MANAGEMENT OF
DIABETES
DR. V. SRAVANI
INTRODUCTION
Diabetes mellitus(DM) refers to a group of common
metabolic disorders that share the phenotype of
hyperglycemia.
Factors contributing to hyperglycemia :
Reduced insulin secretion
Decreased glucose utilization
Increased glucose production
CLASSIFICATION
DM is classified on the basis of the pathogenic process
leading to hyperglycemia as opposed to : age of onset
type of
therapy
Type1 DM – autoimmunity against beta cells
Type2 DM – insulin resistance + impaired insulin
secretion +increased glucose production
SCREENING
Recommended for all individuals >45 years of age
every 3 years
at an earlier age if overweight plus 1 other risk factor
DIAGNOSIS
GLUCOSE HOMEOSTASIS
In fasting state : insulin levels, glucagon =
glucose through gluconeogenesis, glycogenolysis and
lipolysis.
In postprandial state : insulin, glucagon = glucose
through uptake by skeletal muscles, storage and fat
and protein synthesis.
PATHOPHYSIOLOGY
Insulin resistance
Impaired insulin secretion
Increased hepatic glucose and lipid production
GLYCEMIC TARGETS
An A1C goal of 7% without significant hypoglycemia
Less stringent goals (<8%) for older fragile patients
Mean Plasma Glucose
HBA1C
6% 126mg/dl
7% 154mg/dl
8% 184mg/dl
9% 212mg/dl
10% 240mg/dl
11% 269mg/dl
12% 298mg/dl
TREATMENT
Wt loss Wt gain Wt neutral
- Metformin - Insulin - DPP IV i
- SGLT 2 I - Sulfonylureas - AG i
- GLP-1 RA - Thiazolidinediones
- Pramlintide
INSULIN
TYPES OF INSULIN
Short Acting : aspart, glulisine, lispro, regular
Long Acting : degludec, detemir, glargine, NPH
Commonly used preparations :
- MIXTARD : 70% NPH, 30% regular
- BASALOG : Glargine(plain)
- ACTRAPID : Regular (plain)
- RYZODEG : 70% Degludec, 30% aspart
INSULIN REGIMENS
Long acting insulins supply basal insulin whereas
short acting ones provide prandial insulin.
Short acting insulins are injected just before a meal
whereas regular insulin is injected 30 mins before a
meal.
MDI regimens refer to combination of basal and bolus
insulin in which bolus insulin dose is adjusted
according to the pre prandial glucose.
Another common regimen consists of NPH and regular
insulin mix given twice daily. Such regimen has 2/3
daily dose in the morning and 1/3 dose in the evening.
Requires a rigid schedule from the patient and daily
variations of diet and activity causes hyper and
hypoglycemia.
Long acting insulin is given at bedtime to prevent
nocturnal hypoglycemia and to prevent dawn
phenomenon.
RECOMMENDATIONS
First line therapy includes : metformin(look for Sr.
Creatinine) and lifestyle modification.
Metformin should be continued even after initiation of
insulin.
High risk ASCVD, Heart Failure and CKD need to be
started with SGLT 2 I or GLP 1 RA with or without
metformin.
Insulin is started if :
there is ongoing catabolism (wt loss)
symptoms of hyperglycemia
HBA1C levels > 10%
High blood glucose >300mg/dl
Renal or hepatic disease
Acutely ill/hospitalized
Mild hyperglycemia (126-199mg/dl) – 1 oral agent
Moderate (200- 250 mg/dl) – 2 oral agents or 1 oral
agent plus insulin
Severe >250mg/dl – oral + insulin to reduce “glucose
toxicity”.
Insulin secretagogues, biguanides, GLP-1 receptor
agonists, and thiazolidinediones improve glycemic
control to a similar degree (1–2% reduction in HbA1c)
and are more effective than α-glucosidase inhibitors,
DPP-IV inhibitors, and SLGT2 inhibitors;
Not all agents are effective in all individuals with type
2 DM
Insulin secretagogues, GLP-1 receptor agonists, DPP-IV
inhibitors, α-glucosidase inhibitors, and SLGT2
inhibitors begin to lower the plasma glucose
immediately, whereas the glucose-lowering effects of
the biguanides and thiazolidinediones are delayed by
weeks
Durability of glycemic control is slightly less for
sulfonylureas compared to metformin or
thiazolidinediones.
DIABETES IN PERIOPERATIVE PERIOD
Prone to hyper/hypoglycemia in perioperative period.
Perioperative hyperglycemia is a predictor of adverse
outcomes.
Acute hyperglycemia may lead to DKA/HHS.
Good long term control of glucose reduces long term
complications retinopathy/maculopathy and need for
cataract surgery
The concern in patients undergoing cataract surgery
with poorly controlled diabetes is the potential for
surgical complications and poorer outcomes :
infection, post operative inflammation and delayed
wound healing.
But no published evidence on the adverse effects of
high intraop blood glucose on outcome after cataract
surgery.
Rapid preop glycemic correction i.e reducing HBA1C
>9% bt atleast 3% in three months before surgery is
not recommended as it may cause post op
progression of both retinopathy and maculopathy in
patients who already have moderate to severe non
proliferative diabetic retinopathy
GLYCEMIC TARGETS IN HOSPITALIZED
PATIENTS
ADA recommends that blood glucose concentrations
should be maintained between 140 – 180 mg/dl
during perioperative period.
UK guideline recommends that pre operative HBA1C
of <8.5% should be considered acceptable for surgery.
During minor surgeries many small studies did not
demonstrate any adverse effects of maintaining
perioperative glucose concentrations between 90 –
198mg/dl.
Whenever possible HbA1c concentrations should be
obtained in all persons with diabetes.
It may be substituted with average daily blood
glucose concentrations.
However, a single value of random blood glucose
concentration may not be always useful , particularly
if it is above normal values.
Therefore if the patient has hyperglycemia on the day
of the surgery but has had “good” long term glycemic
control but with an acceptable range of 72 – 216
mg/dl it may be appropriate to proceed with the
surgical procedure.
HYPERGLYCEMIA
Individuals with type 1 or type 2 DM and severe
hyperglycemia should be assessed for clinical stability
including mentation and hydration
Symptoms : Nausea/vomiting, thrist/polyuria, abd
pain, dysnoea
Physical findings : tachycardia, dehydration,
tachypnoea, abd tenderness
Ketones measurement should be done if
hyperglycemia with the above symptoms are present.
HYPOGLYCEMIA
Symptoms :
Neuroglycopenic : behavioural changes, confusion,
fatigue, seizures and death
Autonomic : palpitations, tremors, anxiety, sweating,
hunger, paraesthesias
THANK YOU
