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

2. Pathophysiology of type 2 DM

3. 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

5. 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

6. 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

7. Chronic complications of diabetes in relation to glucose control

8. Causes of death in patients with DM in Ontario

9. Risk of cardiovascular death

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

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

12. 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).

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

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

15. 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

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

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

18. Nutrition

19. 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.

20. 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

22. Monitoring