
Reduce macrovascular events
optimize glycemic control
target blood pressure levels
target lipid levels
Summary of recommendations for adults with
Diabetes
Parameter
•
HbA1c
pre-prandial plasma glucose
post-prandial plasma glucose
Blood pressure
LDL- cholesterol
HDL- cholesterol
•
Triglycerides
•
•
•
•
•
Target Value
< 7%
70 - 130 mg/dL
< 180 mg/dL
< 130/80 mmHg
< 100 mg/dL (<2.6 mmol/l)
> 40 mg/dL (1 mmol/l) for men
> 50 mg/dL (1.3 mmol/l) for wom.
< 150 mg/dL (17 mmol/l)
ADA 2009
Key concepts in setting glycemic goals
Goals should be individualized based on:
● duration of diabetes
● pregnancy status
● age
● co-morbid conditions
● hypoglycemia unawareness
● individual patient considerations
Follow up
24
Things to keep in mind during
management of Diabetes
Type 2: Deterioration of beta cells over time
Increasing prevalence with increasing risk factors,
e.g obesity
Hyperglycemia affects morbidity, mortality and
resources
Tight glycemic control with insulin may reduce
costly complications
30% to 40% of patients ultimately require insulin
Non-pharmacologic Therapy for DM
Lifestyle therapeutic modifications
Diet
Improved food choices
Spacing meals
Individualized carbohydrate content
Moderate calorie restriction
Exercise
improve blood glucose control
reduce cardiovascular risk factors
contribute to weight loss.
improve well-being.
Nutritional recommendations for DM
patients
• Protein to provide 10-20% of kcal/day
• Saturated fat to provide < 10% of kcal/day (< 7 % for those with
elevated LDL).
• Polyunsaturated fat to provide < 10 % of kcal.
• Remaining calories to be divided between carbohydrate &
monounsaturated fat, based on medical needs & personal
tolerance.
• Use of caloric sweeteners is acceptable.
Considerations in Pharmacologic
Treatment of Diabetes
•
•
•
•
Complications/tolerability
Frequency of hypoglycemia
Compliance/complexity of regimen
Cost
Sulfonylureas
Drug
Dose
Side effects
Tolbutamide
Restinon®
500-2000mg
Od-Bid
Weight gain
hypoglycemia
Glibenclamide
15-20 mg
Od-Bid
Daonil ® 5mg
Weight gain
Hypoglycemia
40-320mg
Od-Bid
Weight gain
hypoglycemia
Glipizide
Minidiab ® 5mg
2.5-20mg
Od
Weight gain
hypoglycemia
Glimerpiride
Amaryl ® 1,2,4 mg
1-8mg
Od
Weight gain
hypoglycemia
Gliclazide
Diamicron ® 80mg
Drug
Dose
Side effects
Drug class
Metformin
Glocophage®
500-850mg
10002550mg
Bid-Tid
Diarrhea
Lactic acidosis
Biguanides
Acrobose
Glucobay ®
150-300 mg
Tid
Gas , Abdominal
pain, Diarrhea
Rosiglitazone
Avandia ®
4-8mg
Od-Bid
Oedema,weight
gain,hepatic
failure
50-100 mg
2,4,8 mg
Repaglinide
Novonorm ®
0.5,1,2 mg
↓ hepatic glucose production
α –Glucosidase
inhibitors
↓ intestinal absorption
Thiazolidinediones
↑ preipheral glucose
disposal
Meglitinides
1.5-16mg
Tid-Qid
Weight gain
hypoglycemia
↑ pancreatic insulin
secretion