Académique Documents
Professionnel Documents
Culture Documents
of Medical
care in
diabetes2017
Group 7&8
1
2
Classification (4 types)
1. onset
2. Diabetic ketoacidosis (DKA)
autoimmune -cell destruction, 2
1. Type 1 diabetes usually leading to absolute ins 3. DM type1 :
ulin deficiency polyuria/polydipsia
1/3 DKA
1. DM type 1
a progressive loss of -cell ins 2. experts: DM
2. Type 2 diabetes ulin secretion frequently on the Type 1 2
background of insulin resistanc
cell
e
cell
hyperglyce
mia
3
Classification (4 types)
2
3. Gestational diabetes mellitus (GDM)
3
5
Diagnosis
Criteria for the diagnosis of diabetes
FPG 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
OR
2-h PG 200 mg/dL (11.1 mmol/L) during an OGTT. The test should be performed as described
by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose
dissolved in water.*
OR
A1C 6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that
is NGSP certified and standardized to the DCCT assay.*
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a randomplasma
glucose 200 mg/dL (11.1 mmol/L).
*In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing.
6
Glycemic Targets
A1C < 7%
Preprandial capillary plasma
glucose 80130 mg/dL
Peak postprandial capillary plasma gl
ucose < 180 mg/dL
severe hypoglycemia
A1C < 8%
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Management
Non-pharmacologic treatment
Pharmacologic treatment
8
Lifestyle Management
Weight Management
type 2 diabetes
>5%
7%
9
Lifestyle Management
PHYSICAL ACTIVITY
type 1 type 2
prediabetes 60 /
3 /
150 /
23 /
Flexibility
balance training 23 /
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SMOKING CESSATION: TOBACCO AND
e-CIGARETTES
PSYCHOSOCIAL ISSUES
Psychosocial care
( 65 ) cognitive impairment depression
Diabetes Distress
diabetes distress /
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Prevention or Delay of Type 2 Diabetes
Lifestyle Intervention
12
PHARMACOLOGIC INTERVENTIONS-Recommendations
1. Metformin
type 2 diabetes IGT, IFG, AIC 5.7-6.4%
- BMI 35 kg/m2 60 gestational dia
betes mellitus
- / A1C
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15
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Biguanides - Metformin
Cellular mechanism : Activates AMP-kinase
Primary physiological action : Hepatic glucose production
Advantages Disadvantages
- - GI side effects (diarrhea, abdominal cra
- hypoglycemia mping, nausea)
- CVD events - Vitamin B12 deficiency
- A1C - Contraindications: eGFR < 30 mL/min/1
.73 m2, acidosis, hypoxia, dehydration
- Lactic acidosis (rare)
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Sulfonylureas
2nd generation : Glyburide, Glipizide, Glimepiride
Cellular mechanism : SUR1 (sulfonylurea receptor1) Closes K
ATP channels on -cell plasma membranes
Advantages Disadvantages
- - Hypoglycemia
- Microvascular risk - Weight
- A1C
18
Meglitinides (glinides) Repaglinide, Nateglinide
Advantages Disadvantages
- Postprandial glucose - Hypoglycemia
- - Weight
-
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TZDs - Pioglitazone
Cellular mechanism : Activates the nuclear transcription factor PPAR-
Primary physiological action : Insulin sensitivity
Advantages Disadvantages
- hypoglycemia - Weight
- A1C - Edema/heart failure
- Durability - Bone fractures
- Triglycerides (pioglitazone) - LDL-C (rosiglitazone)
- ? CVD events (PROactive, pioglitazone)
- Risk of stroke and MI in patients without diab
etes and with insulin resistance and history of re
cent stroke or TIA (IRIS study, pioglitazone)
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- Glucosidase inhibitors- Acarbose, Miglitol
Cellular mechanism : Inhibits intestinal -glucosidase
Primary physiological action : Slows intestinal carbohydrate digestion/
absorption
Advantages Disadvantages
- Rare hypoglycemia - Generally modest A1C efficacy
- Postprandial glucose excursions - Gastrointestinal side effects (flatulen
- CVD events in prediabetes (STOP ce, diarrhea)
-NIDDM) - Frequent dosing schedule
- Nonsystemic
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DPP-4 inhibitors
Sitagliptin , Saxagliptin , Linagliptin, Alogliptin
Cellular mechanism : Inhibits DPP-4 activity, increasing postprandial inc
retin (GLP-1, GIP) concentrations
Primary physiological action : - Insulin secretion (glucose dependent)
- Glucagon secretion (glucose dependent)
Advantages Disadvantages
- hypoglycemia - Angioedema/urticaria and other immune-medi
- ated dermatological effects
- ? Acute pancreatitis
- Heart failure hospitalizations (saxagliptin; ?
alogliptin)
22
Bile acid sequestrants - Colesevelam
Cellular mechanism : Binds bile acids in intestinal tract,
increasing hepatic bile acid production
Advantages Disadvantages
- Rare hypoglycemia - Modest A1C efficacy
- LDL-C - Constipation
- Triglycerides
- May absorption of other medications
23
Dopamine-2 agonists - Bromocriptine (quick release)
Cellular mechanism : Activates dopaminergic receptors
Primary physiological action :
- Modulates hypothalamic regulation of metabolism
- Insulin sensitivity
Advantages Disadvantages
- Rare hypoglycemia - Modest A1C efficacy
- ? CVD events (Cycloset Safet - Dizziness/syncope
y Trial) - Nausea
- Fatigue
- Rhinitis
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SGLT2 inhibitors Canagliflozin, Dapagliflozin , Empagliflozin
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GLP-1 receptor agonists
Exenatide, Exenatide extended release, Liraglutide, Albiglutide, Lixisenatide , Dulaglutide
Cellular mechanism : Activates GLP-1 receptors
Primary physiological action : - Insulin secretion (glucose dependent)
- Glucagon secretion (glucose dependent)
- Slows gastric empty
- Satiety
Advantages Disadvantages
- Rare hypoglycemia - Gastrointestinal side effects (nausea/vomiting/
- Weight diarrhea)
- Postprandial glucose excursions - Heart rate
- Some cardiovascular risk factors - ? Acute pancreatitis
- Associated with lower CVD event rate and mort - C-cell hyperplasia/medullary thyroid tumors in
ality in patients with CVD (liraglutide LEADER) animals
(30) - Injectable
- Training requirements 26
Insulins
Rapid-acting analogs Basal insulin analogs
Lispro Glargine
Aspart Detemir
Glulisine Degludec
Inhaled insulin Premixed insulin product
Short-acting s
Human Regular NPH/Regular 70/30
Intermediate-acting 70/30 aspart mix
Human NPH 75/25 lispro mix
50/50 lispro mix
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HYPERTENSION / BLOOD PRESSURE CONTR
OL
Screening and Diagnosis
Goals
140/90 mmHg
ASCVD
120160/80105 mmHg
Treatment
Lifestyle therapy
29
Treatment for hypertension
ACEIs ARBs first-line treatment
ACE inhibitors urinary albuminto creatinine 300 mg/g
creatinine creatinine 30299 mg/g
Angiotensin receptor blockers
Thiazide-like diuretics
Dihydropyridine calcium channel blockers
ACEIs, ARBs or diuretics sCr, eGFR
Combination
Serum potassium
NO ACEIs+ARBs
lifestyle interventio
n 30
LIPID MANAGEMENT
31
LIPID MANAGEMENT
statins side effe
cts,
tolerability, LDL cholesterol levels Statin therapy
ACS LDL cholesterol
o ezetimibe + moderate-intensity statin therapy >50 mg/dL (1.3 mmol/L)
moderate-intensity statin ASCVD
high-intensity statin ther
apy
o fibrates + statins
ASCVD triglyceride level 204 mg/d
L (2.3 mmol/L) HDL cholesterol level 34 mg/dL
(0.9 mmol/L)
o niacin+statins
stroke
34
ANTIPLATELET AGENTS
aspirin therapy (75162 mg/day) secondary prevention
aspirin clopidogrel (75 mg/day)
Dual antiplatelet therapy acute coronary syndrome
aspirin therapy (75162 mg/day) primary prevention type 1
or type 2 50
major risk 1 bleeding
(major risk family history of premature atherosclerotic cardiovascular disease,
hypertension, dyslipidemia, smoking, or albuminuria)
Aspirin
36
Coronary Heart Disease
Treatment
aspirin st
atin therapy ( ) ACE inhibitor therapy
cardiovascular events
myocardial infarction b-blockers
2
symptomatic heart failure thiazolidinedione
type 2 diabetes stable congestive heart failure metfor
min estimated glomerular filtration 30 mL/min
unstable
37
Microvascular Complications
and Foot Care
38
DIABETIC KIDNEY DISEASE
Renal function DM type1 5
DM type2
Diagnosis : albumintocreatinine ratio (UACR) 30 mg/g
eGFR < 60 mL/min/1.73 M2
Albuminuria
Nutrition : 0.8 g/kg/day
CVD Diabetic
kidney disease ACEIs ARB
s CCBs, Beta blockers,Diuretics
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DIABETIC RETINOPATHY
DM type1 eye examination 5
DM type2
Treatment : Photocoagulation surgery , AntiVascular Endothelial Growth
Factor Treatment (Intravitreal injections)
Laser photocoagulation
macular edema, severe non proliferative, diabetic retinopathy
Retinopathy Aspirin cardioprotection
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NEUROPATHY
Peripheral neuropathy
Treatment:
o neuropathy
o Autonomic neuropathy
o Pregabalin Duloxetine Neuropathy
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FOOT CARE
o Poor glycemic control
o Peripheral neuropathy with LOPS
o Cigarette smoking
, o Foot deformities
o Preulcerative callus or corn
o PAD
o History of foot ulcer
o Amputation
o Visual impairment
o Diabetic nephropathy
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Diabetes Care in the Hospital
43
Diabetes Care in the Hospital
Insulin therapy 180mg/dL (10.0 mmol/L).
target glucose range =140180 mg/dL (7.810.0 mmol/L)
140 mg/dL hypoglycemia
Basal insulin basal + bolus correction insulin regimen
. hypoglycemia
hypoglycemia (b
lood glucose value is <70 mg/dL (3.9 mmol/L))
44
Diabetes Care in the Hospital
BEDSIDE BLOOD
4
GLUCOSE -6
MONITORING 30
2
Point-of-Care Meters (POC) glucos
e meters
Continuous Glucose Monitoring (CGM)
POC hypoglycemia
CGM
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Diabetes Care in the Hospital
ANTIHYPERGLYCEMIC A Insulin Therapy
Critical Care Setting
GENTS
Noncritical Care Setting SC rapid short actin
g insulin 4-6
Type 1 DM DM type 1
Transitioning Intravenous to Subcutaneous Insulin
SC 1-2
Noninsulin Therapies
DPP-4 inhibitors basal insulin
hypoglycemia
SGLT-2 inhibitors DKA, urosepsis, UTI
46
Diabetes Care in the Hospital
Hypoglycemia Triggering Events
Hypoglycemia corticosteroi
(blood glucose d dose, reduced oral intake, emesis, new NPO status
levels short-acting
70 mg/dL) dextrose
Predictors of Hypoglycemia
- 6
Prevention
47
Diabetes Care in the Hospital
Medical nutrition t
herapy in the hos
pital A1C
Self-Management
in the hospital
48
STANDARDS FOR SPECIAL SITUATIONS
1. Enteral/Parenteral Feedings
49
STANDARDS FOR SPECIAL SITUATIONS
2. Glucocorticoid Therapy
, ,
3. Perioperative Care
1. 80-180 mg/dL (4.4-10.0 mmol/L)
2.
3. metformin 24
4. hypoglycemia or procedure and give
half of NPH dose or 6080% doses of a long-acting analog or pump basal insulin
5. 4-6
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STANDARDS FOR SPECIAL SITUATIONS
4. Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State
DKA Sepsis
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Diabetes Care in the Hospital
Transition from The Acute C 1
are Setting
1-2 A1C 3
A1C
Structured Discharge 1.
Communication 2. primary physician
3.
hypoglycemia, hyperglycemia
Prevention admissions and Preventing Hypoglycemic Admissions in Older Adults
readmissions Oral antihyperglycemic
Hypoglycemia
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Hypoglycemia
3
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Summary
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Reference
American Diabetes Association.standards of medical care in diabetes 2017;40:1-142
54