1. T McD Kluyts1 GUIDELINES FOR THE FOLLOW-UP OF DIABETES MELLITUS TYPE 2 PATIENTS by T McD Kluyts University of Pretoria

2. T McD Kluyts2 PRE-TEST List the target organs in DM2 Indicate the main reasons for routine urinalysis Indicate the principle lifestyle modification measures that should be employed in DM2. CNS including autonomic system, Eyes, Kidney, C-V system Proteinuria, Ketonuria, Occult infection Diet, exercise, weight loss, addiction management.

3. T McD Kluyts3 CRITERIA FOR THE DIAGNOSIS OF DIABETES MELLITUS Fasting plasma glucose  7.0 mmol/l. or Symptoms of diabetes plus: casual plasma glucose concentration  11.1 mmol/l. 1 or 2-h PG  11.1 mmol/l during an OGTT.

4. T McD Kluyts4 Diabetes Mellitus Type 2 Previously NIDDM, Adult type DM, type 2 DM DM 2 Not insulin dependent for survival Age 30+ at diagnosis Usually obese Few classic symptoms Ketoacidosis rare

5. T McD Kluyts5 The following measures are directed towards : G lycaemic control and Prevention of complications

6. T McD Kluyts6 SUBJECTIVE Compliance Complications Patients questions OBJECTIVE Examinations Sideroom procedures Special investigations MONTHLY FOLLOW-UP

7. T McD Kluyts7 SUBJECTIVE Compliance: Check the patients medicines Discuss the taking of medicines Establish supervision and monitor bloodglucose, diet and exercise records

8. SUBJECTIVE Complications: Ask about:  Vision  Feet  Infections  Pains and Sensations

9. T McD Kluyts9 SUBJECTIVE Questions from the Patient: Encourage patient to talk and to ask questions Re-affirm treatment schedule Explore family situation

10. T McD Kluyts10 OBJECTIVE Physical examination: Pulse, bloodpressure, temperature, respiratory rate. Eyes: Cataracts and vision CVS: Heart and peripheral circulation CNS: Muscle strength, reflexes, sensation, proprioception BMI

11. OBJECTIVE Objective  Sideroom procedures: Blood glucose Urine Labstix Urine microscopy  Special investigations: Never routinely, only as and when indicated by examination

12. T McD Kluyts12 OBJECTIVE  Urine: glucose and ketones are important  Blood glucose: measure with glucometer  Foot examination: skin,circulation, shoes  Look at home monitoring chart

13. T McD Kluyts13 Three- to six monthly :  As monthly + lab tests: HbA1c – measurement Urine for proteinuria Snellen test, visual fields ECG Lipid profile Feet examination

14. T McD Kluyts14 ANNUALLY  Monthly examination + Lab tests  Neurological status  Cerebral function  Micro-circulation  Lipid profile  Micro-albuminuria  ECG  Fundoscopy

15. T McD Kluyts15 KEY TESTS TEST OR EXAMFREQUENCY Glycated Hb2x per year Fundoscopy1x per year Foot examQuaterly Lipid profile1-2 yearly S-createnineYearly MicroalbuminuriaYearly Blood pressureEach visit BMIEach visit ECG2x per year

16. T McD Kluyts16 PATIENT EDUCATION  This is the cornerstone of effective diabetes care.  Sufficient time and resources should be made available in order to do this effectively.

17. T McD Kluyts17 RECORD DEGREE OF CONTROL  Patients with poor or brittle control, should be seen at least once a month.  Well controlled diabetics can be seen at longer intervals eg 2-4 monthly.

18. T McD Kluyts18 Criteria for intervention CRITERIA OPTIMALACCEPTABLEACTION NEEDED BLOOD GLUCOSE FASTING4-66-8>8 POST- PRANDIAL 4-88-10>10 GLYCATED Hb % <77-8>8

19. T McD Kluyts19 WEIGHT As obesity virtually always accompanies type 2 diabetes, it should be targeted in its own right. A weight loss of 5-10% should be the initial aim. It has been shown to improve insulin resistance and all its associated parameters

20. T McD Kluyts20 Weight Body Mass Index (BMI) = Mass in kg/Length in meter 2 OptimalAcceptableAction needed BMI<2520 - 26>27

21. T McD Kluyts21 WEIGHT Evidence demonstrates that: structured, intensive lifestyle programs involving participant education, reduced dietary fat and energy intake, regular physical activity and frequent participant contact are necessary to produce long-term weight loss of >5% of starting weight.

22. T McD Kluyts22 GLUCOSE TREATMENT RECOMMENDATIONS FOR DM2  Always provide or refer for dietary and lifestyle advice at diagnosis  If random glucose values > 15 mmol/L ~ consider starting oral agents together with lifestyle modification from the start  If overweight (BMI > 25) ~ consider metformin unless contra-indicated  If postprandial glucose values constitute the major abnormality or sulphonylureas contra- indicated (e.g. renal failure) ~ acarbose or meglitinides may be considered

23. T McD Kluyts23 GLUCOSE TREATMENT (Continued)  If insulin resistance is the major abnormality, metformin should be considered as first line or add on therapy. If metformin is contra-indicated or poorly tolerated (e.g. raised serum creatinine or major cardio-pulmonary risks),then thiazolidinediones may be used.  Always start with monotherapy and titrate dosage to maximum over 1-3 months

24. T McD Kluyts24 GLUCOSE TREATMENT (Continued)  If goals still not reached, add second agent (lowest dose, titrate when necessary).  If goals still not attained despite good compliance and absence of major stressors such as infection, consider insulin therapy  In such cases, insulin therapy may be initiated as intermediate or long-acting insulin at bedtime (titrate against pre- breakfast reading), with or without oral agents. If possible, self glucose monitoring should be done in all patients on insulin.

25. T McD Kluyts25 GLUCOSE TREATMENT (Continued)  Initial insulin dose is 0.2-0.3 U/kg  If more than 30 U per day are required or clinical judgment indicates, use twice daily biphasic insulin (2/3 intermediate, 1/3 short acting). Consider referral.

26. T McD Kluyts26 BLOOD PRESSURE GOALS SYSTOLIC<130 DIASTOLIC<80 With Proteinuria SYSTOLIC<120 DIASTOLIC<70

27. T McD Kluyts27 BLOOD PRESSURE TREATMENT  Angiotensin converting enzyme (ACE) inhibitor based  Low dose diuretics, eg hydrochlorothiazide (HCTZ) 12.5mg or Indapamide 1.25 -2.5 mg/day may be appropriate first line agents  Most patients will require at least 2 agents

28. T McD Kluyts28 BLOOD PRESSURE (continued)  ACE inhibitors or angiotensin II receptor antagonists are indicated in the presence of micro- or macroalbuminuria  In patients over age 55 yrs with or without hypertension, but with another cardiovascular risk factor, an ACE inhibitor should be considered to reduce the risk of cardiovascular events.

29. T McD Kluyts29 LIPID GOALS Total Cholesterol<5.0 LDL<3.0 HDL>1.2 Triglycerides<1.5

30. T McD Kluyts30 LIPID TREATMENT LDL-cholesterol above 3 mmol/l ~ consider a statin as therapy Triglycerides above 1.5 mmol/l ~ check for secondary causes, consider using a fibrate LDL-cholesterol and triglycerides elevated ~ statin and fibrate if persistant Fibrates contra-indicted with impaired renal function ~ refer.

31. T McD Kluyts31 ASPIRIN RECOMMENDATIONS As a primary prevention strategy in high-risk men and women with type 1 or type 2 diabetes including diabetic subjects with the following: a family history of coronary heart disease, cigarette smoking, hypertension, obesity, albuminuria (micro or macro), age >30 years or dyslipidaemia.

32. T McD Kluyts32 ASPIRIN RECOMMENDATIONS (continued) Use aspirin therapy as a secondary prevention strategy in individuals who have evidence of large vessel disease, eg a history of myocardial infarction, vascular bypass procedure, stroke or transient ischaemic attack, peripheral vascular disease, claudication and/or angina.

33. T McD Kluyts33 ASPIRIN RECOMMENDATIONS (continued)  Use 150-300 mg aspirin per day (enteric coated if possible)  People with aspirin allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease are not candidates for aspirin therapy.

34. T McD Kluyts34 ASPIRIN RECOMMENDATIONS (continued) Aspirin therapy should not be recommended for patients under the age of 21 years because of the increased risk of Reye’s syndrome associated with aspirin use in this population

35. T McD Kluyts35 Exercise Record The exercise parameters are as follow: To reach a pulse rate of max – 20% for age and sex and maintain for 20 minutes at least 3 times per week at least Walking or running or cycling or swimming or any combination thereof

36. T McD Kluyts36 Weight and diet record This should include weekly weight measurements Dietary notes where indicated to explain weight changes Doctor/dietician’s comments

37. T McD Kluyts37 Glucose control record  The ideal would be twice daily blood-glucose recording: morning and evening.  This might be impossible for unsubsidised patients to attain, and daily urine testing will have to suffice as a minimum requirement.  Blood glucose should be done fasting in the mornings, and 2 hours postprandial at night.  Urine glucose should be measured fasting in the morning 1 hour after emptying the overnight bladder, and/or 15 minutes after emptying the 2 hour postprandial bladder in the evening.

38. T McD Kluyts38 SCENARIO 1 A 24 year old male student presents to you with a history of Diabetes Mellitus 2 for 2 years, complicated by systolic hypertension. He tells the story that he suddenly became ill while attending a rugby training camp 2 years ago. He has never before been ill in his life except for a chronic seasonal rhinitis for which he has been taking numerous treatment regimes in the past.

39. T McD Kluyts39 SCENARIO 1 (Continued) At the moment he is taking Glucophage and Diamicron one each twice daily On examination he is well built, weighs 110kg and is 1,8m tall His BP is 128/84 His father’s sister is a diabetic

40. T McD Kluyts40 SCENARIO 1 (Continued) He is still participating in sport, but had to retire from provincial level participation since the start of his illness He is complaining of tiring easily His random blood glucose today is 8.6mmol/l He is not keeping record of his exercise efforts or his diet

41. T McD Kluyts41 SOLVING THE PROBLEM Main problemAdditional factors Help seekingEducation

42. T McD Kluyts42 SCENARIO 2 A 38 year old lady with Diabetes Mellitus 2 on insulin replacement therapy visits you for a renewal of her medication She has been on Humoloc Mix 25 but when she went to the chemist last month for a repeat, she was told that it was no longer “on code”

43. T McD Kluyts43 SCENARIO 2 (Cont) She was not given any instruction on how to use it She is using 46 Units nocte On examination her blood pressure is 160/90; blood glucose = 18,6; she has 1+ oedema of the legs; her BMI = 31,5 She is also taking Coversyl 4mg daily with Natrilix 2,5mg daily for her blood pressure

44. T McD Kluyts44 SOLVING THE PROBLEM Main problemAdditional factors Help seekingEducation

45. T McD Kluyts45 ACKNOWLEDGEMENT Parts adapted from SEMDSA guidelines 2002 (Prof Paul Rheeder) ADA clinical practice recommendations 2002. Diabetes Care 2002; 25(1) supl 1 WEBSITE: http://www.novonordisk.com

46. T McD Kluyts46 Thanks !