Diabetes Mellitus management updates

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Mohamed Shehata,MD Assistant Professor of Medicine Baylor College of Medicine Houston TX

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Diabetes Mellitus management updates:

Diabetes Mellitus management updates Mohamed Shehata, M.D Assistant professor of Medicine Baylor College of Medicine American Board Certified Doctors for E gypt

Topics of discussion:

Topics of discussion Introduction D.M control Goals D.M control for the hospitalized patient. D.M control Guidelines updates. Sliding scale insulin friend or a foe.

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Long-term glycemic control is one of the most important treatment goals for type 2 diabetes. Micro vascular complications control: Diabetic retinopathy ,Nephropathy , Neuropathy However, very tight glycemic control appears to be less beneficial regarding the risk for cardiovascular disease, with some research suggesting that tight control actually increases the risk for cardiovascular mortality.

New Guidelines:

New Guidelines ADA and European Association for the Study of Diabetes (EASD) has issued combined new guidelines On the basis of findings from ACCORD (Action to Control Cardiovascular Risk in Diabetes study) and other studies, the ADA has set the hemoglobin A1c (HbA1c) goal at 7% in general. Some individualization.

“patient Centered Management”:

“patient Centered Management” Re: diet and nutrition , exercise, Pharmacotherapy Rather than using clearly defined algorithms, the new guidelines are less prescriptive and more patient-centered. Recommendations are tailored to individual patient needs, preferences, and tolerances and are based on differences in age and disease course. Other factors affecting individualized treatment plans include specific symptoms, comorbid conditions, weight, race/ethnicity, sex, and lifestyle

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■Current guidelines suggest that the goal HbA1c level should be less than 7%. This goal can be achieved with fasting glucose levels of less than 130 mg/ dL and postprandial glucose levels of less than 180 mg/ dL . ■More strict HbA1c targets may be considered among patients with long life expectancy and no history of cardiovascular disease. Advice on exercise should target a minimum of 150 minutes per week of activity

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■Metformin is the mainstay of oral therapy for type 2 diabetes because it effectively lowers serum glucose levels without raising body weight or the risk for hypoglycemia. It should be initiated at a low dose to reduce the incidence of gastrointestinal adverse effects. ■Patients with poor glycemic control at baseline, as characterized by an HbA1c level of 9% or more, may receive combination therapy at the outset of treatment

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■Insulin therapy should be considered as the initial therapy for patients with plasma glucose levels of more than 300 mg/ dL or HbA1c levels greater than 10%. ■Adding a second agent is associated with an average additional reduction of HbA1c levels of 1%. The choice of a second agent should be based not only on improving HbA1c values but also on improving the treatment's adverse effect profile and cost. ■Patients with an HbA1c value exceeding 8.5% with 2-drug therapy should receive insulin as opposed to a third ant diabetic agent.

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■Insulin is usually started at a low dose of 0.1 to 0.2 unit/kg/day. It is reasonable to have patients slowly titrate up their insulin dose once or twice weekly if glycemic targets are not met. ■The addition of prandial to basal insulin is usually necessary when the dose of insulin climbs to 0.5 to 1 unit/kg/day.

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Human Insulins and Insulin Analogues Onset Peak Duration Rapid-acting (lispro, aspart, glulisine) 10-15 min 1-2 h 3-5 h Short-acting (regular) 0.5-1 h 2-4 h 4-8 h Intermediate-acting (NPH) 1-3 h 4-10 h 10-18 h Long-acting Glargine 2-3 h none 24+ h Detemir 1 h none 12-24 h Premixed insulins 70% NPH/30% regular 0.5-1 h 2-10 h 10-18 h 50% NPH/50% regular 0.5-1 h 2-10 h 10-18 h 75% NPL/25% lispro 10-15 min 1-3 h 10-16 h 50% NPL/50% lispro 10-15 min 1-3 h 10-16 h 70% NPA/30% aspart 10-20 min 1-4 h 10-16 h

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■Insulin secretagogues such as sulfonylureas may be continued during treatment with basal insulin only but should be stopped when prandial insulin is prescribed. ■HbA1c targets up to 8% may be acceptable among older and frail patients with diabetes. Older adults are at higher risk for severe complications related to hypoglycemia, and this complication should be assiduously avoided among these patients.

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■Metformin may be used among patients with mild heart failure, and current practice standards regarding the use of metformin in the setting of chronic kidney disease are too restrictive. Metformin can be used until the estimated glomerular filtration rate decreases to 30 mL/minute or less. ■Some evidence exists that pioglitazone may be particularly advantageous for patients with mild steatohepatitis

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A 54-year-old woman with a 6-year history of type 2 diabetes mellitus is evaluated for suboptimal glycemic control. Her current hemoglobin A1cvalue is 8.1%. Her diabetes regimen consists of metformin, 1000 mg twice daily, and glimepiride, 4 mg/d; the patient declines all injection therapy at this time. She has no other medical problems. There are no abnormalities in cardiovascular, kidney, or liver function. In addition to reinforcing lifestyle modifications, which of the following is most likely to maximally improve her glycemic control? A)Add acarbose B)Add exenatide C)Add pioglitazone D)Increase the glimepiride dosage E)Increase the metformin dosage

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In addition to her current therapy, this patient should also take pioglitazone to improve her glycemic control. According to the American Diabetes Association, most patients with diabetes mellitus should have a hemoglobin A1cvalue of less than 7%. This patient is substantially above that target despite dual therapy with metformin and a sulfonylurea. Several options are available, including increasing lifestyle modifications, adding a third oral agent (such as a thiazolidinedione, an α- glucosidase inhibitor, or a dipeptidyl peptidase-IV inhibitor), or adding an injectable agent, such as exenatide or insulin. This patient has expressed the desire to avoid injections, at least for the time being. As a result, her options are more limited. Of the choices provided, the only one that has been shown to reduce hemoglobin A1c values by approximately 1% is pioglitazone

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This treatment has been endorsed by the recent American Diabetes Association/European Association for the Study of Diabetes Consensus Statement on the management of type 2 diabetes. The glucose-lowering power of acarbose ranges between a 0.5% and 0.8% reduction in hemoglobin A1cvalues and is thus inferior to that of pioglitazone. Furthermore, acarbose may have substantial gastrointestinal side effects, including bloating, abdominal cramps, diarrhea, and flatulence. Increasing the dosage of a sulfonylurea, such as glimepiride, above half the maximum recommended dosage provides little additional therapeutic benefit. Similarly, patients taking metformin, 2000 mg/d, are unlikely to get much additional benefit from increasing the dosage to 2550 mg/d (the maximum recommended dosage).

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A 72-year-old man comes to the office for a follow-up evaluation. He has had type 2 diabetes mellitus for 13 years. Over the past 5 years, his hemoglobin A 1c value has slowly risen to 9.8%, and his fasting blood glucose levels at home have frequently exceeded 180 mg/ dL (10.0 mmol /L). He has been adherent to recommended lifestyle changes. The patient is currently on metformin, 1000 mg twice daily, and extended-release glipizide , 20 mg/d. He has hypertension treated with candesartan and hydrochlorothiazide and hyperlipidemia treated with atorvastatin. Results of physical examination are normal

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Which of the following is the best next step in therapy? A) add insulin therapy B) Add exetanide C) Add poiglitazone D)Double his dose of glipzide E) Add Sigalpitin

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Insulin glargine should be added to this patient’s regimen. Type 2 diabetes mellitus is associated with progressive beta cell dysfunction, resulting in deterioration of endogenous insulin secretory capacity over time. This leads to secondary failure rates of previously successful oral pharmacologic therapy and, ultimately, the need for insulin therapy in most patients with diabetes

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This patient has poor glycemic control, despite combination therapy with metformin and extended-release glipizide (a sulfonylurea), and thus requires insulin. The standard method of initiating insulin therapy is to begin with a single daily injection of a basal insulin, such as insulin glargine , insulin detemir , or neutral protamine Hagedorn (NPH) insulin; this approach minimizes the risk of hypoglycemia. Starting doses in the 0.2 to 0.3 U/kg range will be well tolerated in most patients, with future titration based on the results of home glucose monitoring. Dose changes are typically made in increments of 2 to 4 units every few days or weekly until the fasting glucose level is consistently in the range of 70 to 130 mg/ dL (3.9 to 7.2 mmol /L).

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The addition of insulin glargine or insulin detemir to this patient’s regimen should result in a substantial reduction in his hemoglobin A 1c value. Randomized studies of stepped therapy in type 2 diabetes showed that most patients were able to achieve target hemoglobin A 1c goals of 7% using a combination of oral antihyperglycemic agents and basal insulin therapy. If such a reduction is not achieved and postprandial hyperglycemia occurs, the addition of a mealtime rapid-acting insulin analogue or the substitution of a premixed insulin should be recommended

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Adding the injectable agent exenatide or another oral agent to this patient’s medication regimen is unlikely to reduce his hemoglobin A 1c value sufficiently. When added to a combination oral regimen, exenatide has been shown to reduce hemoglobin A 1c values by only 1% and the oral agents pioglitazone and sitagliptin by 1% or less. In most studies of patients with diabetes, increasing the sulfonylurea dosage beyond the half maximal dosage has resulted in little to no improvement in glycemic control. Therefore, doubling this patient’s dosage of glipizide is unlikely to be effective.

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A 78-year-old man is evaluated in the hospital for poor glycemic control before undergoing femoral-popliteal bypass surgery. He has been on the vascular surgery ward for 3 weeks with a nonhealing foot ulcer. The patient has an extensive history of arteriosclerotic cardiovascular disease, including peripheral vascular disease, and a 20-year-history of type 2 diabetes mellitus. His most recent hemoglobin A 1c value, obtained 2 months before admission, was 8.9%. His diabetes regimen consists of glipizide , 40 mg/d. While in the hospital, his plasma glucose levels have generally been in the 200 to 250 mg/ dL (11.1 to 13.9 mmol /L) range. He is eating well

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In addition to stopping glipizide , which of the following is the most appropriate treatment for this patient? A)Basal insulin and post prandial isnulin B)Insulin infusion C) NPH insulin Twice daily D) Sliding scale isnulin

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There are no data demonstrating improved clinical outcomes after treatment to achieve better glycemic control in patients on general hospital wards, but such treatment has been shown to improve outcomes in critically ill patients in the intensive care unit.

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This patient has uncontrolled diabetes mellitus during an acute medical illness requiring hospitalization. Although there are no data demonstrating improved clinical outcomes with better glycemic control in patients on general hospital wards, such treatment likely improves outcomes in the intensive care unit. Accordingly, national consensus guidelines recommend attempting to improve glycemic control in all hospitalized patients ( premeal glucose level <140 mg/ dL [7.8 mmol /L] and random glucose level <180 mg/ dL [10.0 mmol /L]). Thus, a basal-bolus insulin regimen consisting of a long- or intermediate-acting insulin and a rapid-acting insulin analogue before meals is recommended for this hospitalized patient with diabetes mellitus. Such an approach allows for a more easily titratable regimen and can conveniently be held during diagnostic testing or procedures when nutritional intake is interrupted

PowerPoint Presentation:

A regimen of neutral protamine Hagedorn (NPH) insulin twice daily will likely improve glycemic control but is not as easily titratable as a basal-bolus correction and does not provide for premeal coverage to prevent postprandial glucose spikes

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Sliding scale regular insulin has been associated with increased hyperglycemic and hypoglycemic excursions and has been found to result in inferior glycemic control compared with a basal-bolus correction regimen in hospitalized patients. Initiating this approach is therefore inappropriate.

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. Insulin Management of Diabetic patients on General medical and surgical floors

A-Patients receiving meals:

A-Patients receiving meals 0.5 unit/kg basal insulin And 0.1 unit/kg rapid insulin at each meal. Lower basal dose by 0.2 unit/kg If high sensitivity to insulin ( Renal,hepatic,thin,elderly,frail,adrenal insuff ., Hyprethyroid ,

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Alternatively increase dose by 0.2 unit/kg if Obese, open wounds, infection If tube feeding is to receive the same 24 hours dose 0.6-1.0 unit/kg in divided doses over 24 hours one dose every 8 hours of insulin 70/30 If patient is off tube feeding for 8 hours daily eliminate one dose daily. For patients on TPN, use one unit of insulin or every 10 gm of carbohydrate place part of the daily dose in the TPN bag and split the rest of the dose every 8 hours 70/30 insulin to goal insulin 110-180

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