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Standards

of Medical
care in
diabetes2017
Group 7&8

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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


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Classification (4 types)
2
3. Gestational diabetes mellitus (GDM)
3

monogenic diabetes syndromes


( neonatal diabetes, maturity-onset
diabetes of the young [MODY])
diseases of the exocrine pancreas
( cystic fibrosis)
4. Specific types (other causes)
Drug or chemical-induced diabetes
- glucocorticoid HIV/AIDS

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Staging of type 1 diabetes

Stage 1 Stage 2 Stage 3


Stage Autoimmunity Autoimmunity New-onset hyperglycemia
Normoglycemia Dysglycemia Symptomatic
Presymptomatic Presymptomatic
Diagnostic criteria Multiple autoantibo Multiple autoantibodies Clinical symptoms
dies Dysglycemia: IFG and/or IGT Diabetes by standard
FPG 100125 mg/dL criteria
2-h PG 140199 mg/dL
A1C 5.76.4%
or 10% increase in A1C

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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.
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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

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Lifestyle Management
Weight Management

type 2 diabetes
>5%

7%

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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

Diabetes Prevention Program (DPP)


3
2 58 %
Goals of DPP

Diabe
tes Prevention Program (DPP) 7%
150
The 7% weight loss goal was selected because it was feasible to achieve an
d maintain and likely to lessen the risk of developing diabetes. Participants were encoura
ged to achieve the 7% weight loss during the first 6 months.

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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

2. Long-term use of metformin


vitamin B12
metformin considered anemia
peripheral neuropathy

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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

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Meglitinides (glinides) Repaglinide, Nateglinide

Cellular mechanism : Closes KATP channels on b-cell plasma membranes


Primary physiological action : Insulin secretion

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)
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Bile acid sequestrants - Colesevelam
Cellular mechanism : Binds bile acids in intestinal tract,
increasing hepatic bile acid production

Primary physiological action : - ? Hepatic glucose production


- ? Incretin levels

Advantages Disadvantages
- Rare hypoglycemia - Modest A1C efficacy
- LDL-C - Constipation
- Triglycerides
- May absorption of other medications
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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

Cellular mechanism : Inhibits SGLT2 in the proximal nephron


Primary physiological action : Blocks glucose reabsorption by t
he kidney, increasing glucosuria
Advantages Disadvantages
- Rare hypoglycemia - Genitourinary infections
- Weight - Polyuria
- Blood pressure - Volume depletion/hypotension/dizziness
- Associated with lower CVD event rate and m - LDL-C
ortality in patients with CVD (empagliflozin E - Creatinine (transient)
MPA-REG OUTCOME) - DKA, urinary tract infections leading to
urosepsis, pyelonephritis

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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

160/100 mmHg lifestyle therapy

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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

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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

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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

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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

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Microvascular Complications
and Foot Care

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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

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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))

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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

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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

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Diabetes Care in the Hospital

Medical nutrition t
herapy in the hos
pital A1C

Self-Management
in the hospital


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STANDARDS FOR SPECIAL SITUATIONS
1. Enteral/Parenteral Feedings

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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

*** DKA Hyperosmolar hyperglycemia


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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

ADA 2017 VS 2016


DM type 1 3 stage
` A1C9% dual therapy A1C10%
comorbidity

metformin Vitamin B12 B12

flexible insulin

empagliflozin liraglutide

Clinically significant hypoglycemia glucose <54 mg/dL (3.0 mmol/L)

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Reference
American Diabetes Association.standards of medical care in diabetes 2017;40:1-142

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