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Diabetes Mellitus
Dr Arshid Rafiq(Diploma in diabetes. Fellowship in diabetes)
Under supervision of
Dr Rakesh Gupta MD (medicine).FIACM
Senior consultant physician
Indraprastha Apollo Hospitals
Respected doctor’s
Diabetes: A global emergency
Diabetes around the world
Diabetes around the world
Pancreas secretes 40-50 units of insulin daily in two steps:
Secreted at low levels during fasting ( basal insulin secretion)
Increased levels after eating (prandial)
An early burst of insulin occurs within 10 minutes of eating
Then proceeds with increasing release as long as hyperglycemia is present
Insulin
Insulin allows glucose to move into cells to make energy
Inhibits glucagon activity
DIABETES MELLITUS
is a chronic disorder of carbohydrate, protein, and fat metabolism resulting from insulin deficiency or abnormality in the use of insulin
Types1.Type I
formerly known as Insulin –Dependent Diabetes Mellitus (IDDM)Autoimmune (Islet cell antibodies)
•Early introduction of cow’s milk and cereals•Intake of medicine during pregnancy •Indoor smoking of family members
destruction of beta cells of the pancreas little or no insulin productionrequires daily insulin admin. may occur at any age, usually appears below age 15
2. Type II formerly known as Non Insulin–Dependent
Diabetes Mellitus (NIDDM) probably caused by: disturbance in insulin reception in the cells number of insulin receptors loss of beta cell responsiveness to glucose
leading to slow or insulin release by the pancreas
occurs over age 40 but can occur in children common in overweight or obese w/ some circulating insulin present, often do
not require insulin
Gestational diabetes
3.Gestational Diabetes ;
a).blood sugar levels are high during
pregnancy in women
b) .Women who give birth to children over 9 lbs.
c). high risk of type 2 diabetes and cardiovascular disease
Pre-Diabetes
Impaired fasting glucose (IFG)
FPG- 100-125mg/dL
Impaired glucose tolerance (IGT)
OGTT 140-199mg/dL
HbA1c 5.7-6.4%
Who are at
risk? ?
Risk Factors Obesity
Race
History of CVD
HTN
Physical inactivity
Familial history
Polycystic Ovary Syndrome
Gestational Diabetes
? ? ? ? ? ? ?
“Of course too much is bad for
you”
Fasting plasma glucose (FPG)≥126 mg/dL (7.0 mmol/L)
OR
2-h plasma glucose ≥200 mg/dL(11.1 mmol/L) during an OGTT
OR
A1C ≥6.5%
OR
Random plasma glucose ≥200 mg/dL (11.1 mmol/L)
Criteria for the Diagnosis of Diabetes
American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S2216
Clinical Manifestations ( Signs and Symptoms)
- Polyuria - weakness- Polydipsia - fatigue- Polyphagia - blood sugar / glucose level- weight loss - (+) glucose in urine (glycosuria)- nausea / vomiting - changes in LOC (severe hyperglycemia)
(sleepiness, drowsiness coma)- recurrent infection, prolonged wound healing- altered immune and inflammatory response, prone to
infection (glucose inhibits the phagocytic action of WBC resistance)
- genital pruritus – (hyperglycemia and glycosuria favor fungalgrowth : candidal infection – resulting in pruritus, commonpresenting symptom in women)
- Erectile dysfunction
Diagnostics
Fasting Plasma Glucose
Oral Glucose Tolerance Test (OGTT)
Glycoselated Hemoglobin (HbA1c)
HbA1c is a test that measures the
amount of glycated hemoglobin in
your blood. Glycated hemoglobin is a
substance in red blood cells that is
formed when blood sugar (glucose)
attaches to hemoglobin.
Urinalysis
Glycosuria
Ketone bodies
Diabetes Mellitus
Summary Treatable, but not curable.
Preventable in obesity, adult client.
Controllable- DIET and EXERCISE
Diagnostic Tests
Signs and symptoms of hypoglycemia and hyperglycemia.
Treatment of hypoglycemia and hyperglycemia – diet and oral hypoglycemics.
Nursing implications – monitoring, teaching and assessing for complications.
Management of DM
American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S2225
The major components of the
treatment of diabetes are:
• Medical Nutrition Therapy (Diet and Exercise) [MNT]1
• Oral Antihyperglycemic Drug [OAD]2
• Insulin & Other Injectables326
Medical Nutrition Therapy (MNT)
● An individualized MNT program is
recommended for all people with type 1 and type 2
diabetes.
● For people with T1DM or those with T2DM who
are on a flexible insulin program, education on carb
counting or estimation.
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3527
…….MNT
● For patients on a fixed insulin
program, having a consistent pattern of
carbohydrate intake with respect to time
and amount can result in improved
glycemic control and a reduced risk of
hypoglycemia.
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3528
Adults with diabetes: at least 150 min/wk of
moderate-intensity aerobic activity or 30
minutes brisk walking over at least 3
days/week with no more than 2
consecutive days without exercise
Physical Activity
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S3529
Children with diabetes/prediabetes:
at least 60 min/day physical activity
Physical Activity
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3530
All individuals, including those with diabetes,should reduce sedentary time, particularly bybreaking up extended amounts of time (>90min) spent sitting.
Physical Activity
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S3531
Advise all patients not to use cigarettes, othertobacco products, or e-cigarettes.
Include smoking cessation counseling and otherforms of treatment as a routine component ofdiabetes care.
Smoking Cessation
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3532
A complete medical evaluation should be performedat the initial visit to:
Confirm & classify diagnosis
Detect complications & potential comorbidconditions
Comprehensive Medical Evaluation
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3533
Components of the Comprehensive Diabetes Evaluation
Laboratory Evaluation
A1C, if results not available within past 3months
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3534
….Components of the Comprehensive Diabetes Evaluation
If not performed/available within past year:
Fasting lipid profile
Liver function tests
Spot urine albumin-to-creatinine ratio
Serum creatinine and eGFR
Thyroid-stimulating hormone in patients with
type 1 diabetes or dyslipidemia or women aged
>50 years
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3535
Glycemic Targets
36
Two primary techniques available for health
providers and patients to assess effectiveness of
management plan on glycemic control
1. Patient self-monitoring of blood glucose
(SMBG)
2. A1C
..Glycemic Control
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4637
CGM or interstitial glucose may be a useful
adjunct to SMBG in selected patients.
Glycemic Control
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4638
Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG
Prior to meals and snacks
At bedtime
Prior to exercise
When they suspect low blood glucose
Glucose Monitoring
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4639
When they suspect low blood glucose
After treating low blood glucose until they are normoglycemic
Prior to critical tasks such as driving
Possibly also post-prandially
Glucose Monitoring
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4640
Perform the A1C test at least twice annually in
patients that meet treatment goals (and have stable
glycemic control).
Perform the A1C test quarterly in patients whose
therapy has changed or who are not meeting
glycemic goals.
A1C Testing
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4641
Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemicgoals.
Use of point-of-care (POC) testing for A1C provides the opportunity for more timely treatment changes.
A1C Testing
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4642
Lowering A1C to <7% has been shown to reduce
microvascular complications and, if implemented
soon after the diagnosis of diabetes, is associated
with long-term reduction in macrovascular
disease.
Glycemic Goals in Adults
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4643
Consider more stringent goals (e.g. <6.5%)
for select patients if achievable without
significant hypos or other adverse effects.
Glycemic Goals in Adults
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4644
A1C <7.0%*
Preprandial capillary plasma glucose
4.4–7.2 mmol/L*
(80–130 mg/dL)
Peak postprandial capillary plasma
glucose†
<10.0 mmol/L*
(<180 mg/dL)
Glycemic Recommendations forNonpregnant Adults with Diabetes
* Goals should be individualized.† Postprandial glucose measurements should be made 1–2 hours after the beginning of the meal.
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4645
An A1C goal of <7.5% is recommended across all pediatric age-groups.
Type 1 Diabetes: GlycemicControl
American Diabetes Association Standards of Medical Care in Diabetes.
Children and adolescents. Diabetes Care 2017; 39 (Suppl. 1): S86-S9346
Blood glucose goal range
A1C Rationale
Before mealsBedtime/
overnight
5.0–7.2 mmol/L
(90–130 mg/dL)
5.0–8.3 mmol/L
(90–150 mg/dL)<7.5%
A lower goal (<7.0%)
is reasonable if it can
be achieved without
excessive hypos
T1 DM: Glycemic Control
1. Goals should be individualized; lower goals may be reasonable.
2. Modify BG goals in youth w/ frequent hypos or hypoglycemia unawareness.
3. Measure postprandial BG if discrepancy between preprandial BG and A1C & to
assess glycemia in basal–bolus regimens. American Diabetes Association Standards of Medical Care in Diabetes.
Children and adolescents. Diabetes Care 2017; 39 (Suppl. 1): S86-S9347
Approaches to Glycemic Treatment
48
Most people with T1DM should be treated with
multiple dose insulin (MDI) injections (3–4 injections
/day of basal & prandial insulin) or continuous
subcutaneous insulin infusion (CSII).
Individuals who have been successfully using CSII
should have continued access after they turn 65 years
old.
Pharmacological Therapy for T1DM
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to
glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S5949
Pharmacological Therapy for T1DM
Consider educating individuals with T1DM on
matching prandial insulin dose to carbohydrate
intake, premeal blood glucose, and anticipated
activity.
Most individuals with T1DM should use insulin
analogs to reduce hypoglycemia risk.
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to
glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S5950
Pramlintide FDA approved for T1DM
Amylin analog
Delays gastric emptying, blunts pancreatic
glucose secretion, enhances satiety
Induces weight loss, lowers insulin dose
Requires reduction in prandial insulin to reduce
risk of severe hypos
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to
glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S5951
Can normalize glucose but require lifelong
immunosuppression.
Reserve for T1D patients:
Undergoing renal transplant
Following renal transplant
With recurrent ketoacidosis or severe hypos
Pancreas and Islet Cell Transplantation
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to
glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S5952
Can normalize glucose but require lifelong
Islet cell transplant investigational
Consider for patients requiring pancreatectomy
who meet eligibility criteria.
Pancreas and Islet Cell Transplantation
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to
glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S5953
Pharmacological
Therapy for T2DM
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to
glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S5954
55
Noninsulin Agents Available for T2D
Class Primary Mechanism of Action Agent(s) Available as
-Glucosidase inhibitors
Delay carbohydrate absorption from
intestine
AcarboseMiglitol
Precose or genericGlyset
Amylin analogue
Decrease glucagon secretion
Slow gastric emptying
Increase satiety
Pramlintide Symlin
Biguanide Decrease HGP
Increase glucose uptake in muscleMetformin Glucophage or generic
Bile acid sequestrant Decrease HGP?
Increase incretin levels?Colesevelam WelChol
DPP-4 inhibitors
Increase glucose-dependent insulin
secretion
Decrease glucagon secretion
AlogliptinLinagliptinSaxagliptinSitagliptin
NesinaTradjentaOnglyzaJanuvia
Dopamine-2 agonist Activates dopaminergic receptors Bromocriptine Cycloset
Glinides Increase insulin secretionNateglinideRepaglinide
Starlix or genericPrandin
56
DPP-4 = dipeptidyl peptidase; HGP = hepatic glucose production.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
. How are glycemic targets achieved for T2D?
Continued on next slide
Noninsulin Agents Available for T2D
Class Primary Mechanism of Action Agent(s) Available as
GLP-1 receptor agonists
Increase glucose-dependent insulin
secretion
Decrease glucagon secretion
Slow gastric emptying
Increase satiety
AlbiglutideDulaglutideExenatideExenatide XRLiraglutide
TanzeumTrulicityByettaBydureonVictoza
SGLT2 inhibitors Increase urinary excretion of glucoseCanagliflozinDapagliflozinEmpagliflozin
InvokanaFarxigaJardiance
Sulfonylureas Increase insulin secretion
GlimepirideGlipizideGlyburide
Amaryl or genericGlucotrol or genericDiaeta, Glynase, Micronase, or generic
Thiazolidinediones
Increase glucose uptake in muscle
and fat
Decrease HGP
PioglitazoneRosiglitazone
ActosAvandia
57
Q4. How are glycemic targets achieved for T2D?
GLP-1 = glucagon-like peptide; HGP = hepatic glucose production; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
Continued from previous slide
Effects of Agents Available for T2D
58
Q4. How are glycemic targets achieved for T2D?
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
FPG = fasting plasma glucose; GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; PPG =
postprandial glucose; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
*Mild: albiglutide and exenatide; moderate: dulaglutide, exenatide extended release, and liraglutide.
Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QRSU/
GlinideInsulin Pram
FPG lowering
ModMild to mod*
Mod Mild Mod Neutral Mild NeutralSU: modGlinide:
mild
Mod to marked (basal
insulin or premixed)
Mild
PPG lowering
MildMod to marked
Mild Mod Mild Mod Mild Mild Mod
Mod to marked (short/ rapid-acting
insulin or premixed)
Mod to marked
Continued on next slide
Effects of Agents Available for T2D
59
Q4. How are glycemic targets achieved for T2D?
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; NAFLD, nonalcoholic fatty liver disease;
SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
*Especially with short/ rapid-acting or premixed.
Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QRSU/
GlinideInsulin Pram
NAFLD benefit
Mild Mild Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral
Hypo-glycemia
Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
SU: mod to severeGlinide: mild to
mod
Mod to severe*
Neutral
Weight Slight loss Loss Loss Neutral Gain Neutral Neutral Neutral Gain Gain Loss
Continued from previous slide
Effects of Agents Available for T2D
60
. How are glycemic targets achieved for T2D?
Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QRSU/
GlinideInsulin Pram
Renal impair-ment/ GU
Contra-indicated in stage 3B, 4, 5
CKD
Exenatide contra-
indicated CrCl <30 mg/mL
GU infection
risk
Dose adjust-ment
(except lina-
gliptin)
May worsen
fluid retention
Neutral Neutral Neutral
Increased hypo-
glycemia risk
Increased risks of hypo-
glycemia and fluid retention
Neutral
GI adverse effects
Mod Mod* Neutral Neutral* Neutral Mod Mild Mod Neutral Neutral Mod
CHF Neutral Neutral Neutral Neutral† Mod Neutral Neutral Neutral Neutral Neutral Neutral
CVDPossible benefit
Neutral Neutral Neutral Neutral Neutral Neutral Safe ? Neutral Neutral
Bone Neutral Neutral Bone loss NeutralMod bone
lossNeutral Neutral Neutral Neutral Neutral Neutral
Continued from previous slide
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; CHF = congestive heart failure; CVD =
cardiovascular disease; DPP4I = dipeptidyl peptidase 4 inhibitors; GI = gastrointestinal; GLP1RA = glucagon-like peptide 1 receptor
agonists; GU = genitourinary; Met = metformin; Mod = moderate; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU =
sulfonylureas; TZD = thiazolidinediones.
*Caution in labeling about pancreatitis.†Caution: possibly increased CHF hospitalization risk seen in CV safety trial.
The progressive nature of T2DM should be
regularly & objectively explained to T2DM
patients.
For T2DM patients not achieving glycemic goals,
promptly initiate insulin therapy.
Avoid using insulin as a threat, describing it as a
failure or punishment.
Give patients a self-titration algorithm.
Insulin Therapy in T2DM
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to
glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S5961
Insulin
injection
sites
63
64
Insulin initiation in Type 2 DM:
When
1. HbA1c ≥ 10% [start combination insulins] (ADA 2017) but if
HbA1c ≥ 9%, Basal alone may be initiated
2. Symptomatic hyperglycemia
3. PPG > 19.4 mmol/L, FPG> 16.6 moml/L
4. If the glycemic target is not achieved by using three non-insulin
agents (metformine/pioglitazone, secretagogue,
ɑGi/DPP4i/SGLT2i) by at least 3 months
5. In some specific situations
Short term use of insulin therapy in patients
with T2DM may also be considered in the
following conditions:
• Acute illness, surgery, stress and emergencies
• Pregnancy and lactation
• As initial therapy in T2DM with severe
hyperglycemia
• Severe metabolic decompensation (eg. DKA,
HHS)
Types of insulin;
Type of Insulin Onset Peak DurationRole in Blood Sugar
Management
Rapid-Acting
Lispro 15-30 min. 30-90 min 3-5 hours Covers insulin needs for
meals eaten at the same
time as the injection.Aspart 10-20 min.40-50
min.3-5 hours
Glulisine 20-30 min.30-90
min.1-2½ hours
Short-Acting
Regular (R)30 min- 60
min2-5 hours 5-8 hours
Covers insulin needs for
meals eaten within 30-60
minutes
Intermediate-Acting
NPH (N) 1-2 hours4-12
hours18-24 hours
Covers insulin needs for
about half the day or
overnight.
Types of insulin
Name of
InsulinOnset Duration
Role in Blood
Sugar
Management
Long-Acting
Long-acting
insulin covers
insulin needs
for about one
full day.
Degludec 30-90 min
No peak:
insulin is
delivered at a
steady level.
Longer than 24
hours
Glargine 30-90 min Up to 24 hours
Detemir 1-120 min 20-24 hours
Types of insulin
Type of Insulin Onset Peak DurationRole in Blood Sugar
Management
Pre-Mixed*
30/70 30 min. 2-4 hours 14-24 hours These products are
generally taken two
or three times a day
before mealtime.50/50 30 min. 2-5 hours 18-24 hours
25/75 15 min.30 min.-2½
hours16-20 hours
Inhaler
Exubera Banned
Afrezza With in min 12 to 15 min 2-3 hoursPost prandial
effects.
*Premixed insulins are a combination of specific proportions of intermediate-
acting and short-acting insulin in one bottle or insulin pen (the numbers the brand
name indicate the percentage of each type of insulin).
Common Insulin Regimens
Split Mix Regimens
Two injections (intermediate + soluble) per day
* before breakfast & before bedtime
Proportion/dosage of insulin titrated based on
BG profile
Drawback
Mixing insulins is tedious and problematic
Inaccuracy of dose
Not preferred –more problems for patients
69
Common Insulin Regimens
Basal insulin
Usually given at night
Proportion/dosage of insulin titrated based on FBG
Drawback
Expensive
Fasting blood glucose is primary targeted
May be with sensitizer and or secretagogue
70
Common Insulin Regimens
Basal PlusBasal insulin at night
Any rapid acting insulin premeal.
May be useful during early years of T2DM and in
uncomplicated well motivated patients.
May be needed to shifted to Basal bolus
regimen
titrated based on BG profile
Drawback
Mixing insulins is tedious and problematic
Inaccuracy of dose 71
Common Insulin Regimens (4)
Basal Bolus
Basal insulin at night and one rapid acting insulin
immediately before each major meal (3 times).
Basal insulin is titrated following FBG
Rapid acting insulin is titrated by post meal BGs
Drawback Expensive
4 times needle prick a day.
Most preferred –most flexible 72
Management of Diabetes in Pregnancy
73
Provide preconception counseling that
addresses the importance of tight glycemic
control, ideally <6.5%, to reduce the risk of
congenital anomalies.
Pregestational Diabetes
American Diabetes Association. Management of diabetes in pregnancy.
Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S9874
75
• Family planning should be discussed
and effective contraception should be
prescribed and used until a woman is
prepared and ready to become
pregnant.
American Diabetes Association. Management of diabetes in pregnancy.
Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S98
Women preexisting type 1 or type 2 diabetes
who are pregnant or planning to become
pregnant should be counseled on the risk of
development and/or progression of diabetic
retinopathy. Eye exams should occur before
pregnancy or in the first trimester & then be
monitored every trimester and for 1 year
postpartum as indicated by degree of
retinopathy.
Pregestational Diabetes
American Diabetes Association. Management of diabetes in pregnancy.
Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S9876
Lifestyle change is an essential part GDM
mgmt. and may suffice for many women.
Add medications if needed to achieve
glycemic targets.
Gestational Diabetes Mellitus (GDM)
American Diabetes Association. Management of diabetes in pregnancy.
Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S9877
Preferred medications in GDM are insulin and
metformin; glyburide may be used but may have
higher rate of neonatal hypoglycemia &
macrosomia than insulin or metformin. Other
agents have not been adequately studied. Most
oral agents cross the placenta and all lack long-
term safety data. A
Gestational Diabetes Mellitus (GDM)
American Diabetes Association. Management of diabetes in pregnancy.
Standards of Medical Care in Diabetes-2017. Diabetes Care 2016;39(Suppl. 1):S94–S9878
The following targets for women with
pregestational type 1 or type 2 diabetes:
Fasting ≤90 mg/dL (5.0 mmol/L)
One-hour postprandial ≤130–140mg/dL (7.2–7.8
mmol/L)
Two-hour postprandial ≤120 mg/dL (6.7 mmol/L)
Glycemic Targets in Pregnancy(Preexisting Type 1 or Type 2)
American Diabetes Association. Management of diabetes in pregnancy.
Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S9879
Treatment of GDM
MNT [Dietary Therapy, Exercise]
Self BG monitoring
Administration of Insulin if target blood
glucose level are not met by diet alone
Fetal surveillance
Intrapartum care
Post partum care
Insulin therapy
Recommendations for starting Insulin (ADA
guideline)
FPG> 5.8mmol/l or
1 hr PG> 8.6 mmol/l
2hr PG > 7.2 mmol/l
Target blood glucose:
Pre prandial <5.3mmol/l
1 hr post prandial <7.8 mmol/l
2 hr post prandial <6.7 mmol/l
Insulin therapy cont.
Calculating dose:
Total insulin- 20-30 U/day
½ Basal or 2/3rd intermediate acting
½ Bolus or 1/3rd regular Insulin
Calculated daily dose of insulin:
1st trimester-0.8 unit ×kg BW
2nd trimester- 1 unit ×kg BW
3rd trimester- 1.3 unit×kg BW
The dose and type of insulin used is calculated
according to the blood glucose level
If the FBG is high then, a long acting (or
intermediate- acting insulin), is given before
bedtime.
If postprandial blood glucose levels are high,
then regular rapid-acting insulin are added before
meals.
Insulin Therapy cont.
Regular Insulin is withheld during labor; a
sliding scale of soluble insulin should be started
(or infusion pump as may be fit)
Maternal hyperglycemia should be avoided
during labor to prevent fetal hyperinsulinemia
and subsequent neonatal hypoglycemia
Maternal blood glucose should be maintained
between 4- 5 mmol/L.
Peripartum Management:
Key Take-Home Messages
MNT is the corner stone of diabetes
management.
MNT is also essential to reach optimal
glycemic control with fewer hypoglycemic
episodes
85
Key Take-Home Messages
OADs may attain or maintain good glycemic
control for a variable periods
Insulin may need to be started in any time
mean while.
86
Diabetes Mellitus -Complications
Complications of diabetes mellitus
Acute (Metabolic) Chronic (Angiopathy)
Macro Vascular Complications
Micro Vascular Complications
Risk factors and complications
Microvascular
disease
Eyes
Kidneys
Nerves
Macrovascular disease
Ischaemic heart disease
Strokes
Peripheral vascular
disease
Feet
HypertensionHyperglycaemia
DyslipidaemiaCoagulopathy
Smoking
Acute Complications
Diabetic Ketoacidosis (DKA)
Hyperosmolar non-ketomic Coma (HONK)
Hypoglycemia
Metabolic injury to large vessels
Heart Brain Extremities
Coronary artery disease– Coronary
syndrome– MI– CHF
Cerebrovascular disease
Peripheral vascular disease– Ulceration– Gangrene–Amputation
Biology of MacrovascularInjury
Hyperglycemia
Neuropathy
– Peripheral
– Autonomic
Kidney Nerves
Retinopathy- Cataract- Glaucoma
Nephropathy– Microalbuminuria– Gross albuminuria
Blindness Kidney failure Amputation
Death and/or disability
Eye
Biology of MicrovascularInjury
Microvascular Complications of Diabetes-1
Retinopathy: Damage to blood vessels in and around the retina. It could occur with varying degrees of severity.
Normal ------------- Small hemorrhages --------- Large hemorrhage
Nephropathy:
Glomeruli are damaged in the kidneys.
Results in loss of protein
DIAGNOSTIC VALUE-Normal microalbumin level is 30mg/24 hours.
May lead to kidney failure
Microvascular Complications of Diabetes-2
Microvascular Complications of Diabetes-3
Neuropathy
Nerve fibres degenerate
Blood vessels supplying the nerves are ‘grossly diseased’
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Diabetes is Managed,But it Does Not Go Away.
GOAL:
To maintain target blood glucose
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Thanks to All