share our experiences of management share our experiences of management of diabetes in local perspective.of diabetes in local perspective.

early identify the diabetic pts and early identify the diabetic pts and complications of DIABETEScomplications of DIABETES

motivate patients to achieve targetsmotivate patients to achieve targets understand the advantages of understand the advantages of

treatment and disadvantages of not treatment and disadvantages of not achieving targetsachieving targets

attain Hb A1c less than 7%attain Hb A1c less than 7%

Principal Aims in Diabetes CareMedical/Diabetes Care Team-orientated

( A)Promote overall well-being and a normal life expectancy

(B) Prevent/delay the onset of cardiovascular disease

(C)Manage diabetes-related complications early and aggressively as appropriate

(D) Minimize hypo glycaemia and adverse drug event rate

(E) Provide specialist care at optimal time points

Patient/Care-orientated

(1)To acquire the education and skills to self-manage

(2) Maintain an optimal level of physical and cognitive function

(3) To be confident of access to services and support where necessary to manage their

DIABETES

DefinitionDefinitionDiabetes mellitus is a Diabetes mellitus is a

complex metabolic disorder complex metabolic disorder characterisedcharacterised

by persistent hyperglycaemia due to by persistent hyperglycaemia due to

relative or absolute deficiency of insulin or relative or absolute deficiency of insulin or

insulin resistanceinsulin resistance

IS Diagnostic IS Diagnostic Criteria????Criteria????

FPGFPG (Fasting Plasma (Fasting Plasma Glucose) >126mg/dlGlucose) >126mg/dl

RPGRPG (Random Plasma (Random Plasma Glucose) >200mg/dlGlucose) >200mg/dl

OGTTOGTT (Oral Glucose (Oral Glucose Tolerance Test)2hr pp Tolerance Test)2hr pp >200mg/dl(75GM GLUCOSE)>200mg/dl(75GM GLUCOSE)

AACE AACE GOALGOAL

ADA ADA GOALGOAL

Pre-Pre-mealmeal

<110<110

mg/dlmg/dl90-90-130130

Mg/dlMg/dl

2 hour 2 hour PPPP

<140<140

Mg/dlMg/dl<180<180

Mg/dlMg/dl

TYPES of DIABETESTYPES of DIABETESType 1 Diabetes:Type 1 Diabetes: 5 to 10% patients 5 to 10% patients

have type 1 diabetes.have type 1 diabetes.

Type 2 DiabetesType 2 Diabetes: 90 to 95% patient : 90 to 95% patient have type 2 diabetes.have type 2 diabetes.

Other Types.Other Types. GDMGDM IGTIGT IFGIFG

CharacteristicCharacteristic Type 1 Type 1 ( 10% )( 10% ) Type 2Type 2

Onset (Age)Onset (Age) Usually < 30 Usually < 30 Usually > 40 Usually > 40

Type of onsetType of onset AbruptAbrupt GradualGradual

Nutritional statusNutritional status Usually thinUsually thin Usually obeseUsually obese

DietDiet Mandatory with insulinMandatory with insulin Mandatory with or without Mandatory with or without drugdrug

COMPLICATIONSCOMPLICATIONS AFTER 5 AFTER 5 YEARS(MAJORITY)YEARS(MAJORITY)

40-50% AT DIAGNOSIS40-50% AT DIAGNOSIS

Hypoglycemic drugsHypoglycemic drugs Should not be usedShould not be used Clinically indicatedClinically indicated

Clinical symptomsClinical symptoms Polydipsia, polyphagia, Polydipsia, polyphagia, polyurea, Wt losspolyurea, Wt loss

Often asymptomaticOften asymptomatic

KetosisKetosis FrequentFrequent Usually absentUsually absent

Endogenous insulinEndogenous insulin AbsentAbsent Present, but relatively Present, but relatively ineffective (in. resistance)ineffective (in. resistance)

Related lipid Related lipid abnormalitiesabnormalities

Hypercholesterolemia Hypercholesterolemia frequent, all lipid fractions frequent, all lipid fractions elevated in ketosiselevated in ketosis

Cholesterol & triglycerides Cholesterol & triglycerides often elevated; carb often elevated; carb induced hyper TG induced hyper TG commoncommon

Insulin therapyInsulin therapy Required FOR WHOLE Required FOR WHOLE LIFE(DEPENDS ON INSULIN)LIFE(DEPENDS ON INSULIN)

Required in only 20 - 30% Required in only 20 - 30% of patients FOR CONTROLof patients FOR CONTROL

Table 4—Table 4—Criteria for testing for diabetes in Criteria for testing for diabetes in asymptomatic adult individualsasymptomatic adult individuals

1. Testing should be considered in all adults who are 1. Testing should be considered in all adults who are overweight (BMI 25 kg/m2*) andoverweight (BMI 25 kg/m2*) and

have additional risk factors:have additional risk factors: ● ● physical inactivityphysical inactivity ● ● first-degree relative with diabetesfirst-degree relative with diabetes ● ● members of a high-risk ethnic population (e.g., African members of a high-risk ethnic population (e.g., African

American, Latino, NativeAmerican, Latino, Native American, Asian American, Pacific Islander)American, Asian American, Pacific Islander) ● ● women who delivered a baby weighing 9 lb or were women who delivered a baby weighing 9 lb or were

diagnosed with GDMdiagnosed with GDM ● ● hypertension (140/90 mmHg or on therapy for hypertension (140/90 mmHg or on therapy for

hypertension)hypertension) ● ● HDL cholesterol level 35 mg/dl (0.90 mmol/l) and/or a HDL cholesterol level 35 mg/dl (0.90 mmol/l) and/or a

triglyceride level 250triglyceride level 250mg/dl (2.82 mmol/l)mg/dl (2.82 mmol/l)

● ● women with polycystic ovary syndromewomen with polycystic ovary syndrome ● ● A1C 5.7%--6.4%, IGT, or IFG on previous testingA1C 5.7%--6.4%, IGT, or IFG on previous testing ● ● other clinical conditions associated with insulin other clinical conditions associated with insulin

resistance (e.g., severe obesity,resistance (e.g., severe obesity, acanthosis nigricans)acanthosis nigricans) ● ● history of CVDhistory of CVD 2. In the absence of the above criteria, testing 2. In the absence of the above criteria, testing

diabetes should begin at age 45 yearsdiabetes should begin at age 45 years 3. If results are normal, testing should be 3. If results are normal, testing should be

repeated at least at 3-year intervals, withrepeated at least at 3-year intervals, with consideration of more frequent testing depending consideration of more frequent testing depending

on initial results and riskon initial results and risk status.status. *At-risk BMI may be lower in some ethnic groups*At-risk BMI may be lower in some ethnic groups

The foundation of our current practices in The foundation of our current practices in diabetes stems from large prospective studies, diabetes stems from large prospective studies,

such as thesuch as the

UK Prospective Diabetes Study (UKPDS)UK Prospective Diabetes Study (UKPDS)

and theand the

Diabetes Control and Complications Trial (DCCT), Diabetes Control and Complications Trial (DCCT),

which suggested that better control of blood which suggested that better control of blood glucose reduces complicationsglucose reduces complications

Diabetes Mellitus: Diabetes Mellitus: Health Impact of the DiseaseHealth Impact of the Disease

DiabetesDiabetesBlindnessBlindness

Renal Renal failure failure

AmputationAmputation

Life expectancy Life expectancy 55to 10 yrto 10 yr

CardiovascularCardiovasculardisease disease 2 to 4X2 to 4X

Diabetes is the most common cause of renal failure, blindness, and nontraumatic amputationsDiabetes is the most common cause of renal failure, blindness, and nontraumatic amputations

Nerve damage in Nerve damage in 60 to 70% of patients60 to 70% of patients

6th leading cause 6th leading cause of death of death

Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412.

UKPDS: decreased risk of diabetes-related complications UKPDS: decreased risk of diabetes-related complications associated with a 1% decrease in A1Cassociated with a 1% decrease in A1C

UKPDS: decreased risk of diabetes-related complications UKPDS: decreased risk of diabetes-related complications associated with a 1% decrease in A1Cassociated with a 1% decrease in A1C

Per

cen

tag

e d

ecre

ase

in r

ela

tive

ris

k co

rres

po

nd

ing

to

a 1

% d

ecre

ase

in H

bA

1C

**

Any diabetes-related endpoint

21%

**

Diabetes-related death

21% **

All cause

mortality

14%*

Stroke

12%

**

Peripheral vascular disease†

43%

**

Myocardial infarction

14%

**

Micro-vascular disease

37%

**

Cataract extraction

19%

Observational analysis from UKPDS study data

†Lower extremity amputation or fatal peripheral vascular disease*P = 0.035; **P < 0.0001

Stages of Type 2 Diabetes—Stages of Type 2 Diabetes—UKPDSUKPDS

-C

ell

Funct

ion (

%)

PostprandialHyperglycemia

IGT Type 2DiabetesPhase I Type 2

DiabetesPhase II

Type 2 DiabetesPhase III

25

100

75

0

50

-12 -10 -6 -2 0 2 6 10 14

Years From Diagnosis

Lebovitz H. Diabetes Review. 1999;7:139.

TABLE OF OHATABLE OF OHAS S / OAD/ OADSS SECRETOGOGUESSECRETOGOGUES INSULIN INSULIN

SENSITIZERSSENSITIZERSINHIBITORS OF INHIBITORS OF CHO ABSORPTIONCHO ABSORPTION

SULFONYLUREASSULFONYLUREAS BIGUANIDESBIGUANIDES ALPHA ALPHA GLUCOSIDASE GLUCOSIDASE INHIBITORSINHIBITORS

GLICLAZIDEGLICLAZIDE METFORMINMETFORMIN ACARBOSEACARBOSE

GLIBENCLAMIDEGLIBENCLAMIDE

TZDTZDSS OTHERS-OTHERS-NEWNEW

GLIMEPIRIDEGLIMEPIRIDE PIOGLITAZONEPIOGLITAZONE DI -PEPTIDYL DI -PEPTIDYL PEPTIDASE-4 PEPTIDASE-4 INHIBITORSINHIBITORS

NONNON - -SULFONYLUREASSULFONYLUREAS

ROSIGLITAZONEROSIGLITAZONE

Black box warningBlack box warningGLIPTINSGLIPTINS

REPAGLINIDEREPAGLINIDE

SulfonylureasSulfonylureas MeglitinidesMeglitinides BiguanidesBiguanides α-α-glucosidase glucosidase inhibitorinhibitor

ThiazolidinThiazolidine-dionese-diones

HypoglycemiaHypoglycemia ++ ±± BW gainBW gain ++ ±± ++GI upsetGI upset ++ ++Lactic acidosisLactic acidosis ++

HepatotoxicityHepatotoxicity ++Increased plasma Increased plasma

volumevolume ++

ContraindicationContraindication SignificantSignificant

liver/kidneyliver/kidney

dysfunctiondysfunction

SignificantSignificant

liverliver

dysfunctiondysfunction

Cr (M) >1.5, Cr (M) >1.5,

(F) >1.4 m/dl(F) >1.4 m/dl

AcidosisAcidosis

CHFCHF

HypoxiaHypoxia

RadiocontrastRadiocontrast

GastroparesisGastroparesis

IBDIBDActive liverActive liver

disease ordisease orGPT >2.5 UNLGPT >2.5 UNL

CHFCHF

relativerelative Short & rapidShort & rapid

onset onset

relativerelative

The Moral of the TaleThe Moral of the Tale

As long as we As long as we reach the reach the objective objective (TARGETS), it (TARGETS), it doesn’t matter doesn’t matter how we get therehow we get there

Tools to manage Diabetes Tools to manage Diabetes

Whether it is pills, Whether it is pills, insulin shots or both insulin shots or both

GOAL IS CONTROLGOAL IS CONTROL

HbA1cHbA1c <7%<7%

The August 2006 guidelines from the The August 2006 guidelines from the ADAADA

and the European Association for and the European Association for the Study the Study

of Diabetes recommends the of Diabetes recommends the inclusion ofinclusion of

METFORMIN METFORMIN

in initial diabetes treatment, in initial diabetes treatment, AS PART OF TLCAS PART OF TLC

An An Algorithm Algorithm to Guide to Guide

…..…..

Advantages of Insulin TherapyAdvantages of Insulin Therapy Most clinical experienceMost clinical experience Most effective (lowering Most effective (lowering

glycemia)glycemia)Can decrease any level of elevated Can decrease any level of elevated

HbAHbA1c1c

No maximum dose of insulin beyond No maximum dose of insulin beyond which a therapeutic effect will not occurwhich a therapeutic effect will not occur

Beneficial effects on triglyceride Beneficial effects on triglyceride and HDL cholesterol levelsand HDL cholesterol levels

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

Why Aren’t Patients Achieving Why Aren’t Patients Achieving Blood Glucose Goals?Blood Glucose Goals?

Physicians not setting appropriate Physicians not setting appropriate glycemic targetsglycemic targets

Type 2 diabetes is progressive - Type 2 diabetes is progressive - what works now may not work in what works now may not work in the futurethe future

Type of medications used are not Type of medications used are not appropriateappropriate

Insulin therapy only used as a Insulin therapy only used as a “threat”“threat”

Yikes! I have 5 minutes to tell this patient everything about diabetes!!

(ABC )–ALPHABET STRETEGY)(ABC )–ALPHABET STRETEGY) JOINT BRITISH JOINT BRITISH

SOCIETIES GUIDELINES- 2005SOCIETIES GUIDELINES- 2005 AA ADVICE ADVICE EDUCATION, COMPLIANCE, SMOKING EDUCATION, COMPLIANCE, SMOKING CESSATION, DIET,CESSATION, DIET, PHYSICAL ACTIVITY,WEIGHT REDUCTION.PHYSICAL ACTIVITY,WEIGHT REDUCTION. BB BLOOD PRESSURE < 130/80, BLOOD PRESSURE < 130/80, ACE/ARB, DIURETICS, CCBACE/ARB, DIURETICS, CCB1.1. CC CHOLESTREROL < 160 MG/DL, LDL<100MG/DL, TG<160, CHOLESTREROL < 160 MG/DL, LDL<100MG/DL, TG<160,

HDL>40 IN MALES >50 IN FEMALESHDL>40 IN MALES >50 IN FEMALES DD DIABETES CONTROL HBA1C < 6.5% METFORMIN 1ST DIABETES CONTROL HBA1C < 6.5% METFORMIN 1ST CHOICECHOICE EE EYE CAREEYE CARE ANNUAL OPHTHALMOLOGICAL EXAMANNUAL OPHTHALMOLOGICAL EXAM FF FOOT CAREFOOT CARE ANNUAL EXAMANNUAL EXAM GG GUARDIAN DRUGS GUARDIAN DRUGS ASPIRIN > 50 YRS, > 10 YRS DM, ASPIRIN > 50 YRS, > 10 YRS DM,

HTNHTN / PROTEINUREA( NEPHROPATHY) / PROTEINUREA( NEPHROPATHY) ACE/ARBACE/ARB STATINS(EVEN IF LIPID PROFILESTATINS(EVEN IF LIPID PROFILE IS WITHIN NORMAL LIMITS)IS WITHIN NORMAL LIMITS)

TAKE HOME TAKE HOME MESSAGEMESSAGE

““Insulin should not be the Insulin should not be the treatment of treatment of last resortlast resort for many for many of our patients, but should be the of our patients, but should be the treatment of treatment of best resort. best resort. Starting Starting

insulin is always insulin is always resisted. resisted. A lot A lot depends on the depends on the clinician clinician to handle to handle the different situations in a tactful the different situations in a tactful

way”way”

DIABETES”S therapy should be DIABETES”S therapy should be

individualizedindividualized

and adjusted according to the changing and adjusted according to the changing needs of the patientsneeds of the patients

TAKE HOME TAKE HOME MESSAGEMESSAGE

•THANK YOU