Guidelines of Management of Type 2 DM

7/31/2019 Guidelines of Management of Type 2 DM

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DIABETES .An Overview

ByDr.Hala Aly Gamal El Din

Professor Of Diabetes & EndocrinologyFaculty of Medicine- Cairo University


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Diabetes in the 21st century

One of the most challenging health problemsfacing the world

246 million people worldwide diagnosed in 2007

5th leading cause of death in developed countries

Complications heart attacks, stroke, kidney

failure, amputations and blindness

380 million people worldwide projected to bediagnosed by 2025


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Facts

Diabetes is a chronic, debilitating and costly diseaseassociated withsevere complications, which poses

severe risksfor families, Member States and theentireworld.

UN Resolution 61/225. World Diabetes Day

Every 5 seconds 1 person develops diabetes

Every 10 seconds 1 person dies of diabetes

Every 30 seconds a limb is lost due to diabetes


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Natural History of DM-2

0

100

200

300

-10 -5 0 5 10 15 20 25 30

50

150

250

350

At risk forDiabetes

Glucose

RelativeFunction

Post Meal Glucose

Fasting Glucose

Insulin Resistance

Insulin LevelBeta Cell Failure

Years of Diabetes

Bergenstal, 2000 International Diabetes CenterUsed with permission.


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Criteria for the Diagnosis of Diabetes

A1C 6.5%

OR

Fasting plasma glucose (FPG)

126 mg/dl (7.0 mmol/l)OR

Two-hour plasma glucose 200 mg/dl (11.1

mmol/l) during an OGTT

OR

A random plasma glucose 200 mg/dl (11.1

mmol/l)

ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.


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A1C 6.5%

The test should be performed in a laboratory

using an NGSP-certified method standardizedto the DCCT assay*

*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.



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Fasting plasma glucose (FPG)

126 mg/dl (7.0 mmol/l)

Fasting: no caloric intake forat least 8 h*

*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.



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Two-hour plasma glucose 200 mg/dl (11.1

mmol/l) during an OGTT

The test should be performed as described bythe World Health Organization, using a

glucose load containing the equivalent of 75 g

anhydrous glucose dissolved in water*

*n the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.



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Prediabetes: IFG, IGT, Increased A1C

Categories of increased risk for diabetes

(Prediabetes)*

FPG 100-125 mg/dl (5.6-6.9 mmol/l): IFG

or

2-h plasma glucose in the 75-g OGTT

140-199 mg/dl (7.8-11.0 mmol/l): IGT

or

A1C 5.7-6.4%

*For all three tests, risk is continuous, extending below the lower limit of a range and becomingdisproportionately greater at higher ends of the range.



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Two thirds of individuals do not

achieve target HbA1c

Saydah SH, et al. JAMA 2004; 291:335342.

Liebl A, et al.Diabetologia2002; 45:S23S28.


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Why?

The major limiting factor to achieving

intensive glycemic control for peoplewith type 2 diabetes is Hypoglycaemia

Briscoe VJ, et al. Clin Diab2006;24:115-121.


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CVD=cardiovascular; HbA1c=haemoglobin A1c; T2DM=type 2 diabetes mellitus.

American Diabetes Association. Diabetes Care.2011; 34 (Suppl 1): S4S10.

More stringent HbA1c goals may be suitable for

selected patients with early stage disease, if this canbe achieved without significant hypoglycaemiaorother adverse effects

Less stringent HbA1c goals may beappropriate for patients with a history ofhypoglycaemia, CVD or late-stage disease

Normal Controlled T2DM Uncontrolled T2DM

7%6.16.9%HbA1c


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Glycemic targets

- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9mmol/l])

- Pre-prandial PG


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It is time to say...

Our goal is early controlof hyperglycemia

to preventthe short and long-term

complications of diabetes

with low risk of

hypoglycemia


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Tips to get control

Lifestyle should be used in all patients but only as part ofthe treatment

Start aggressively and back off

Assume each medication will improve HbA1c 1%

Never substitute medsAlways add new agent first

Titrate to get control

Then stop first agent

Ask the patient what they want Shots may be better than more pills

Develop a plan that prevents hypoglycemia


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ADASummary of Recommendations forAdults with Diabetes

Goals

Glycemic control:

A1C* < 7%

Preprandial BG 90

130 mg/dl

Peak postprandial BG


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Screening For Diabetes


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Screening For Diabetes

A1C or FPG or 75 g oral GTT Testing should be considered in all adults who are

overweight (BMI >25 kg/m2)

And

Have the following additional risk factors.


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Risk Factors for Screening

Physical inactivity

First-degree relative with diabetes

High-risk race/ethnicity (e.g., African American,

Latino, Native American, Asian American, Pacific

Islander) Women who delivered a baby weighing 9 lb or were

diagnosed with GDM

Diabetes Care 34:Supplement 1, 2011


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Risk Factors for Screening(contd)

Hypertension (140/90 mmHg or on therapy forhypertension)

HDL 250mg/dl

Women with polycystic ovarian syndrome (PCOS)

A1C >5.7%, IGT, or IFG on previous testing

Other clinical conditions associated with insulin

resistance (e.g., severe obesity, acanthosis nigricans)

History of CVD



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Risk Factors for Screening

In the absence of the previous criteria, testing beginsat age 45

Normal results, repeat at least at 3-year intervals

Consider more frequent testing depending on resultsand risk status



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23

A A

C

E

A CE

Robard HW, et al. Endocr Pract. 2009; 15: 540559.

AACE / ACE Di b t Al ith f


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DPP-4TZDMET AGI

MET

Dual therapy Dual therapy

TZD

Glinide or SU

MET +GLP-1orDPP-4

AACE / ACE Diabetes Algorithm for

%*6.5


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25

NATIONAL INSTITUTEFOR HEALTH AND

CLINICAL EXCELLENCE

NICE Guidelines for the Management of


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NICE Guidelines for the Management of

Type 2 Diabetes

*Avoid aggressive targets (6.5%) and individually agree target with patient; **With active dose titration;

***If at significant risk of hypoglycemia or its consequences, or if SU not tolerated / contraindicated;#If insulin is unacceptable (eg personal reasons or obesity); ##If weight is an issue. NICE, Clinical Guideline 87, 2009.

If HbA1c targetnot reached*

Increase insulin doseand intensify regimenover time. Consider

pioglitazone

Metformin + SU(or glinides)

Metformin + SU

+ insulin Start insulin

Metformin + SU+ sitagliptin or

metformin + SU + TZD#

or metformin +SU + exenatide##

SU + DPP-4inhibitor or TZD

Metformin + DPP-4inhibitor or TZD***

If HbA1c target

not reached*


If HbA1c target

not reached*


OR

OR

OR

Metformin**(mainly overweight /

obese patients)

Lifestyle intervention

If HbA1ctarget not

reached*

If HbA1c

target notreached*

Ste

p

1

Step

2

Step

3

Ste

p

4

SU if not overweight,metformin not tolerated, or

rapid response required


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27

Canadian Diabetes

AssociationAlgorithm


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Clinical assessment

Lifestyle intervention (initiation of nutrition therapy and physical activity)

A1C < 9% A1C 9% Symptomatic hyperglycemia with

metabolic decompensation

Initiate metformin

Initiating pharmacotherapy immediately without waiting effect from

lifestyle intervention

Consider initiating metformin with another agent from different classor

initiate insulin

Initiate insulin

metformin

If not at target

Add on agent best suited to the individual based on the advantage/disadvantage listed below

Class A1C Hypoglycemia Other advantage Other disadvantage

Alpha glucosidase inhibitors Rare Improved postprandial control, weight neutral GI side effects

Incretin DPP4 inhibitors to Rare Improved postprandial control,weight neutral

New agent (unknownlong term safety)

Insulin Yes No dose ceiling, f lexible regimens, many

types

Weight gain

Insulin secretogogus

Meglitinides

Sulhonylurea

to

Yes*

Yes

Improved postprandial control

Newer sulphonylurea (gliclazide &

glimeperide) are associated with less

hypoglycemia than glyburide

RequiresTid or QiDWeight gain

TZD Rare Durable monotherapy Weight gain, requires 6-12weeks to

Weight loss agent none Weight loss Increased heart rate/BPGI side effects

if not at target

Add another drug from a different classAdd bedtime basal insulin to another agent

Or intensify insulin regimen

*less hypoglycemia in the

context of missed meals

: 2% decrease in HBA1C

DPP4: Dipeptidyl peptidase-4

TZD: Thiazolidnedione

GI: gastrointestinalCHF: congestive heart failure

BP: blood pressure

A1C:glycated hemoglobin


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29

I

DF


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P ti f Di b t


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Prevention of DiabetesKey Messages As safe and effective preventive therapies for type 1

diabetes have not yet been identified, any attempts toprevent type 1 diabetes should be undertaken only within theconfines of formal research protocols.

Intensive and structured lifestyle modification that results inloss of approximately 5% of initial body weight can reducethe risk of progression from impaired glucose tolerance totype 2 diabetes by almost 60%.

Progression from prediabetes to type 2 diabetes can also bereduced by pharmacologic therapy with metformin (~30%reduction), acarbose (~30% reduction) and thiazolidinedione(~60% reduction).


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Recommendations:Medical Nutrition Therapy (MNT)

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S22.

Individuals who have prediabetes or diabetesshould receive individualized MNT as needed to

achieve treatment goals (A)

For people with diabetes, it is unlikely one optimal mixof macronutrients for meal plans exists

The best mix of carbohydrate, protein, and fat

appears to vary depending on individual

circumstances


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Recommendations: Physical Activity

Advise people with diabetes to perform at least150 min/week of moderate-intensity aerobic

physical activity (50-70% of maximum heart rate)

(A)

In absence of contraindications, people with type

2 diabetes should be encouraged to perform

resistance training three times per week (A)



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Recommendations: Hypoglycemia

Glucose (15-20 g) is preferred treatment for

conscious individual with hypoglycemia (E)

Glucagon should be prescribed for all individuals

at significant risk of severe hypoglycemia, and

caregivers/family members instructed inadministration (E)

Those with hypoglycemia unawareness or one

or more episodes of severe hypoglycemia

should raise glycemic targets to reduce risk offuture episodes (B)



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Recommendations: Bariatric Surgery

Consider bariatric surgery for adults with BMI

>35 kg/m2 and type 2 diabetes (B)

After surgery, life-long lifestyle support and

medical monitoring is necessary (E)

Insufficient evidence to recommend surgery inpatients with BMI


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Recommendations: Immunization

Provide an influenza vaccine annually to all

diabetic patients 6 months of age (C)

Administer pneumococcal polysaccharide

vaccine to all diabetic patients 2 years

One-time revaccination recommended for those>64 years previously immunized at 5 years ago

Other indications for repeat vaccination:

nephrotic syndrome, chronic renal disease,immunocompromised states (C)



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Male patient 78 years old , diabetic for 5 years uncontrolled ,

hypertensive with IHD. Our Hb A1c goal is

1. 6.5%2. 6.5 - 7%

3. 7 7.5%

4. 7.5 - 8%


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Female patient 45 years old , BMI 33 kg/m2 ,with sedentary

life newly discovered diabetes . FBS is 350mg/dl , PPS

460 mg/dl , HbA1c 10% .Our ideal treatment will be :

1. Life style modification LSM

2. LSM & Metformin

3. Insulin therapy only

4. Insulin therapy & SU

5. Insulin therapy & Metformin

6. Insulin therapy & DPP4Is

7. Metformin & TDZs8. Metformin & DPP4Is

9. Metformin & GLP1


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Q&A


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Guidelines of Management of Type 2 DM

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