diabetes mellitus - peacocks medical · pdf filediabetes mellitus medical management and...
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Diabetes MellitusMedical Management and Latest Developments
Dr Ahmad Abou-Saleh
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What is Diabetes Mellitus?
A disease characterised by a state of chronic elevation of blood glucose levels due to:
- The body’s inability to produce insulin (insulin deficiency)
And/Or
- The body’s inability to respond to insulin (insulin resistance)
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United Kingdom
• 6 – 8% of UK Population is Diabetic
• Approximately half a million undiagnosed Diabetics in the UK at any one time
• 5 Million Diabetics in UK by 2025
• 10% of NHS Budget is spent on Diabetes care (~£10 Billion)
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Type 1 Diabetes Mellitus
• A disorder of the immune system where the body’s own ability to produce insulin is destroyed (nearly 100%)
• Immune system wrongly target
and destroy β-cells in the Pancreas
• This can only be managed by
immediately starting insulin therapy
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Type 2 Diabetes Mellitus
• 95% of all Diabetics are Type 2
• Combination of insulin deficiency (though not as much as Type 1 Diabetes Mellitus) and insulin resistance
• Associated with Obesity, Hypertension and Hypercholesteraemia
• Managed by a combination of diet, oral medications and injectable therapies (e.g. insulin)
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Diabetic Complications
Eye Disease
Kidney Disease
Heart Disease
Cerebrovascular Disease
Nerve Disease
Peripheral Vascular Disease
Foot Disease
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Some of the potential outcomes of Diabetes!Cataracts
Glaucoma
Retinopathy
Blindness
End-Stage Renal Failure
Dialysis
Kidney Transplant
Heart Attack
Heart Failure
Arrhythmias
Mini-Stroke
Stroke
Sensory Ataxia
Painful Peripheral Neuropathy
Mononeuritis Multiplex
Lumbosacral Plexopathy
Muscle Infarction
Intermittent Claudication
Acute Ischaemia and Necrosis
Foot Ulceration
Toe Amputation
Major Limb Amputation
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Diabetic Foot Disease
• Definition: Localised injury to the skin and/or underlying tissue (below the ankle) in a person with Diabetes
10% of all Diabetics will be diagnosed with a foot ulcer in their lifetime
50% will die within 5 years of developing a diabetic foot ulcer
70% will die within 5 years of having an amputation
• Diabetes is the most common cause of non-traumatic limb amputation
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Risk Factors for Diabetic Foot Disease
• Neuropathy
• Peripheral ischaemia
• Swelling
• Skin breakdown
• Infection
• Deformity
• Callus
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Treatment for Diabetes
• Type 1 Diabetes Mellitus
Multiple daily insulin injections
Diet and Exercise
• Type 2 Diabetes Mellitus
Diet, exercise and weight loss
Oral and/or injectable anti-diabetic medications (including insulin)
Treat Hypertension and Hypercholesteraemia
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Aims of Treatment
• Prevent onset of complications
• Slow the progression or cause reversal of existing complications
• Prevent extremes of blood glucose levels (hyperglycaemia, hypoglycaemia)
• Manage other risk factors e.g. Hypertension, Hypercholesteraemia
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NICE Guidance on Type 2 Diabetes Mellitus
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Treatment for Diabetes – Oral Medication
• Biguanides – Metformin – Improve insulin sensitivity
• Sulphonylureas – Gliclazide – Enhance insulin secretion
• Thiazolidinediones – Pioglitazone – Improve insulin sensitivity
• DPP4-inhibitors – Sitagliptin – Enhance effect of beneficial gut hormones
• GLP-1 Analogues – Liraglutide (injection) – Synthetic beneficial gut hormone
• SGLT2 inhibitors – Empagliflozin – Enhance excretion of glucose into urine
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Diabetes and Insulinhow far have we come?
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Glucose lowering agentstypes of insulin available
• Mealtime insulins
• unmodified human
• soluble
• regular
• rapid-acting analogues
• Basal insulin
• NPH insulin
• protamine complex
• long-acting analogues
• Insulin mixes
• soluble + NPH
• rapid acting analogues + NPH
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• Type 1 Diabetes Mellitus
• Fast-acting insulin with meals and 1- 2 basal insulin injections – optimal
• Twice daily mix insulin
• Type 2 Diabetes Mellitus
• Once – Twice daily basal insulin
• Twice daily mix insulin
• Fast-acting insulin with meals and 1- 2 basal insulin injections
Glucose lowering agentspossible insulin regimens
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Monitoring Diabetes
• Daily self-monitoring with use of blood glucose meters
• Glycosylated Haemoglobin (HbA1c): Spot blood test providing information on average blood glucose over last 2 – 3 months
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Updates in Type 2 Diabetes Mellitus
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Personalised Care
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New Glucose Lowering Agents
• GLP-1 Analogues (injection): Synthetic gut hormone which works to reduce weight as well as blood glucose
• SGLT2 inhibitors: Stimulates the kidney to allow more glucose to be removed in the urine – also helping to reduce weight alongside blood glucose
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GLP-1 Analogue: Liraglutide injections
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SGLT2 Inhibitor: Empagliflozin
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SGLT2 Inhibitor: Canagliflozin
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Diabetes reversal after <6 months low calorie diet
• Special formula diet (approximately 820 kcal/day)
• Nearly 50% had average blood glucose below the diabetic range (in “remission”) versus 4% through conventional measures
• Progressively greater odds of successful remission of Diabetes with a higher amount of weight loss
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Updates in Type 1 Diabetes Mellitus
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Peptide Vaccine for newly Diagnosed Type 1 Diabetes Mellitus
• Similar principles to vaccines for infections!
• Newly diagnosed diabetics given subcutaneous injections every 2 –4 weeks for 6 months
• Preserves insulin production and better diabetic control (and lower insulin doses) in treatment group
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Closed-Loop System “Artificial Pancreas”
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Benefits• Improved diabetic control (glucose
variability and average glucose values
• Reduced amount of time patients spent with low blood glucose values (hypoglycaemia)
• Automatic suspension of insulin delivery via pump when blood glucose drops too low
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Glucose Monitoring now available on the NHS
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Islet Cell Transplantation
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Summary
Diabetes caused by insulin deficiency and/or resistance
Rising numbers UK and worldwide
Managed by lifestyle modification, oral and injectable therapies
Various developments – ongoing!