Lecture 50 Management of Diabetes Mellitus

Management of Diabetes Mellitus
Management of DM
• The major components of the treatment of diabetes
are:
A • Diet and Exercise
• Oral hypoglycaemic
B therapy
C • Insulin Therapy
A. Diet
 Diet is a basic part of management in every case. Treatment cannot be effective
unless adequate attention is given to ensuring appropriate nutrition.
 Dietary treatment should aim at:

◦ ensuring weight control
◦ providing nutritional requirements
◦ allowing good glycaemic control with blood glucose levels as close to normal
as possible
◦ correcting any associated blood lipid abnormalities
A. Diet (cont.)
The following principles are recommended as dietary guidelines for people with
diabetes:
 Dietary fat should provide 25-35% of total intake of calories but saturated fat
intake should not exceed 10% of total energy. Cholesterol consumption should
be restricted and limited to 300 mg or less daily.
 Protein intake can range between 10-15% total energy (0.8-1 g/kg of desirable
body weight). Requirements increase for children and during pregnancy. Protein
should be derived from both animal and vegetable sources.
 Carbohydrates provide 50-60% of total caloric content of the diet. Carbohydrates
should be complex and high in fibre.
 Excessive salt intake is to be avoided. It should be particularly restricted in
people with hypertension and those with nephropathy.
Exercise
 Physical activity promotes weight reduction and improves insulin
sensitivity, thus lowering blood glucose levels.
 Together with dietary treatment, a programme of regular physical

activity and exercise should be considered for each person. Such a
programme must be tailored to the individual’s health status and
fitness.
 People should, however, be educated about the potential risk of

hypoglycaemia and how to avoid it.
B. Oral Anti-Diabetic Agents
• There are currently four classes of oral anti-diabetic agents:
i. Biguanides
ii. Insulin Secretagogues – Sulphonylureas
iii. Meglitinide
iv. α-glucosidase inhibitors
v. Thiazolidinediones (TZDs)
vi. Dipeptidyl peptidase IV( DPP-IV) Inhibitors
Vii. Selective sodium-glucose transporter-2( SGLT2)
B.1 Oral Agent Monotherapy
 If glycaemic control is not achieved (HbA1c > 6.5% and/or; FPG > 7.0 mmol/L or;
RPG >11.0mmol/L) with lifestyle modification within 1 –3 months, ORAL ANTI-
DIABETIC AGENT should be initiated.
 In the presence of marked hyperglycaemia in newly diagnosed symptomatic type

2 diabetes (HbA1c > 8%, FPG > 11.1 mmol/L, or RPG > 14 mmol/L), oral anti-
diabetic agents can be considered at the outset together with lifestyle
modification.
B.1 Oral Agent Monotherapy (cont.)
As first line therapy:
 Obese type 2 patients, consider use of metformin, acarbose or TZD.
 Non-obese type 2 patients, consider the use of metformin or insulin
secretagogues
 Metformin is the drug of choice in overweight/obese patients. TZDs and
acarbose are acceptable alternatives in those who are intolerant to metformin.
 If monotherapy fails, a combination of TZDs, acarbose and metformin is
recommended. If targets are still not achieved, insulin secretagogues may be
added
B.2 Combination Oral Agents
Combination oral agents is indicated in:
• Newly diagnosed symptomatic patients with HbA1c >10
• Patients who are not reaching targets after 3 months on monotherapy

B.3 Combination Oral Agents and Insulin
 If targets have not been reached after optimal dose of combination therapy for 3
months, consider adding intermediate-acting/long-acting insulin (BIDS).
 Combination of insulin+ oral anti-diabetic agents (BIDS) has been shown to
improve glycaemic control in those not achieving target despite maximal
combination oral anti-diabetic agents.
 Combining insulin and the following oral anti-diabetic agents has been shown to
be effective in people with type 2 diabetes:
◦ Biguanide (metformin)
◦ Insulin secretagogues (sulphonylureas)
◦ Insulin sensitizers (TZDs)(the combination of a TZD plus insulin is not an
approved indication)
◦ α-glucosidase inhibitor (acarbose)
 Insulin dose can be increased until target FPG is achieved.
Diabetes
Management
Algorithm
Oral Hypoglycaemic Medications
Oral hypoglycaemic Medications
• Dipeptidyl peptidase IV Inhibitor ( e.g Linagliptin, Sitagliptin, Vildagliptin,
saxagliptin)
• They act by prolonging the action of incretin hormones. DPP-4 degrades
numerous biologically active peptides, including the endogenous incretins GLP-1
and Glucose-dependent insulinotropic polypeptide (GIP).
• Can be given as monotherapy or in combination, is weight neutral
Oral hypoglycaemic Medications
• Selective sodium-glucose transporter 2-inhibitors (SGLT-2 Inhibitor) (e.g
Canagliflozin, dapagliflozin, empagliflozin)
• SGLT -2 Inhibition lowers the renal glucose threshold ( ie the plasma glucose
concertation that exceeds the maximum glucose capacity of the kidney).
Lowering the renal threshold results in increased urinary glucose excretion.
General Guidelines for Use of Oral Anti-Diabetic Agent in Diabetes
 In elderly non-obese patients, short acting insulin secretagogues can be started
but long acting Sulphonylureas are to be avoided. Renal function should be
monitored.
 Oral anti-diabetic agents are not recommended for diabetes in pregnancy
 Oral anti-diabetic agents are usually not the first line therapy in diabetes
diagnosed during stress, such as infections. Insulin therapy is recommended for
both the above
 Targets for control are applicable for all age groups. However, in patients with co-
morbidities, targets are individualized
 When indicated, start with a minimal dose of oral anti-diabetic agent, while
reemphasizing diet and physical activity. An appropriate duration of time (2-16
weeks depending on agents used) between increments should be given to allow
achievement of steady state blood glucose control
GLP1-AGONISTS
• Glucagon like peptide 1- Agonists (ie Liraglutide, exenatide, dulaglutide) mimic
the endogenous incretin GLP-1; they stimulate glucose- dependent insulin
release, reduce glucaon, and slow gastric emptying.
• Can result in modest weight loss in use with metformin and or sulfonylurea
• Given as Sc
• Oral
C. Insulin Therapy
Short-term use:
 Acute illness, surgery, stress and emergencies
 Pregnancy
 Breast-feeding
 Insulin may be used as initial therapy in type 2 diabetes
 in marked hyperglycaemia
 Severe metabolic decompensation (diabetic ketoacidosis, hyperosmolar Hyperglycaemic
state, lactic acidosis, severe hypertriglyceridaemia)
Long-term use:
 If targets have not been reached after optimal dose of combination therapy or BIDS,
consider change to multi-dose insulin therapy. When initiating this, insulin secretagogues
should be stopped and insulin sensitisers e.g. Metformin or TZDs, can be continued.
Insulin regimens
 The majority of patients will require more than one daily injection if good
glycaemic control is to be achieved. However, a once-daily injection of an
intermediate acting preparation may be effectively used in some patients.
 Twice-daily mixtures of short- and intermediate-acting insulin is a commonly
used regimen.
 In some cases, a mixture of short- and intermediate-acting insulin may be
given in the morning. Further doses of short-acting insulin are given before
lunch and the evening meal and an evening dose of intermediate-acting insulin is
given at bedtime.
 Other regimens based on the same principles may be used.
 A regimen of multiple injections of short-acting insulin before the main meals,
with an appropriate dose of an intermediate-acting insulin given at bedtime,
may be used, particularly when strict glycaemic control is mandatory.
Overview of Insulin and Action
Self-Care
 Patients should be educated to practice self-care. This allows the patient to assume
responsibility and control of his / her own diabetes management. Self-care should
include:
◦Blood glucose monitoring

◦Body weight monitoring
◦Foot-care
◦Personal hygiene
◦Healthy lifestyle/diet or physical activity
◦Identify targets for control
◦Stopping smoking

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Management of Diabetes Mellitus

A • Diet and Exercise

 Dietary treatment should aim at:

 Together with dietary treatment, a programme of regular physical

 People should, however, be educated about the potential risk of

• There are currently four classes of oral anti-diabetic agents:

 In the presence of marked hyperglycaemia in newly diagnosed symptomatic type

Combination oral agents is indicated in:

• Newly diagnosed symptomatic patients with HbA1c >10

• Patients who are not reaching targets after 3 months on monotherapy

◦Blood glucose monitoring

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