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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