A detailed slide on the MANAGEMENT OF DIABETES

Slide

1. A.A ALABI MANAGEMENT OF DIABETES MELLITUS- M1 Medical Student’s Lecture

2. Outline Problems in Diabetes care Management of blood glucose Classification of anti- diabetic agents Oral anti- diabetic agents Injectable anti-diabetic agents Considerations in management plan Treatment targets in diabetes care Benefits of treatment

3. Problems in diabetes Hyperglycaemia Hypertension Dyslipidaemia Other co-morbid conditions- cardiovascular disease, renal disease, liver disease etc Diabetes complications

4. Goals of therapy Eliminate symptoms related to hyperglycaemia Reduce/ Eliminate long term micro/ Macro vascular complications Achievement of a normal lifestyle as much as possible

5. Management of blood glucose Education, Nutrition and Exercise Oral anti- diabetic agents Injectables Combination of any of above

6. Education on Diabetes A continuous effort Education on Nutrition and exercise Care during illness Education on medications and side effects

7. Components of DM Education Self monitoring of blood glucose (SMBG) Urine ketone monitoring Insulin administration Diabetes during illness Treatment of hypoglycaemia Foot care

8. Nutrition (DIET) Medical nutrition therapy (MNT) Optimal coordination of caloric intake with other aspects of diabetes therapy( insulin, exercise, weight loss) Divided into Primary, Secondary and Tertiary Primary - targeted for DM prevention Secondary - to prevent complications in DM Tertiary - to prevent worsening of DM complications

9. Nutrition (DIET) contd General principles- diet that contains fruits, vegetables, fibre containing food and low fat milk Food with low glycaemic index Glycaemic index of a food is the estimate of the post prandial rise in blood glucose after taking such food In T2DM- caloric reduction and reduced fat intake

10. Components of MNT CHO 45-65% of total caloric intake FAT- 20- 35% of total calorie Mainly unsaturated fats Saturated fat < 7% of total calorie <200mg/day of dietary cholesterol

11. Components of MNT Protein 10- 35% of total calorie Others Fibre containing food Non- nutritive sweetners

12. Oral Anti-diabetic agents a.k.a Oral hypoglycaemic agents Classification Insulin sensitizers - biguanide , thiazolidinediones Insulin secretagogues - Sulphonylureas , meglitinides Others - DPP 4 inhibitors, α - glucosidase inhibitors

13. Biguanides Metformin - only biguanide in use Foremost anti- diabetic agent Usually first line in Type 2 DM, especially obese patients Phenformin - withdrawn years ago due to side effects of lactic acidosis

14. Metformin Acts on the liver by inhibiting hepatic gluconeogenesis and increasing insulin sensitivity Its is readily available and low cost Does not cause hypoglycaemia and weight gain Side effects include GI disturbance-(diarrhoea, abdominal cramps), lactic acidosis Contraindicated in renal and hepatic failure

15. Thiazolidinediones a.k.a Glitazones , examples Pioglitazone, Rosiglitazone Activates PPAR- gamma- peroxisome proliferator activated receptor Increases insulin sensitivity Does not cause hypoglycaemia S/E- fluid retention, increased risk of heart failure, fractures

16. Sulphonylureas Acts on beta cell to increase insulin secretion 1 st generation- tolbutamide , chlorpropramide 2 nd generation- glibenclamide , gliclazide , glimeperide Available and affordable Good reduction in HbA1c S/E- hypoglycaemia, weight gain

17. Meglitinides Acts by increasing insulin secretion E.g Nateglinide , Repaglinide S/E hypoglycaemia

18. DPP- 4 inhibitors Sitagliptin , Vildagliptin , Saxagliptin Incretin based therapy Inhibits DPP-4 activity, increasing GLP-1 concentration Effects include glucose dependent increase in insulin secretion and reduction in glucagon production

19. Alpha glucosidase inhibitors Reduces glucose absorption in GIT, by inhibiting enzymes that cleaves oligosaccharides to simple sugars s/e flatulence, diarrhoea, abdominal distension

20. Injectable Anti- Diabetics Insulin GLP-1 agonist (aka incretin analogues/ mimetics )- exanatide , liraglutide Amylin agonist eg pramlintide

21. Insulin Classification Animal vs Human vs Analogue Rapid vs Short vs Intermediate Vs Long acting Single vs Mixed preparation Inhaled

22. In 1921 the Canadian scientists Fredrick G. Banting, Charles H. Best, J.J.R. Macleod and James B. Collip discovered insulin. They extracted insulin from the islets of animal pancreases. Up to that time type 1 diabetes was a virtual death sentence for patients suffering from it.

23. Insulin action Increases glucose uptake, particularly in muscle, liver and adipose tissue Suppresses glucose output from the liver Increases formation of fat Inhibits breakdown of fats Promotes amino-acid uptake and prevents protein breakdown

24. Insulin types and action Onset ( hrs ) Peak (hrs) Duration (hrs) Rapid Lispro Aspart Glulisine <¼ ½ - 1 3-5 Short Soluble (regular) ½-1 2-4 6-8 Intermediate NPH 2-4 6-8 12-16 Long acting Glargine Detemir 2-4 1-2 No peak No peak ≥24 or more 12-24 (dose-dependent) Inhaled Insulin Exubera ¼ - ½ ½ - 1½ 4 - 6 Slides current until 2008

25. International Colour Coding for Insulin Preparations Insulin Preparation Color Code Rapid - Acting Analogs Insulin lispro (Humalog) Insulin aspart ( NovoLog ) Insulin glulisine ( Apidra )   Dark brown Orange Dark purple Short Acting Regular   Yellow Intermediate - Acting NPH   Green Long-Acting Analogs Insulin glargine ( Lantus) Insulin detemir ( Levemir )   Purple Dark Green

26. International Colour Coding for Insulin Preparations Insulin Preparation Colour Code Pre-Mixed Insulin’s Conventional 30/70 (30% Regular +70%NPH) 50/50 (50% Regular+50% NPH) 25/75 (25% Regular+75% NPH)   Brown Grey Sky blue Pre-Mixed Insulin’s Analog Humalog Mix 25/75(25% lispro + 75% lispro protamine) Humalog Mix 50/50 (50% lispro +50% lispro protamine) NovoLog Mix/ Novomix 30/70 (30% aspart +70% aspart protamine) Golden yellow   Red Deep Blue

27. INJECTION SITES The abdomen Deltoid area Thighs Buttock -subcutaneous injection Rotation of the injection site is important to prevent lipodystrophy Rotating within one area is recommended Exercise increases the rate of absorption from injection sites

28. Indications for insulin therapy Type 1 diabetes Type 2 diabetes with OHA failure Type 2 diabetes with nephropathy Hyperglycaemic emergency Sepsis, DM foot ulcer Surgery GDM

29. Insulin Syringe

30. Insulin Pen

31. Insulin Pump

32. Inhaled Insulin

33. Complications of Insulin Hypoglycaemia Weight gain Lipohypertrophy Lipoatrophy Insulin oedema Allergic reaction( animal insulin)

34. GLP-1 agonist Amplifies glucose stimulated insulin action Reduces glucagon secretion and slows gastric emptying Also causes weight loss s/e- nausea

35. Amylin agonist Reduce glucagon secretion Slows gastric emptying s/e- nausea

36. Consideration in management plan Duration of diabetes- the shorter the duration the need for more stringent control to prevent complications Age- for very old individuals control is usually less stringent Presence of co- morbities , past severe hypoglycaemia and non motivated patients may require less stringent control

37. HbA 1C Pre-meal 2 hours post-meal ADA < 7% 4.4 – 7.2mmol/L (80-130mg/dl) <10 mmoL /L (180mg/dl) ACE <6.5% 4 - 6.0mmol/L (72 - 110mg/dl) < 7.8 mmol/L (< 140 mg/dl) Targets for blood glucose

38. Targets of treatment It is individualised for each patient Hypertension also controlled to < 140/90 Treatment of dyslipidaemia with Statins Anti- platelets where indicated Treatment of proteinuria

39. Benefits of treatment Reduces onset of complications May reverse complications Total well being of patients Reduces mortality

40. Thank You