Management of Diabetes.pptx

Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes

1. Management of Diabetes Dr. ORIBA DAN LANGOYA, MBChB Resident Internal Medicine, Supervisor: Dr. Edrisa Mutebi , Endocrinologist , Lecturer Makerere University College of Health Sciences

2. Introduction The treatment of diabetes has traditionally concentrated on correcting hyperglycemia. Intensive control of hyperglycemia has been shown to reduce both microvascular & macrovascular complications of DM The principal cause of morbidity & premature death is CVD. Control of hyperlipidemia & hypertension are key factors in reducing CVD events

3. Diet and lifestyle modification & management of obesity About 80% of patients with type 2 diabetes are obese

4. Diet & activity recommendations C orrect obesity Reduce CVD risk, By limiting fat, cholesterol, sodium, and alcohol intakes A void hypoglycaemia in patients receiving insulin or sulphonylureas B y optimizing the timing and content of meals Current advice is close to the healthy eating recommendations for the whole population

5. PROPERTIES OF INSULIN PREPARATIONS

6. Pharmacologic Approaches to Glycemic Treatment PHARMACOLOGIC THERAPY FOR ADULTS WITH TYPE 1 DIABETES Most individuals with type 1 diabetes should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion. A Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk. A Individuals with type 1 diabetes should receive education on how to match mealtime insulin doses to carbohydrate intake, fat and protein content, and anticipated physical activity. B

7. Insulin regimens

8. TYPE 2 DIABETES MELLITUS Essential elements in comprehensive care of type 2 diabetes

9. Glucose-lowering agents

10. AGENTS USED FOR TREATMENT OF TYPE 1 OR TYPE 2 DIABETES

11. AGENTS USED FOR TREATMENT OF TYPE 1 OR TYPE 2 DIABETES

12. AGENTS USED FOR TREATMENT OF TYPE 1 OR TYPE 2 DIABETES

13. Pharmacologic Approaches to Glycemic Treatment PHARMACOLOGIC THERAPY FOR ADULTS WITH TYPE 2 DIABETES First-line therapy depends on comorbidities, patient-centered treatment factors, and management needs and generally includes metformin and comprehensive lifestyle modification. Other medications (GLP 1 receptor agonists, SGLT-2 inhibitors ), with or without metformin based on glycemic needs, are appropriate initial therapy for individuals with type 2 DM with or at high risk for atherosclerotic CVD, heart failure, and/or CKD

14. Glycemic management o f Type-2 DM Agents that can be combined with metformin include I nsulin secretagogues, T hiazolidinediones , α- glucosidase inhibitors , DPP-IV inhibitors, GLP-1 receptor agonists, SLGT2 inhibitors , I nsulin .

15. Pharmacologic Approaches to Glycemic Treatment Glucose-lowering Medication in Type 2 Diabetes: 2021 ADA Professional Practice Committee (PPC) adaptation of Davies et al. and Buse et al. Pharmacologic Approaches to Glycemic Management: Standards of Medical Care in Diabetes - 2022 . Diabetes Care 2022;45(Suppl. 1):S125-S143

16. Acute metabolic complications of diabetes and their treatment Diabetic ketoacidosis This is uncontrolled hyperglycemia with hyperketonemia severe enough to cause metabolic acidosis . Causes Diabetic ketoacidosis only develops when severe insulin deficiency, compounded by an excess of glucagon, stimulates lipolysis and a massive increase in ketogenesis

17. Pathophysiology of Diabetic Ketoacidosis Cellular dysfunction induced by intracellular acidosis , as well as cerebral oedema & shock are potentially life-threatening.

18. Mechanisms for increased ketone bodies in DKA

19. Clinical features In pts with DM always think on DKA!

20. MANIFESTATIONS OF DKA

21. DKA Diagnostic criteria

22. Guidelines for the management of diabetic ketoacidosis

23. Hyperglycemic hyperosmolar state (HHS ) HHS is distinguished from DKA by the absence of marked hyperketonemia (< 3.0mmol/l) & metabolic acidosis (pH >7.3). Hyperglycemia can be greater than in DKA (typically > 30mmol/l) R ise in urea due to dehydration & prerenal failure, may elevate the plasma osmolality to well over 350mosmol/kg Complications include thrombotic events due apparently to increased blood viscosity .

24. Management of hypoglycaemia

25. . Cardiovascular Disease and Risk Management

26. Screening and Diagnosis Cardiovascular Disease and Risk Management Blood pressure should be measured at every routine clinical visit. When possible , patients found to have elevated BP (140/90 mmHg), should have BP confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension. A Patients with blood pressure 180/110 mmHg & CVD could be diagnosed with hypertension at a single visit . All hypertensive patients with diabetes should monitor their BP at home. A

27. Cardiovascular Disease and Risk Management Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes - 2022 . Diabetes Care 2022;45(Suppl. 1):S144-S174

28. Treatment Goals Cardiovascular Disease and Risk Management For patients with DM & HTN, BP targets should be individualized through a shared decision-making process that addresses CVD risk, potential adverse effects of antihypertensive medications , and patient preferences. B For individuals with DM & HTN at higher CVD risk ( existing atherosclerotic, CVD [ASCVD] or 10-year ASCVD risk ≈ 15 %), a BP target of < 130/80 mmHg may be appropriate, if it can be safely attained. B For individuals with DM & HTN at lower risk for CVD (10- year atherosclerotic CVD risk < 15%), treat to a BP target of <140/90 mmHg. A In pregnant patients with DM and preexisting HTN, a BP target of 110–135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal HTN A & minimizing impaired fetal growth

29. Cardiovascular Disease and Risk Management Randomized controlled trials of intensive versus standard hypertension treatment strategies Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes - 2022 . Diabetes Care 2022;45(Suppl. 1):S144-S174

30. Cardiovascular Disease and Risk Management Recommendations for the Treatment of Confirmed Hypertension in People with Diabetes (1 of 2) Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes - 2022 . Diabetes Care 2022;45(Suppl. 1):S144-S174

31. Cardiovascular Disease and Risk Management Recommendations for the Treatment of Confirmed Hypertension in People with Diabetes (2 of 2) Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes - 2022 . Diabetes Care 2022;45(Suppl. 1):S144-S174

32. Lipid Management—Lifestyle Intervention Lifestyle modification focusing on weight loss (if indicated); application of a Mediterranean style or Dietary Approaches to Stop Hypertension (DASH) Intensify lifestyle therapy & optimize glycemic control for patients with elevated triglyceride levels ( ≥ 150 mg/Dl [1.7 mmol /L]) and/or low HDL cholesterol (<40 mg/ dL [1.0 mmol /L] for men, <50 mg/ dL [1.3 mmol /L] for women ).

33. Statin Treatment—Primary Prevention Cardiovascular Disease and Risk Management For patients with DM aged 40 – 75 years without atherosclerotic CVD, use moderate-intensity statin therapy in addition to lifestyle therapy. A For patients with DM aged 20 – 39 years with additional atherosclerotic CVD risk factors, it maybe reasonable to initiate statin therapy in addition to lifestyle therapy. C In patients with DM at higher risk, especially those with multiple atherosclerotic CVD risk factors or aged 50 – 70 years, it is reasonable to use high-intensity statin therapy. B In adults with DM & 10-year ASCVD risk of 20% or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL cholesterol levels by 50% or more. C

34. Cardiovascular Disease and Risk Management Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes - 2022 . Diabetes Care 2022;45(Suppl. 1):S144-S174

35. Antiplatelet Agents Cardiovascular Disease and Risk Management Use aspirin therapy (75 – 162 mg/day) as a secondary prevention strategy in those with DM & a history of ASCVD. A For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. B Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an ACS and may have bene fi ts beyond this period. A Long-term treatment with dual antiplatelet therapy should be considered for patients with prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse cardiovascular events. A

36. Cardiovascular Disease—Treatment (continued) Cardiovascular Disease and Risk Management I n patients with type 2 DM & established HFrEF , a SGLT-2 inhibitor with proven benefit in this patient population is recommended to reduce risk of worsening heart failure and cardiovascular death. A In patients with known atherosclerotic cardiovascular disease, particularly CAD, ACE inhibitor or ARB therapy is recommended to reduce the risk of cardiovascular events. A In patients with type 2 DM and established atherosclerotic CVD or multiple risk factors for atherosclerotic CVD, a GLP-1 receptor agonist with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events A

37. Cardiovascular Disease—Treatment (continued) Cardiovascular Disease and Risk Management In patients with prior myocardial infarction, b-blockers should be continued for 3 years after the event. B Treatment of patients with heart failure with reduced ejection fraction should include a b-blocker with proven cardiovascular outcomes benefit, unless otherwise contraindicated. A In patients with type 2 diabetes with stable heart failure, metformin may be continued for glucose lowering if estimated glomerular filtration rate remains >30 mL/min/1.73 m2 but should be avoided in unstable or hospitalized patients with heart failure. B

38. Cardiovascular Disease and Risk Management Figure 10.3—Approach to risk reduction with SGLT2 inhibitor or GLP-1 receptor agonist therapy in conjunction with other traditional, guideline-based preventive medical therapies for blood pressure, lipids, and glycemia and antiplatelet therapy Cardiovasc ular Disease and Risk Management: Standards of Medical Care in Diabetes - 2022 . Diabetes Care 2022;45(Suppl. 1):S144-S174

39. Chronic Kidney Disease and Risk Management

40. Chronic Kidney Disease At least annually, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and eGFR should be assessed in patients with type 1 DM with duration of ≥5 years and in all patients with type 2 DM regardless of Rx. Patients with DM & urinary albumin ≥300 mg/g creatinine and/or an eGFR of 30–60 mL/min/1.73 m 2  should be monitored twice annually to guide therapy.

41. Date of Download: 4/19/2022 Copyright © 2022 American Diabetes Association. All rights reserved. From: 11. Chronic Kidney Disease and Risk Management: Standards of Medical Care in Diabetes—2022 Diabetes Care. 2021;45(Supplement_1):S175-S184. doi:10.2337/dc22-S011 Risk of chronic kidney disease (CKD) progression, frequency of visits, and referral to a nephrologist according to glomerular filtration rate (GFR) and albuminuria are depicted. The GFR and albuminuria grid depicts the risk of progression, morbidity, and mortality by color, from best to worst (green, yellow, orange, red, dark red). The numbers in the boxes are a guide to the frequency of visits (number of times per year). Green can reflect CKD with normal eGFR and albumin-to-creatinine ratio only in the presence of other markers of kidney damage, such as imaging showing polycystic kidney disease or kidney biopsy abnormalities, with follow-up measurements annually; yellow requires caution and measurements at least once per year; orange requires measurements twice per year; red requires measurements three times per year; and dark red requires measurements four times per year. These are general parameters only, based on expert opinion, and underlying comorbid conditions and disease state as well as the likelihood of impacting a change in management for any individual patient must be taken into account. “Refer” indicates that nephrology services are recommended. *Referring clinicians may wish to discuss with their nephrology service, depending on local arrangements regarding treating or referring. Reprinted with permission from Vassalotti et al. (115). Figure Legend:

42. Anti-hyperglycemic drugs for patients with T2D & CKD

43. Retinopathy , Neuropathy, and Foot Care

44. Diabetic Retinopathy Retinopathy, neuropathy, and foot care Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. A Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. A Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. B Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis . B

45. Diabetic Retinopathy—Treatment Retinopathy, neuropathy, and foot care Promptly refer patients with any level of macular edema, moderate or worse nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy to an ophthalmologist who is knowledgeable and experienced in the management of diabetic retinopathy. A Panretinal laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy. A

46. Retinopathy, neuropathy, and foot care The risk of ulcers or amputations is increased in people who have the following risk factors: Poor glycemic control Peripheral neuropathy with LOPS Cigarette smoking Foot deformities Pre-ulcerative callus or corn PAD History of foot ulcer Amputation Visual impairment CKD (especially patients on dialysis)