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Diabetes mellitus
1. Management of diabetes mellitus
((ADA Guidelines
Dr. Faisal Al Hadad
Consultant of Family
Medicine & Occupational
Health
PSMMC
2. Introduction
DM is a group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin secretion,
insulin action or both
DM is a common health problem in Saudi Arabia
The overall prevalence of DM in adults in KSA is 23.7%
according to Al Nozha et al (Saudi Med J 2004; Vol. 25 (11):
1603-1610)
3. Criteria for the diagnosis of diabetes
1. Classic symptoms of diabetes and a casual plasma glucose ≥200
mg/dl (11.1 mmol/l). Casual is defined as any time of day without
regard to time since last meal. The classic symptoms of diabetes
include polyuria, polydipsia, and unexplained weight loss.
2. FPG≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake
for at least 8 h.
3. 2-h plasma glucose ≥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.
*Each (1, 2 and 3) must be confirmed on a subsequent day
4. IFG/IGT
Recently, IFG and IGT have been officially termed “prediabetes.”
IFG and IGT are risk factors for future diabetes and CVD.
IFG = FPG 100-125 mg/dl (5.6-6.9 mmol/l)
● IGT = 2-h plasma glucose 140-199 mg/dl (7.8-11.0 mmol/l)
* These criteria should be confirmed by repeat testing on a
different day.
5. Gestational DM
Diagnostic criteria for the 100-g OGTT are as follows:
≥95 mg/dl fasting
≥180 mg/dl at 1 h
≥155 mg/dl at 2 h
≥140 mg/dl at 3 h
Two or more values must be met or exceeded for a positive
diagnosis. OGTT should be done in the morning after an
overnight fast of 8–14 h.
6. Self-monitoring of blood glucose
SMBG should be carried out three or more times daily for
patients using multiple insulin injections.
● For patients using less frequent insulin injections or oral agents
or medical nutrition therapy alone, SMBG is useful in achieving
glycemic goals.
● Instruct the patient in SMBG and routinely evaluate the
patient’s technique and ability to use data to adjust therapy.
7. Glycemic goals
● Perform the A1C test at least two times a year in patients who are
meeting glycemic goals and quarterly in patients whose therapy has
changed or who are not meeting glycemic goals.
● The A1C goal for patients in general is an A1C goal of <7%.
● The A1C goal for the individual patient is an A1C as close to normal
(<6%) as possible without significant hypoglycemia.
● Less strict treatment goals (A1C <7%) may be appropriate for
patients with a history of severe hypoglycemia, patients with limited
life expectancies, very young children or older adults, and
individuals with comorbid conditions.
8. Management
Medical Nutrition Therapy (MNT)
Oral hypoglycemic agents
Insulin therapy
Prevention of diabetes complications (e.g. aspirin,
statin, ACEI or ARB)
9. Medical Nutrition Therapy
Weight loss is recommended for all overweight or obese
individuals who have diabetes.
Physical activity and behavior modification are important
components of weight loss programs and are most helpful in
maintenance of weight loss.
Low-fat diets
Low-carbohydrate diets
13. Drug
Dose
Side effects
Drug class
Metformin
® Glocophage
500-850mg
1000-2550mg
BID-TID
Dyspepsia,
diarrhea, lactic
acidosis
Biguanides
mg 150-300
TID
Gas, abdominal
pain, diarrhea
α –Glucosidase inhibitors
4-8mg
OD-BID
Oedema, weight
gain, hepatic
failure
1.5-16mg
TID-QID
Weight gain
hypoglycemia
Acrobose
® Glucobay
mg 50-100
Rosiglitazone
Avandia ® 2,4,8
mg
Repaglinide
Novonorm ®
0.5,1,2 mg
Thiazolidinediones
Meglitinides
14. HTN and DM
BP should be measured at every routine diabetes visit. Patients
found to have systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg
should have BP confirmed on a separate day.
Patients with a systolic BP of 130–139 mmHg or a diastolic BP of
80–89 mmHg should be given lifestyle and behavioral therapy alone
for a maximum of 3 months and then, if targets are not achieved, in
addition, be treated with ACEI or ARB.
Patients with hypertension (systolic BP ≥140 or diastolic BP ≥90
mmHg) should receive drug therapy (ACEI/ARB± thiazide diuretic)
in addition to lifestyle and behavioral therapy.
15. Dyslipidemia and DM
● In adult patients, test for lipid disorders at least annually.
In adults with low-risk lipid values (LDL<100 mg/dl, HDL >50
mg/dl, and triglycerides <150 mg/dl), lipid assessments may be
repeated every 2 years.
● Lifestyle modification (reduction of fat and cholesterol intake,
weight loss and increased physical activity) has been shown to
improve the lipid profile in patients with diabetes.
16. Dyslipidemia and DM
In individuals without overt CVD
● The primary goal is an LDL <100 mg/dl (2.6 mmol/l).
● > 40 years, statin therapy is recommended.
● < 40 years but at increased risk of CVD who do not achieve
lipid goals with lifestyle modifications alone, the addition of
statin therapy is appropriate.
In individuals with overt CVD
● All patients should be treated with a statin.
● A lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a
high dose of a statin, is an option.
17. Dyslipidemia and DM
Lower TG to<150 mg/dl (1.7 mmol/l).
Raise HDL cholesterol to >40 mg/dl (1.0 mmol/l) in men and
>50 mg/dl (1.25 mmol/l) in women.
● Combination therapy using statins and other lipid-lowering
agents may be necessary to achieve lipid targets.
● Statin therapy is contraindicated in pregnancy.
18. Antiplatelet agents
As a secondary prevention strategy in those with diabetes with a
history of CVD.
As a primary prevention strategy in those with diabetes and at
increased CV risk (> 40 years of age or additional risk factors)
Combination therapy using other antiplatelet agents such as
clopidrogel in addition to aspirin should be used in patients with
severe and progressive CVD.
19. Diabetic Nephropathy
● To reduce the risk and/or slow the progression of
nephropathy, optimize glucose control and BP control.
● Perform an annual test for the presence of microalbuminuria
in type 1 diabetic patients with diabetes duration of ≥5 years
and in all type 2 diabetic patients, starting at diagnosis and
during pregnancy.
In the treatment of both micro- and macroalbuminuria, either
ACEI or ARBs should be used except during pregnancy.
20. Diabetic Nephropathy
Serum creatinine should be measured at least annually for the
estimation of GFR in all adults with diabetes regardless of the
degree of urine albumin excretion
Consider referral to a physician experienced in the care of diabetic
renal disease when the estimated GFR has fallen to <60 ml/min per
1.73 m2.
● Reduction of protein intake is recommended
21. Diabetic retinopathy
Optimal glycemic and BP control can substantially reduce the risk
and progression of Diabetic retinopathy .
Annual comprehensive eye examination by an ophthalmologist is
recommended in type 1 diabetic patients with diabetes duration of
≥5 years and in all type 2 diabetic patients.
● Women who are planning pregnancy or who have become pregnant
should have a comprehensive eye examination and should be
counseled on the risk of development and/or progression of diabetic
retinopathy.
22. Diabetic neuropathy
● All patients should be screened for distal symmetric
polyneuropathy (DPN) at diagnosis and at least annually
thereafter, using simple clinical tests.
● Once the diagnosis of DPN is established, special foot care is
appropriate for insensate feet to decrease the risk of
amputation.
● Simple inspection of insensate feet should be performed at 3to 6-month intervals. An abnormality should trigger referral for
special footwear, preventive specialist, or podiatric care.
