Management of diabetes mellitus (DM)

WORKSHOP

Dimitris Karanasios

• The Importance of DM Management in Primary Care

• The role of the GP / FM in everyday practice

• Diagnosis and management of DM

• Major complications resulting from DM

• Strategies for a patient-centred care approach to achieving intensive glycemic control

• Patients’ empowerment through education about DM self-management

“Despite the same objectives, these guidelines are substantially different in content.”

Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more clinically relevant than the IDF recommendations?

Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25

“ADA/EASD guidelines offer practical algorithms to help initiate and modify pharmacological therapy for diabetes with detailed descriptions of treatment options.

IDF document, however, concentrates on the role of postprandial hyperglycemia and calls for a lower HbA1c target value of 6.5% as opposed to ADA/EASD guidelines advocating a value of 7%.’’

Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more clinically relevant than the IDF recommendations?

Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25

“Careful analysis of the guidelines’ contents

suggests that an ADA/EASD consensus might be more useful in everyday clinical practice than IDF recommendations, which do not offer a particular treatment algorithm”.

Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more clinically relevant than the IDF recommendations?

Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25

“For example, having been developed by endocrinologists, ACE/AACE guidelines set more aggressive target A1C levels than the ADA/EASD guidelines(≤ 6.5% vs < 7%); they also stratify patients into treatment-nave and treated groups.

In contrast, ADA/EASD guidelines are unstratified and more general.”

Robertson C. Translating Guidelines into Primary Care of Patients With Type 2 Diabetes: What's New About ADA/EASD Guidelines and the ACE/AACE Road Maps? Journal for Nurse Practitioners 2008; 4(9): 661-671. 

Complications: Macrovascular – Atherosclerotic Heart Disease– Myocardial Infarction – Peripheral Vascular Disease– Cerebrovascular Disease– Renal Artery Stenosis

Complications: Microvascular – Diabetic Retinopathy– Diabetic Nephropathy

• Occurs in 40% of Type I Diabetes Mellitus• Occurs in 20% of Type II Diabetes Mellitus

– Peripheral Neuropathy – Autonomic Neuropathy– Gastroparesis– Impotence

Family Practice Notebook, LLC, 2008

Major complications of DM are:

• Cardiovascular Disease

• Diabetic Nephropathy

• Diabetic Retinopathy

Family Practice Notebook, LLC, 2008

• A 58-year-old man, referred by his cardiologist, is feeling very tired and fears that his heart disease has worsened. There are no indicators of a new coronary disease event.

• History:– Stopped smoking 10 years ago (40p/y)– Drinks 1 glass of red wine per night– Underwent angioplasty 10 months previously– Current medication: Statin, beta-blocker, aspirin, ACE inhibitor

and a diuretic

• Physical examination:– BP 130/78 mmHg PULSE 88/min– WEIGHT 120 kg BMI 38.3 kg/m2Examinations:– Fasting Glu 220 mg/dl, HbA1c 8.4%– TC 212 mg/Dl, LDL 124 mg/dL, HDL 24 mg/dL and TG 320

mg/dL

Design a plan for:

• Diagnosis, additional examinations(using current diagnostic criteria)

• Lifestyle modifications – Medication (using current guidelines – treatment algorithms)

• Patient education / self-management (use current guidelines)

• DM management plan – group presentations

• Discussion

• Goals of the workshop

• Challenges in chronic disease management

CRITERIA FOR DIABETES DIAGNOSIS

1. A1C ≥ 6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.

2. FPG ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.

3. 2-h plasma glucose ≥ 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolved in water.

4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dl (11.1 mmol/l).

5. Any of 4 but 1-3 should be confirmed by repeat testing.

AMERICAN DIABETES ASSOCIATIONDiabetes Care January 2010 vol. 33 no. Supplement 1 S62-S69

• Weight loss of 10% of BW in 6 months• Lowering the daily calorie intake (500 kcal-1000 kcal)• Moderate exercise 30 min. daily• Stress control, social and family support, smoking

cessation• Medication lowering lipid levels in case of an inability to

reach target levels within 6 months

http: // www.nhlbi.nih.gov

Copy for trainee

Heine RJ, Diamant M, Mbanya J-C, Nathan DM. Management of hyperglycaemia in type 2 diabetes: the end of recurrent failure?

BMJ 2006; 333: 1200-1204

Agent Mechanism Target organ or tissue

α Glucosidase inhibitors

Pramlintide

Sulfonylureas adn meglitinides

Glucagon-like peptide and dipeptidyl peptidase 4

inhibitors

α Glucosidase inhibitors

α Glucosidase inhibitors

Inhibition or delay of glucose aborption

Increase in muscle insulin sensivity

β Cell differentiation or neogenesis*

Inhibition of glucagon relase

Reduction of lipotoxicity

Increase in hepatic insulin sensivity

Inhibition of hepatic gluconeogenesis

Modulation of appetite or autonomic nervous system function*

Antiapoptotic effects*

Stimulation of insulin biosynthesis

Stimulation of favourable fat redistribution

Suppression of free fatty acid relase

Modulation of adipokine secrection

Acute stimulation of insulin secrection

Slowing of gastric emptying (not dipeptidyl peptidase 4 inhibitors)

Simulation of glucagon-like peptide secretion* Gastrointestinal tract

Pancreatic β Cell

Central nervous system

Liver

Muscle

Adipose tissue

Recommendations: • People with diabetes should receive DSME according to national

standards when their diabetes is diagnosed and as needed thereafter. (B)

• Self-management behaviour change is the key outcome of DSME and should be measured and monitored as part of care. (E)

• DSME should address psychosocial issues since emotional well-being is strongly associated with positive diabetes outcomes. (C)

• DSME should be reimbursed by third-party payers. (E)

Standards of Medical Care in Diabetes—2009.

Diabetes Care 2009 Jan; 32: S13–S61. doi: 10.2337/dc09-S013.

Reducing Risk • What type 2 diabetes mellitus is: (a) insulin deficiency and resistance; (b) progression

of the disease • The long-term effect of high blood sugar, emphasizing the importance of lowering

blood sugar levels in order to prevent complications • What insulin is and why it is important • How lifestyle modification affects long-term complications

Healthy Eating and Activity • How lifestyle (diet and exercise) modification affects blood sugar, i.e., foods that raise

blood sugar and the impact of activity on blood sugar

Monitoring • The importance of rigorous management of blood sugar levels—achieving desired

blood sugar levels • The difference between fasting and postprandial sugar levels

Taking Medications • How various oral anti-diabetic agents affect blood sugar levels • Postprandial medications • When and why insulin should be administered • Which insulin?

Carolyn Robertson, Journal for Nurse Practitioners 2008; 4(9): 661-671

“Treatment involves control of hyperglycemia to improve symptoms and prevent complications while minimizing hypoglycemic episodes.”

Goals for glycemic control are: • Blood glucose between 80 and 120 mg/dl during

the day • Blood glucose between 100 and 140 mg/dL

at bedtime

• HbA1c levels < 7%Merck manuals online medical library