2024.8.11 Trichy Atreatment gjpollo.pptx

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1. Navigating Diabetic Journey & Lifelong voyage of monitoring and management Dr Manikandan Madurai

2. Duality of Interest None

3. Thanks

4. Agenda Introduction Dilemmas at diagnosis Tests for Risk stratification Additional Gadgets

5. Introduction

6. Conclusion

7. Natural History of Diabetes Progression from prediabetes to diabetes and development of diabetes complications over time Prediabetes tends to progress to diabetes. And over time, persistent hyperglycemia leads to the complications that are the major source of morbidity, mortality, and cost . This natural history reflects underlying loss of beta-cell function . Development of Diabetes & Diabetes complications We Can Change the Natural History of Type 2 Diabetes Diabetes Care 2014;37:2668–2676 | DOI: 10.2337/dc14-0817

8. Hyperglycaemia contributes to CV disease and CKD 1. Sarwar N et al. Lancet 2010;375:2215; 2. Thomas M et al. Nat Rev Nephrol 2016;12:73 9 CKD is estimated to affect ~50% of patients with T2D globally 2 Patients with T2D have twice the risk of CV disease compared with the general population 1 2x

9. Dilemmas at diagnosis

10. Case 1 Mrs SL, 54 year old housewife Did Master Health Checkup (MHC) as her son has come from abroad and c/o tiredness FBS- 140, PPBS- 210 and HbA1C- 8.2% On probing c/o 2kg weight loss with recent UTI needing treatment twice

11. Case 2 Mr NS, 45 year old gentleman from Chennai- Contractor. C/o lightheadedness for 5 days. Took MHC. ENT specialist diagnosed severe sinusitis on CT scan and treatment started FBS- 116, PPBS- 240, HbA1C- 6% No history of polyuria, polydipsia and weight loss. BMI- 27.5 with acanthosis.

12. Case 3 Mr. PS, 35 year old architect. Seen dermatologist for wart in his foot causing pain RBS- 146, HbA1C- 7.2% Dad has T2DM. BMI- 32. Poor dietry habits No hyperosmolar symptoms Repeat bloods next day- FBS, 86, PPBS- 130, HbA1C- 5.4%

13. Dilemma -1 Do they have Diabetes?

14. Diabetes Mellitus The term diabetes describes a group of metabolic disorders characterized and identified by the presence of hyperglycemia in the absence of treatment occurring due to defects in insulin secretion, insulin action, or both. Recommended tests are Measurement of fasting plasma glucose; 2-hour (2-h) post-load plasma glucose after a 75 g oral glucose tolerance test (OGTT); HbA1c; Random blood glucose in the presence of signs and symptoms of diabetes

15. Diagnostic criteria Fasting plasma glucose values of ≥ 126 mg/dl, 2-h plasma glucose values during 75-g OGTT ≥ 200 mg/dl HbA1c ≥ 6.5% Random blood glucose ≥ 200 mg/dl in the presence of signs and symptoms are considered to have diabetes. “Prediabetes” is the term used for individuals whose glucose levels do not meet the criteria for diabetes but are too high to be considered normal Fasting plasma glucose values 100 mg / dL to 125 mg / dL (IFG) 2-h plasma glucose values during 75-g OGTT 140 mg / dL to 199 mg / dL (IGT) Hb A1C 5.7–6.4%

16. PIMA Indians

17. Blood Tests FBS PPBS HbA1C 75g OGTT (in Pregnancy and special circumstances)

18. Aldimine Ketoamine HbA1c results from the posttranslational modification of hemoglobin A by the nonenzymatic covalent binding of glucose to the N-terminal valine of the β-globin chain- GLYCATION. HbA1C

19. Advantages of HbA1C Assuming normal erythropoiesis and a stable hemoglobin concentration, HbA1c reflects the average glycemia level during one red blood cell life cycle (2-3 months). Easy to do- It can be performed at any time of the day and does not require any special preparation such as fasting. The use of HbA1c can avoid the problem of day-to-day variability of glucose values, and importantly it avoids the need for the person to fast and to have preceding dietary preparations. Stable in EDTA tube- can be stored for long time

20. Problems with HbA1C Needs reliable method to get HbA1C- need standardised , widely accepted and reliable methods Lots of things interfere with HbA1C

21. Diabetes diagnosis The diagnosis of diabetes in an asymptomatic person should not be made on the basis of a single abnormal plasma glucose or HbA1c value. At least one additional HbA1c or plasma glucose test result with a value in the diabetic range is required, either fasting, from a random (casual) sample, or from the oral glucose tolerance test (OGTT). The diagnosis should be made by the best technology available, avoiding blood glucose monitoring meters and single-use HbA1c test kits.

22. Case 4 Mr JS, 17 year old boy, in XII C/o 5kg weight loss. FBS- 200, PPBS- 390, HbA1C- 10.5% Was given Insulin O/E- BMI- 32, acanthosis+++ Post prandial C-Peptide- 5.4, Anti- GAD antibodies- negative

23. Dilemma 2 Is Insulin needed?

24. Assess Pancreatic ℬ - cell function FBS, PPBS C-Peptide levels Antibodies

25. Antibodies

26. Conclusion The phenotypes of T1DM and T2DM are becoming less distinctive with an increasing prevalence of obesity at a young age, recognition of the relatively high proportion of incident cases of T1DM in adulthood and the occurrence of T2DM in young people. Using appropriate tests from reliable methods is very important in diagnosing and managing diabetes patients appropriately.

27. Tests for Risk stratification

28. Kidney

29. Indian Scenario: ‘I CaRe for Diabetes’ Survey At-least 1 in 2 Patients of T2D had CKD Prevalence of CKD Parameters in T2D AK Das et al. on behalf of I CARE steering committee. JAPI ( Suppl ). May 2018. 66(5): 5-15

30. Patient having raised creatinine (>1.1 mg/dl) = 8.4% Prevalence of CKD (based on eGFR and UACR) = 39.3% MIND study results True burden of CKD is higher by 5 fold 39.3% CKD Prevalence (based on eGFR + UACR) (N=384) 8.4% Raised Ser. Creat . (N=82) T2DM study population (N=977) Rasied ser. Creat >1.1 mg/dl Sahay R et al. Diabetes Research and Clinical Practice-volume106, supplement-1. PO162. 5

31. Faster progression in Asians Asians are more susceptible than Caucasians to diabetic nephropathy and exhibit faster progression from microalbuminuria to macroalbuminuria and renal failure Chandie Shaw PK, South-Asian type 2 diabetic patients have higher incidence and faster progression of renal disease compared with Dutch-European diabetic patients. Diabetes Care, 2006;29:1383-1385.

32. Tests Urea, Creatinine Urine Routine Spot urine- Microalbumin and Creatinine for ALBUMIN CREATININE RATIO (ACR) eGFR

33. eGFR

34. Identifying early clinical markers: Who are at risk? Myth: CKD same as Renal failure CKD includes 5 stages using eGFR and UACR Early intervention can make a difference Prognosis of CKD by GFR and Albuminuria Categories: KDIGO 2012

35. Heart

36. Cardiac assessment Lipid profile ECG If possible- ECHO If needed- Treadmill tests and further cardiac evaluation and cardiology review

37. Development of Anti-diabetic Agents has been at a good pace…

38. Eyes

39. Ophthal eveluation Fundus examination Visual acuity

40. Retinopathy

41. Direct and remotely

42. Foot assessment

43. Pressure ulcers

44. Biothesiometer

45. Pressure point assessment

46. IPSWICH Touch Test

47. ABPI

48. Autonomic Neuropathy

49. Autonomic neuropathy History ECG- Resting tachycardia and ‘R-R intreval ” In its early stages, CAN may be completely asymptomatic and detected only by decreased heart rate variability (HRV) with deep breathing Postural BP

50. Investigations

51. At first visit FBS, PPBS or RBS Urea, Creat - calculate eGFR Urine routine and ACR Cholesterol HbA1C ECG Foot Examination

52. When to recheck? FBS, PPBS- Individualise Urea, Creat - yearly or earlier ACR- recheck in 2-3 months if abnormal or yearly Cholesterol- yearly HbA1C- 3 to 6 monthly ECG- yearly Foot Examination- yearly

53. ADDITIONAL GADGETS

54. Glucometers- structured monitoring

55. Continuous glucose monitoring

56. AGP

57. Conclusion

58. ADA recommendations