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Family H/o DM H/o IHD. Angina, IC H/o Smoking H/o Hypoglycemia Exam for all pulses B.P recording Foot exam - Trophic PNP and ANP Fungal Infect., Pruritus. Mandatory Examinations. Fasting and PP BG Hb A1c on Dx & six monthly Lipid profile, Lp(a), hs-CRP CHD Risk factors MAU - ACR

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Mandatory Examinations

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Mandatory examinations l.jpg

Family H/o DM

H/o IHD. Angina, IC

H/o Smoking

H/o Hypoglycemia

Exam for all pulses

B.P recording

Foot exam - Trophic

PNP and ANP

Fungal Infect., Pruritus

Mandatory Examinations

  • Fasting and PP BG

  • Hb A1c on Dx & six monthly

  • Lipid profile, Lp(a), hs-CRP

  • CHD Risk factors

  • MAU - ACR

  • ECG for LVH, IHD

  • Echo for LVD, LVH

  • Stress test in equivocal cases

  • Fundus exam for DR

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Diagnosis – O-GTT

75g of oral glucose – 2 hrs. after

DM

IGT

Normal

DM

IFG

Normal

FPG

200 mg%

140 mg%

126 mg%

100 mg%

PPG

  • FBG > 126 & PPBG > 200 - same day

  • RBG > 200 mg % on 2 occasions or

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Diagnosis - Practical Points

1. Do not label one a diabetic by glycosuria alone

For, one may have renal glycosuria

2. Benedict’s less accurate; shows any reducing substance.

Glucose oxidase test strips confirm glucosuria

3. Do not neglect urine test for acetone

4. Never base Dx on a single blood sugar test

5. O-GTT (2 sample) is the gold standard for Dx. of DM

6. HbA1c – Not for Dx. Follow up once in 3 to 6 months

7. Majority of diabetics are not symptomatic – so screen

One may present first time with complications – too late

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Correlation of MPG - HbA1c

Mean Plasma Glucose =

(35.6 x HbA1c %) – 77.3

HbA1c =

(MPG mg% + 77.3) / 35.6

Diabetes Care

Vol.26 (S), P33, 2003

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Blood Sample – Practical Points

  • The whole blood glucose is 15% higher

  • We need to estimate plasma glucose

  • Na F is to be used as the anti-coagulant

  • Centrifuge and separate plasma within 1 hour

  • For HbA1c – we need EDTA added blood –

  • HbA1c measurement – No fasting is required

  • C-Peptide or Serum Insulin – Only on fasting

  • Shouldn’t add any anti-coagulant for C peptide

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Stages of T2DM

Insulin Resistance

IR

Stage 1

Insulin Deficiency

  • Insulin Resistance

  • Hyper Insulinemia

  • Normal Glucose Tolerance

Stage 2

  • Insulin Resistance

  • Declining Insulin levels

  • Abnormal Glucose Tolerance

IR + ID

Stage 3

  • Insulin Resistance

  • Very low Insulin levels

  • Hyperglycemia round the clock

ID

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What is new in Rx. of T2DM

  • The step-care therapy is not advocated now.

  • Choice of OAD/Insulin to be individualized

  • Glycemic targets must be achieved quickly

  • Multiple therapies may be needed

  • A1c is the target now - within 6 months

  • Diet alone is not the option now - difficulties

  • Even prediabetes needs Rx. aggressively

  • Total metabolic control – notglycemia alone

  • Combination of OAD + Insulin, early insulin

  • Avoid hypoglycemia by proper drug choice

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Stage Based Management

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Today’s Treatment Goals

Keeping HbA1c and FBG, PPBG with in limits

  • Exercise – Diet – Weight reduction

  • OHAs and Insulin

    Correction of all metabolic abnormalities

  • Normalizing lipids,BP Goal < 130/80

  • Reducing Obesity and Waist Circumference

    Prevention and Rx. of complications

  • Macrovascular, 2. Microvascular, 3. Metabolic

    Special emphasis on Prevention of CHD

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Complications of T2DM

  • Metabolic Complications

    • IR; Obesity, Lipids – ↑TG, ↓HDL, ↑ sLDL

    • Thrombogenic ( ↑PAI-1, ↑ fibrinogen) profile

  • Micro-vascular Complications

    • Diabetic Retinopathy (DR)

    • Diabetic Kidney Disease (DKD) – Nephropathy

    • Diabetic Neuropathy – DPN, DAN

  • Macro-vascular Complication

    • Coronary Artery Disease (CAD)

    • Stroke, CVD, TIA, HT

    • Peripheral Vascular Disease (PVD)

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    Ticking Clock of T2DM

    • Micro-vascular Complications

      • At the onset of hyperglycemia

      • Control of hyperglycemia essential

      • The A1c target of less than 7 must (A)

    • Macro-vascular Complication

      • At the onset of insulin resistance

      • Blood pressure goal of 130/80 (B)

      • Control of lipid abnormalities (C)

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    How to Identify IR ?

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    Diet, Exercise, TLC

    Weight reduction, Waist reduction

    Metformin – unmasks Insulin receptors

    Insulin sensitizers – TZDs - PPARγ

    Abolition of Glucotoxicity

    Control of hypertension

    Control of Metabolic abnormalities

    ID

    IR

    How to treat Insulin Resistance ?

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    Drugs that sensitize the body to insulin and/or control HGO

    Drugs that stimulate the pancreas to make more insulin

    Drugs that slow the absorption of starches

    TZD – Glitazones And Metformin

    Sulfonylureas and Meglitinides

    -Glucosidase Inhibitors – Acarbose, Miglitol, Voglibose

    Major Classes of Medications

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    Metformin, TZD, (-GI add on)

    Insulin

    SU

    Meglitinide

    Lifestyle

    350

    Post Meal Glucose

    300

    250

    Fasting Glucose

    Glucose

    200

    150

    100

    50

    250

    200

    Insulin Resistance

    Relative Function

    150

    100

    Insulin Level

    At risk

    for Diabetes

    Beta cell failure

    50

    0

    -10

    -5

    0

    5

    10

    15

    20

    25

    30

    Years of Diabetes

    Timeline for Utilization of Therapies

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    © International Diabetes Center. From Kendall D, Bergenstal R.


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    Efficacy of Monotherapy - OADs

    DeFronzo Annals of Internal Medicine 1999;131:281-303, Nathan N Engl J Med 2002; 347:1342-1349

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    Summary of all effects of Rx.

    Diabetes Spectrum Vol. 5, # 3, 103-108

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    Basis of Treatment Decisions

    Dx. of T 2 DM (2 readings)

    Test Hb A1c %

    Acute/ DKA

    Hb A1c < 9.0 %

    Early Insulin +/- OAD

    Hb A1c > 9.0 %

    No IR Features

    IR Features +

    DM 5 yr / 5+ yrs

    LIFE STYLE

    RF N / Abn.

    CHF +/-

    LFT N /↑

    SU aller.

    lipid

    HT

    N FBG, ↑ PPBG

    ↑FBG, PPBG N

    ↑FBG, ↑ PPBG

    OAD = BG, SU, TZD, RG, AGI,

    OAD + In. + Amy + Ex

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    HbA1c < 7

    HbA1c < 7%

    HbA1c < 7

    HbA1c < 7

    Treatment Algorithm

    NEJM 355; 2478 23 December 7, 2006

    Dx. of T 2 DM (2 readings)

    HbA1c < 9%

    HbA1c > 9%

    TLC + Metformin 3 mon.

    I+OAD

    Y

    No

    Add Basal Insulin

    Add SU

    3 M

    Add TZD

    3 M

    No

    Y

    No

    Y

    No

    Y

    ↑ Insulin + OAD

    Add TZD

    Basal Insulin

    Add SU

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    Insulin Preparations

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    Three Types of Profiles

    Annals of Internal Medicine Volume 145 • Number 2, July 2006

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    How to prevention Complications of Diabetes ?

    • Weight reduction, Exercise

    • Strict control hyperglycemia

    • Achieving lipid profile targets

    • Smoking cessation

    • Rx. of Hypertension with ACEi/ ARB

    • Low dose Aspirin therapy

    • Statin therapy for all T2DM

    • ACEi or ARB for all with MAU

    • Early detection and evaluation

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    Take Home – A B C D E

    • A A1c – target of < 7%; Better 6%

      Aspirin for all DM

      ACEi or ARB for all DM

    • B Blood Pressure target of 130/80

      Blood Glucose monitoring

    • C Cholesterol LDL <100, Statin for all DM

    • D Diet modifications, Do not smoke

    • E Exercise 45’ every day, Education on DM

      Equivalent to having CAD is DM

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