Management type 2 dm

Management Type 2 DM

Adam IbrahimMBBS.

Remember the Big Picture Manage DM in the context of

reducing MI and CVA Don’t forget other comorbidities

HTN -- goal BP 130/80 or less Dyslipidemia – goal LDL 70-100 Obesity – Goal wt. loss 2 kg/month

Remember blood glucose as one risk factor among many contributing to microvascular and macrovascular disease

Goal HgA1c < 7.0

Management Impaired Glucose Tolerance

Diabetes Prevention Trial NIH sponsored 5 year study

completed 2003 Designed to test strategies for

reducing progression of IGT to DM Oral agent – metformin Lifestyle modification Placebo

Diabetes Prevention Trial

Lifestyle Intervention group Achieve and maintain 7% wt. loss 150 minutes exercise per week Diet and exercise education

16 one on one sessions Monthly group sessions

Metformin Group

Metformin 850 mg QD X 1 month, then BID

Lifestyle recommendations 20-30 session with handouts Food Pyramid Encourage “more exercise”

Placebo

Placebo QD X1 month, then BID Lifestyle recommendations

Results

Metformin reduced progression by 31%

Intensive Lifestyle Modification reduced progression by 58%

Weight loss Placebo 0.1 kg Metformin 2.1 kg Lifestyle 5.6 kg

Management IGT Educate patient as much as possible of

the benefits of intensive lifestyle modification Exercise 150 min/wk Low calorie, low fat diet Goal weight loss at leas 7%

May consider metformin if high clinical suspicion that pt will develop DM

Monitor glucose tolerance at least yearly to catch DM early

Therapy For DM Type 2

Treatment 1999-2000

Diet Only 20.2

Insulin Only 16.4

Oral Agents Only 52.5

Orals and Insulin 11.0

Oral Medications Biguinides (metformin, glucophage)

Primarily reduce hepatic glucose production Also sensitize tissues to insulin Average change in FBS 60-70, HgA1c 1.0 -2.0 Causes modest weight loss Best evidence at preventing macrovascular

complications No hypoglycemia FIRST CHOICE if renal function ok GI side effects Hold if creatinine >1.5

Sulfonylureas (glibenclimide, glyburide, chlorpropramide) Primarily function to stimulate the

pancreas to produce more insulin Change in FBS 60-70, HgA1c 1.0-2.0 Readily available Inexpensive Can cause hypoglycemia, mild weight

gain Choose short-acting over long-acting

Thiazolidinediones (rosiglitazone, pioglitazone) Primarily sensitize tissues to insulin Reduce hepatic glucose production Reduce FBS 35-40, HgbA1c 0.5-1 6 weeks to see maximum effects Caution in CHF – contraindicated class III or IV May cause edema Can potentiate hypoglycemia if taken with insulin

or sulfonylureas Expensive

Meglitinides (repaglinide, nateglinide) Stimulate insulin release in the presence

of glucose Reduces post-prandial glucose

Alpha-glucosidase inhibitors (acarbose) Block enzymes that dissolve starches in

the small intestine

New Medicines Sitagliptin (Januvia)

Causes more insulin to be secreted in response to eating

Less hypoglycemia Byetta (exanatide)

Incretin mimetic – increased insulin production related to glucose load

Twice a day injection More for weight loss

Insulin Therapy

Most Type 2 diabetics will eventually have reduced insulin production

If patient is not well controlled on 2 or more oral agents, should consider starting insulin

Nearly all Type 2 diabetics will eventually require insulin

Insulin Therapy If available, consider long acting

(glargine) insulin at bedtime or at AM Consider NPH if glargine not available Start with low dose (10 units glargine,

5 units NPH) and slowly increase as tolerated

May need to reduce or discontinue some orals (sulfonylureas, TZD)

Summary Treatment Goals

Reduce microvascular and macrovascular complications Glucose goal HgbA1c <7.0 Fasting glucose 90-130 Post-prandial glucose 140-180 BP <130/80 LDL < 100 (close to 70) TG < 250 HDL >40 men, >50 women

Look for a reason to add an ACE inhibitor Reduces diabetic nephropathy

Look for a reason to add a statin Lowers cardiovascular and all cause

mortality

Summary of Treatment

Lifestyle Modification

Oral Monotherapy

Oral Combination Therapy

Combination Oral and Insulin

Diagnosis

Case Ahmed is a 54 yr old Somali male who

comes to see you complaining of fatigue and increased thirst. What other history would you like to ask? Past medical hx – HTN, CVD, dyslipidemia,

AAA Family history – CAD, CVD, DM Smoking history Activity history Symptoms – polyuria, wt loss, wt gain,

blurry vision

Ahmed also has HTN and is taking a-methylopa. BP is 140/90. Lipids unkown. He complains of blurry vision. His father died of MI at age 55. What physical exam would you like to focus on? Dilated retinal exam – microaneurysms, blot

hemorrhages, hard-exudates, cotton-wool spots (retinal infarcts), A-V knicking

Monofilament exam Heart and lungs

Exam reveals decreased sensation with monofilament exam, A-V knicking, and one cotton wool spot. What lab would you like to order next? RBS OGTT Creatinine Lipids (if available) Glycosylated hemoglobin

RBS is 190. OGTT reveals fasting glucose 132, 2

hour glucose 210 – HgbA1c 8.7 Creatinine 1.3 LDL 158 How would you like to manage the

patient next? Metformin Enalapril Lovastatin

When would you like to see the patient back?

What would you like the patient to bring with him if possible? Diet log Glucose log BP log

What labs would you like to check? RBS Creatinine

RBS is 155, creatinine is 1.3, BP is 130/80

When would you like to see him back? What labs would you like to order?

RBS Creatinine SGOT Lipids Glycosylated hemoglobin