Diabetes PSSA presentation Prof Danie van Zyl · Metformin (Biguanide) 1 –2 Obese patients...

Diabetes PSSA presentation

Prof Danie van Zyl

Number of people (20-79 years) with diabetes globally and by IDF Region

IDF diabetes atlas 2019

Diagnostic

Criteria for

DM2

Fasting plasma glucose (FPG) > 7.0 mmol/la

or

2-h plasma glucose (2PG) > 11.1 mmol/l during OGTTb

or

HbA1c > 6.5%c

or

Random plasma glucose (RPG) > 11.1 mmol/l

if classic symptoms or hyperglycaemic crisisd

Classification of Diabetes

Type 1

Destruction of beta cells

Autoimmune (ICA, anti-GAD, anti-Insulin)

Idiopathic

Absolute deficiency of insulin

Not all patients with late onset

of diabetes have type 2

diabetes. LADA diabetes looks

like type 2 but has antibodies

Type 2

Variable degrees of insulin

deficiency and resistance

No specific test for type 2

diabetes

Keto-acidosis does not

exclude type 2 diabetes

Insulin

Resistance

Syndrome

(Syndrome

X, Reaven’s

Syndrome,

Metabolic

Syndrome)

Constellation of abnormalities often seen together:

•Hyperinsulinaemia

• Impaired glucose tolerance

•Hypertension

• Increased plasma TGs

•Decreased HDL cholesterol

•Truncal obesity

Indicates an increased risk for DM2 and atherosclerotic disease

INSULIN RESISTANCE

RISK OF

DIABETES

IN

OBESITY

PROGRESSION OF TYPE 2 DIABETES

Graph adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

Chronic

progressive

disease

Achieving Targets

SEMDSA 2017

Factors to consider when choosing

glucose lowering drugs

Glycaemic targets

Glycaemic efficacy

Hypoglycaemia risk

Weight gain

Adverse effects

Treatment complexity

Patient factors

Clinical Effects of Anti-hyperglycemic Agents

Name HbA1c

reduction

Patient best suited

α glycosidase inhibitor (Acarbose) 0.5 – 1 High postprandial glucose

Metformin (Biguanide) 1 – 2 Obese patients

Meglitinides (Rapa-, Nata-glinide) 1 – 2 High postprandial glucose

Sulphonylureas (Glimepiride, Gliclazide) 1 – 2 Recently Dx type 2 diabetes

Thiazolinediones (Pioglitazone) 0.8 – 1.0 Obese or insulin resistant

DPP4 inhibitors (Sita-, Vilda-, Saxa- and Lina-

gliptin)

0.7 Add-on therapy

GLP-1 receptor agonist (Exena-,Lira-glutide) 0.8 – 1.2 Injectable only

SGLT2 inhibitor (Empa-, Dapa,-Canaglifozin) 0.8 – 1.2

HBA1C vs Average blood glucose control

HBA1c (%) Average blood glucose (mmol/L)

6.5 7.7

7 8.5

8 10.1

10 13.3

12 16.5

14 19,7

16 22.9

Treatment strategy DOH EDL

Metformin

Metformin + Sulphonylurea

Metformin + Sulphonylurea + basal Insulin

Metformin + Intensified Insulin

SEMDSA 2017 strategy

The Importance of BP and Glucose Control

-45

-40

-35

-30

-25

-20

-15

-10

-5

0Stroke

Any DM2endpoint Death Microvasc Compl

% r

ed

uc

tio

n

Effects of tight glucose and BP control

TightGlucosecontrol

Tight BPcontrol42

32

37

UKPDS 33

Patient with optimal life expectancy and best quality of life,

lowest morbidity

Glu

co

se

co

ntro

l

BP

co

ntro

l

Lip

id c

on

trol

Ea

rly d

ete

ctio

n o

f

com

plic

atio

ns

Lifestyle intervention and support

What role

can the

Pharmacist

play?

Early diagnosis of diabetes – Identify at risk

individuals (FINDRISK score)

50% diabetic patients is undiagnosed

The delay in diagnosis is 2 to 12 years

25% of type 2 diabetic patients have complications

at diagnosis

Refer for diagnostic testing if needed

Avoid Fad diet advice but motivate patients to

follow a healthy balanced diet

Motivate compliance to medication

Be vigilant – depression is frequent among diabetic

patient