2. 2 Current Management of Diabetes Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

3. Aim having information on assessing symptoms and signs. developing management plans for diabetes. 3

4. Objectives At the end of this session, the trainees should be able to :- –list diagnostic criteria for DM –describe how to differentiate Type I & II DM –explain symptoms and signs of diabetes –discuss the evidence for lifestyle changes –describe the indications, contraindications, and side effects of antidiabetic agents

5. DM in Saudi Arabia Lifestyle Changes : Social & cultural changes Prevalence : Diabetes mellitus as a health problem in Saudi Arabia prevalence of DM is 23.7 % according to Dr. Al Nozha study (SMJ 2004) –1 / 4 of adults > 30 yr are diabetics. –36 Foot Amputation / day, at Riyadh.

6. D.M in Saudi Arabia cont….. Cost & Impacts. Psychological impact. Family & Social impact. Decreased Productivity. Sick leaves. Work Absence. Economical Costs.

7. Etiologic classification of diabetes mellitus II- Type 2 diabetes. III- Other specific types. IV- Gestational diabetes mellitus. I- Type 1 diabetes:

8. Etiologic Classification of Diabetes Mellitus  Type 1:   -cell destruction with lack of insulin.  has absolute insulin deficiency  predisposed to develop ketoacidosis  insulin is required for survival.

9. Etiologic Classification of Diabetes Mellitus  Type 2  has relative insulin deficiency combined with defects in insulin action.  is the most common form of diabetes, accounting for 90–95% of the disease  is most often found in overweight individuals. Narayan K, Boyle J, Thompson T, Sorensen S, Williamson D (2003). "Lifetime risk for diabetes mellitus in the United States". JAMA 290 (14): 1884–90. doi:10.1001/jama.290.14.1884.

10. Risk Factors for Type 2 DM Modifiable –Overweight and obesity –Sedentary lifestyle –Previously identified IGT and IFG –Metabolic syndrome –Diatery factors –Intrauterine environment –Inflamation 10 Non- Modifiable –Family history –Age –Gender –History of GDM –Polycystic ovary syndrome (PCO)

12. Classical symptoms –Unusual thirst (Polydipsia) –Frequent urination (Polyuria) –Unusual weight loss Other symptoms –Extreme fatigue or lack of energy –Unusually hungry –Moody & irritable –Blurred vision –Have recurrent infections –Wounds and bruises that are slow to heal –Get a lot of yeast infections –Have tingling or numbness in the hands and/or feet Patients may present with a variety of symptoms or even symptomless Symptoms & Signs

13. Criteria to diagnosis diabetes FPG >126 mg/dl (7.0 mmol/l)FPG >126 mg/dl (7.0 mmol/l) ) OR ( Fasting is defined as no caloric intake for at least 8 h ) OR Symptoms of diabetes and a casual plasma glucose > 200 mg/dl ( 11.1 mmol/l) ORSymptoms of diabetes and a casual plasma glucose > 200 mg/dl ( 11.1 mmol/l) OR 2-h plasma glucose > 200 mg/dl (11.1 mmol/l) during an OGTT.2-h plasma glucose > 200 mg/dl (11.1 mmol/l) during an OGTT. ( The test should be performed as described by the W H O (using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water)).

14. Diagnosis of Diabetes : Plasma Glucose Cutoff Points. 2- Hour BS on OGTT FBS mg/dl categories < 140 < 100 Normal _ > 100 and 100 and < 126 IFG > 140 and 140 and < 200_ IGT > 200 > 126 > 126 Diabetes * If without symptoms, there should be more than one measurement in order to diagnose.

15. Diagnosis of gestational DM

16. 16

17. First visit evaluation History taking and clinical assessment Physical examination Height and weight measurement. Blood pressure determination. Fundoscopic examination Oral examination Thyroid palpation Cardiac examination

18. First visit evaluation Physical examination  Abdominal examination (e.g., for hepatomegaly)  Evaluation of pulses by palpation  Hand/finger examination  Foot examination  Skin examination  Neurological examination  Signs of diseases that can cause secondary diabetes (e.g., hemochromatosis, pancreatic disease)

19. First visit evaluation Laboratory evaluation HBA1c Fasting lipid profile Test for microalbuminuria Serum creatinine in adults. Thyroid-stimulating hormone (if indicated) Electrocardiogram in adults (if indicated) Urinalysis for ketones and protein

20. Management Goals Annual visits and examinations should be done regularly Eliminate symptoms and improve well-being Prevent and retard microvascular complications  optimize glycemic control  target blood pressure levels Reduce macrovascular events  optimize glycemic control  target blood pressure levels  target lipid levels

22. Summary of recommendations for adults with Diabetes ParameterTarget Value HbA 1c < 7% pre-prandial plasma glucose70 - 130 mg/dL post-prandial plasma glucose < 180 mg/dL Blood pressure < 130/80 mmHg LDL- cholesterol < 100 mg/dL (<2.6 mmol/l) HDL- cholesterol > 40 mg/dL (1 mmol/l) for men > 50 mg/dL (1.3 mmol/l) for wom. Triglycerides < 150 mg/dL (17 mmol/l) ADA 2009

23. Goals should be individualized based on: ● duration of diabetes ● pregnancy status ● age ● co-morbid conditions ● hypoglycemia unawareness ● individual patient considerations Key concepts in setting glycemic goals

24. Follow up 24

25. Things to keep in mind during management of Diabetes Type 2: Deterioration of beta cells over time Increasing prevalence with increasing risk factors, e.g obesity Hyperglycemia affects morbidity, mortality and resources Tight glycemic control with insulin may reduce costly complications 30% to 40% of patients ultimately require insulin

26. Non-pharmacologic Therapy for DM Lifestyle therapeutic modifications Diet  Improved food choices  Spacing meals  Individualized carbohydrate content  Moderate calorie restriction Exercise  improve blood glucose control  reduce cardiovascular risk factors  contribute to weight loss..  improve well-being.

27. Nutritional recommendations for DM patients Protein to provide 10-20% of kcal/day Saturated fat to provide < 10% of kcal/day (< 7 % for those with elevated LDL). Polyunsaturated fat to provide < 10 % of kcal. Remaining calories to be divided between carbohydrate & monounsaturated fat, based on medical needs & personal tolerance. Use of caloric sweeteners is acceptable.

28. Considerations in Pharmacologic Treatment of Diabetes Complications/tolerability Frequency of hypoglycemia Compliance/complexity of regimen Cost

34. Sulfonylureas DrugDoseSide effects Tolbutamide Restinon® 500-2000mg Od-Bid Weight gain hypoglycemia Glibenclamide Daonil ® 5mg 15-20 mg Od-Bid Weight gain Hypoglycemia Gliclazide Diamicron ® 80mg 40-320mg Od-Bid Weight gain hypoglycemia Glipizide Minidiab ® 5mg 2.5-20mg Od Weight gain hypoglycemia Glimerpiride Amaryl ® 1,2,4 mg 1-8mg Od Weight gain hypoglycemia

35. DrugDoseSide effectsDrug class Metformin Glocophage® 500-850mg 1000- 2550mg Bid-Tid Diarrhea Lactic acidosisBiguanides ↓ hepatic glucose production Acrobose Glucobay ® 50-100 mg 150-300 mg Tid Gas, Abdominal pain, Diarrhea α – Glucosidase inhibitors ↓ intestinal absorption Rosiglitazone Avandia ® 2,4,8 mg 4-8mg Od-Bid Oedema,weight gain,hepatic failure T hiazolidinediones ↑ preipheral glucose disposal Repaglinide Novonorm ® 0.5,1,2 mg 1.5-16mg Tid-Qid Weight gain hypoglycemiaMeglitinides ↑ pancreatic insulin secretion