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Diabetes mellitus typus 2 in primary care

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Presentation on theme: "Diabetes mellitus typus 2 in primary care"— Presentation transcript:

1 Diabetes mellitus typus 2 in primary care

2 Diabetes mellitus Diabetes mellitus (DM) is a heterogeneous group of disorders caused by a relative or absolute insulin deficiency, resulting in abnormalities of carbohydrate and fat metabolism.

3 Clasification of diabetes

4 Pathophysiology Type 2 diabetes is characterized by a combination of peripheral insulin resistance and inadequate insulin secretion by pancreatic beta cells.

5 Pathogenesis

6 The major risk factors for type 2 DM
Age greater then 45 Weight greater than 120% of desirable body weight Family history of type 2 diabetes in first-degree relative History of previous impaired glucose tolerance(IGT) or impaired fasting glucose(IFG) Hypertension (>140/90) or dyslipidemia ( low HDL, high TG>150) History of gestational diabetes mellitus Polycystic ovarian syndrome

7 Epidemiology The prevalence of type 2 DM is increasing, mirroring the increase in the prevalence of obesity prevalence of the disease increases with advancing age.Type 2 diabetes mellitus occurs most commonly in adults aged 40 years or older The prevalence of type 2 diabetes mellitus varies widely among various racial and ethnic groups.

8 Epidemiology USA:Diabetes affects 8.3% of Americans of all ages, 11.3% of adults aged 20 years and older, and 25% of persons age 65 and older, Prediabetes affects 35% of adults aged 20 years and older POLAND: 10,8% people diabetes near 17 % prediabetes

9 Diagnosis Symptoms and signs
Many patients with type 2 DM are relatively asymptomatic Classic symptom:polyuria, polydipsia, polyphagia weight loss, fatigue Blurred vision Lower-extremity paresthesias Yeast infection Ketoacidosis at the time of diagnosis is rare

10 Screning test for DM recommends testing for prediabetes and diabetes beginning at age 45 years all patients.If results are normal, testing should be repeated at least every 3 years. recommends considering testing for prediabetes and diabetes in asymptomatic adults who are overweight and have 1 or more of the following additional risk factors : Physical inactivity First-degree relative with diabetes Member of a high-risk ethnic population Delivered a baby weighing over 9 lb or diagnosed with gestational diabetes mellitus Hypertension (≥140/90 mm Hg or on therapy for hypertension) HDL cholesterol level under 35 mg/dL (0.90 mmol/L) and/or a triglyceride level above 250 mg/dL (2.82 mmol/L) Polycystic ovary disease IGT or IFG on previous testing Other clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans) History of cardiovascular disease

11 Laboratory tests: FPG, OGTT

12 Diagnostic criteria by ADA,EASD include the following:
A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, or A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), or A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis Whether a hemoglobin A1c (HbA1c) level of 6.5% or higher should be a primary diagnostic criterion or an optional criterion remains a point of controversy

13 Type 2 DM is a progressive disease

14 Complications of diabetes.
The prognosis in patients with diabetes mellitus is strongly influenced by the degree of control of their disease the typical patient with type 2 diabetes had diabetes for at least 4-7 years at the time of diagnosis, 25% had retinopathy; 9%, neuropathy; and 8%, nephropathy at the time of diagnosis

15 Approaches to prevention of diabetic complications include the following:
HbA1c every 3-6 months Yearly dilated eye examinations Annual microalbumin checks Foot examinations at each visit Blood pressure < 130/80 mm Hg, lower in diabetic nephropathy Statin therapy to reduce low-density lipoprotein cholesterol

16 Diabetes mellitus-associated mortality and morbidity
DM causes morbidity and mortality because of its role in the development of cardiovascular, renal, neuropathic, and retinal disease. DM is the major cause of blindness in adults DM is the leading contributor to end-stage renal disease DM is the leading cause of nontraumatic lower limb amputations The risk for coronary heart disease (CHD) is 2-4 times greater in patients with diabetes than in individuals without diabetes. Cardiovascular disease is the major source of mortality in patients with type 2 DM People with type 2 DM are at an increased risk for many types of cancer

17 Goals of treatment of DM are as follows:
Microvascular ( eye and kidney disease) risk reduction through control of glycemia and blood pressure Macrovascular ( coronary, cerebrovascular, peripheral vascular) risk reduction through control of lipids and hypertension, smoking cessation Metabolic and neurologic risk reduction through control of glycemia

18 Treatment Diabetes care is best provided by a multidisciplinary team of health professionals working in collaboration with the patient and family. Management includes the following: Appropriate goal setting Dietary and exercise modifications Medications Appropriate self-monitoring of blood glucose (SMBG) Regular monitoring for complications Laboratory assessment

19 Dietary Modifications
Modest weight losses of 5-10% have been associated with significant improvements in cardiovascular disease risk factors ( decreased HbA1c levels, reduced blood pressure, increase in HDL cholesterol, decreased plasma triglycerides) in patients with type 2 diabetes mellitus. Risk factor reduction was even greater with losses of 10-15% of body weight Mediterranean-style diet

20 Activity Modifications
Most patients with type 2 diabetes mellitus can benefit from increased activity. Aerobic exercise improves insulin sensitivity Bariatric Surgery In morbidly obese patients, bariatric surgery has been shown to improve diabetes control and, in some situations, normalize glucose tolerance

21 Pharmacologic Therapy
Early initiation of pharmacologic therapy is associated with improved glycemic control and reduced long-term complications in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following: Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Selective sodium-glucose transporter-2 (SGLT-2) inhibitors Insulins

22 Metformin Metformin is the preferred initial agent for monotherapy and is a standard part of combination treatments. Advantages of metformin include the following: Efficacy Absence of weight gain or hypoglycemia Generally low level of side effects High level of patient acceptance Relatively low cost

23 Metformin Metformin lowers basal and postprandial plasma glucose levels The dose of metformin is titrated over 1-2 months to at least 2000 mg daily, administered in divided doses (during or after meals to reduce gastrointestinal [GI] side effects). Exercise increases metformin levels and interferes with its glucose-lowering effect. Metformin reduces macrovascular risk in patients who are obese[ Metformin may decrease the risk of dementia associated with type 2 diabetes

24 Sulfonylureas Sulfonylureas ( glipizide, glimepiride) are insulin secretagogues that stimulate insulin release from pancreatic beta cells and probably have the greatest efficacy for glycemic lowering of any of the oral agents hypoglycemia the most common side effect. have the greatest efficacy for glycemic lowering of any of the oral agents. that effect is only short-term and quickly dissipates.

25 Alpha-glucosidase inhibitors
These agents delay sugar absorption and help to prevent postprandial glucose surges Meglitinide derivatives Meglitinides ( repaglinide, nateglinide) are much shorter-acting insulin secretagogues than the sulfonylureas are Thiazolidinediones TZDs ( pioglitazone , rosiglitazone ) act as insulin sensitizers Glucagonlike peptide–1 agonists GLP-1 agonists (, exenatide, liraglutide) mimic the endogenous incretin GLP-1; they stimulate glucose-dependent insulin release, reduce glucagon, and slow gastric emptying Dipeptidyl peptidase IV inhibitors DPP-4 inhibitors ( sitagliptin, saxagliptin, linagliptin) are a class of drugs that prolong the action of incretin hormones

26 insulins

27 Treatment of DM t 2 Management of Glycemia

28 Monitoring - goals must be individual
HbA1c (%) <6.5 IFD <7.0 ADA Fasting/preprandial glucose (mmol/L / mg/dL) <6.0 / <110 IFD / ADA 2-h postprandial glucose (mmol/L / mg/dL) <7.8 / <140 IFD <10.0 / <180* ADA *ADA recommends that postprandial glucose measurements should be made 1–2 h after the beginning of the meal.

29 Self-monitoring of blood glucose in non-insulin treated type 2 diabetes (SMBG)
SMBG should be considered at the time of diagnosis to enhance the understanding of diabetes as part of individuals’ education and to facilitate treatment initiation and titration optimization. SMBG should also be considered as part of ongoing diabetes self-management education to assist people with diabetes to better understand their disease and provide a means to actively and effectively participate in its control and treatment, modifying behavioural and pharmacological interventions as needed

30 Management of Dyslipidemia

31 Management of Hypertension
Prefers inhibitors of the renin-angiotensin system (ACE inhibitors, ARBs) because of their proven renal protection effects in patients with diabetes. Diuretics or calcium channel blockers frequently are useful are second and third agents. The SBP goal is < 140 mm Hg in patients with diabetes The target diastolic blood pressure (DBP) remains < 80 mm Hg.

32 Prevention of Type 2 Diabetes Mellitus
Criteria for preventive metformin therapy are as follows: Obesity Age younger than 60 years Both impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) Other risk factors ( HbA1C >6%, hypertension, low HDL cholesterol, elevated triglycerides, or a family history of diabetes in a first-degree relative Weight reduction Proper nutrition Regular physical activity Cardiovascular risk factor reduction Aggressive treatment of hypertension and dyslipidemia

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