Diabetes Dr. J. Antony Gagnon, Pharm.D., CDE, CAE Pharmacy Program Coordinator Hamilton Family Health Team

Pathophysiology of type 2 DM

Definitions FPG 2h PG Normal < 6.1 and < 7.8 IFG (isolated) 6.1 – 6.9 IGT (isolated) 7.8 – 11.0 IFG and IGT Diabetes > 7.0 and/or > 11.1 IFG: Impaired Fasting Glucose IGT: Impaired Glucose Tolerance 2h PG: 2-hour plasma glucose

Risk factors for diabetes 1st degree relative with diabetes High-risk population (e.g., Aboriginal) Hx of IGT or IFG Vascular disease Hypertension Dyslipidemia Overweight Abdominal obesity Schizophrenia Polycystic ovarian syndrome

Recommended targets for glycemic control A1C FPG or preprandial PG (mMol/L) 2-hour postprandial PG (mMol/L) Target for most patients < 0.07 4.0 – 7.0 5.0 – 10.0 Normal range (consider for patients in whom it can be achieved safely) < 0.06 4.0 – 6.0 5.0 – 8.0

Chronic complications of diabetes in relation to glucose control

Causes of death in patients with DM in Ontario

Risk of cardiovascular death

Vascular protection ACE inhibitor, as indicated Aspirin, as indicated BP control Glycemic control Lifestyle modifications Lipid control Smoking cessation

ACE inhibitors Micro-HOPE study (ramipril 10 mg daily) Total mortality - 24% CV death - 37% MI - 22% CVA - 33%

Aspirin (80 to 325 mg/d) Unless contraindicated, recommended in all patients with CVD or with atherosclerothic risk factors. If cannot tolerate aspirin can be substituted with Plavix (clopidogrel).

Blood pressure Risk reduction Diabetes-related death 24% Stroke 44% Microvascular disease 37% *Tight control (<14482 mmHg) vs less tight control (<154/87 mmHg)

Blood pressure targets SBP DBP DM < 130 <80 DM and proteinuria (> 1 g/d) < 125 < 75

Antihypertensive agents ACE inhibitors (ramipril, lisinopril, trandolapril, etc.) ARB (irbesartan, losartan, valsartan, telmisartan, etc.) Calcium Channel Blockers (amlodipine, felodipine,diltiazem, etc.) Beta-blockers (atenolol, metoprolol, etc.) Others

Cholesterol targets LDL (mMol/L) TC:HDL < 2.5 < 4.0

Lipid-lowering agents Statins (atorvastatin, rosuvastatin, simvastatin, pravastatin, fluvastatin) Fibrates (fenofibrate, gemfibrozil) Resins (cholestyramine, colestipol) Niacin

Nutrition

Nutrition Eat 3 meals / d at regular times and space meals no more than 6 h apart. Limits sugars and sweets such as sugar, regular pop, desserts, candies, jam, and honey. Limit amount of high fat food such as fried food, chips, and pastries. Increase amount of fibers (whole grain breads and cereals, fruits, and vegetables). If you are thirsty, drink water.

Physical activity Enhances insulin sensitivity and often weight loss Improves lipids (↓ TG, ↑ HDL) Improves blood pressure Enhances well-being ↓ risk of CVD 150 minutes per week, at least 10 min. at a time

Monitoring