Diabetes Mellitus (DM) Part II PHCL 442 Hadeel Al-Kofide MSc 1.

Diabetes Mellitus (DM)Part II

PHCL 442

Diabetes Mellitus (DM)Part II

PHCL 442

Hadeel Al-Kofide MSc

Topics we will cover in DMTopics we will cover in DM

• Definition & Epidemiology• Carbohydrate metabolism• Classification• Signs & symptoms• Diagnosis• Long term complications• Monitoring parameter & test to Guide management• Principles of management:

Part I: General principlesPart II: a. Insulin & its clinical applications

b. Oral anti-diabetic agents• Prevention & management of diabetes complications

Last lecture

Principles of ManagementPart II: A.Insulin & its Clinical

Applications

Clinical Applications of Insulin in DMClinical Applications of Insulin in DM

• Initiating insulin therapy

• Methods of insulin therapy

• Testing frequency

• Interpreting SMBG

• Fasting hyperglycemia

• Supplemental insulin doses

• Sliding scale

• Sick day management

Initiating Insulin TherapyInitiating Insulin Therapy

Clinical Situation Insulin Dose

Type 1 DM

1. Initial dose 0.5-0.8 U/kg

2. Honeymoon phase 0.2-0.5 U/kg

3. Patients with ketosis, during illnesses, during growth

1-1.5 U/kg

Type 2 DM (insulin resistance) 0.7-1.5 U/kg

After calculating the total daily dose (TDD) of insulin:

1.Split the dose between the regular or short acting insulin &

the intermediate or long acting insulin HOW? Either 50% each,

or 70% (the intermediate or long acting) & 30% (the rapid or

short acting insulin)

2.Then it depends in which method of insulin delivery you will

chose e.g. insulin pump, MDI or conventional method

Methods of Insulin TherapyMethods of Insulin Therapy

• Intensive insulin therapy (IIT):

Insulin pump

Multiple daily injections (MDI)

• Conventional method

• Example on different methods of insulin therapy

Intensive Insulin TherapyIntensive Insulin Therapy

Patient selection criteria:

1. Type 1 DM, healthy, >7 yr, highly motivated & compliant individuals, willing to test blood glucose 4 times/day

2. Diabetic women who plan to get pregnant

3. Pregnant diabetic patient

4. Patients poorly controlled on conventional therapy (including type 2)

5. Technical ability to test blood glucose

6. Intellectual ability to interpret blood glucose concentrations

7. Access to trained & skilled medical staff to direct treatment plan & provide supervision

Methods of Insulin Therapy

When to avoid IIT?

1. Patient with counter-regulatory insufficiency

2. Type 1 DM for more tan 15 years (not all patients)

3. On beta-blockers

4. Autonomic, pituitary or adrenal insufficiency

5. Patients with coronary or cerebral vascular disease

6. Patients who are non-compliant, unable to measure blood glucose, or patients with psychiatric disorders

• Two major methods used to deliver IIT:

1. Insulin pump

2. MDI

Insulin pump:

• The most precise way to mimic normal insulin secretion

• Portable

• Delivers basal & bolus insulin doses

• New: Implantable insulin pumps

Multiple daily injections:

• It mimics the release of insulin from the pancreas

• Contains both basal & bolus insulin

• Insulin is given 3 times or more per day

• There are different methods to deliver MDI of insulin

Conventional Insulin TherapyConventional Insulin Therapy

• Insulin is given twice daily

• It usually contains a mixture of intermediate acting & short acting insulin

• Not commonly used now

Examples of Different Insulin RegimensExamples of Different Insulin Regimens

AM Noon PM Bedtime

Reg/NPH -- Reg/NPH --

Reg/Lente -- Reg/Lente --

Lispro/NPH -- Lispro/NPH --

Lispro/Lente -- Lispro/Lente --

Aspart/NPH -- Aspart/NPH --

Aspart/lente -- Aspart/lente --

Method 1

Why we need a short acting here?

To cover breakfast

Why we need an intermediate acting here?

To cover lunch + basal insulin

Why we need a short acting here?

To cover dinner

Why we need an intermediate acting here?

To cover snack + basal insulin

Disadvantages:

• Peak of NPH will be between 2-4 am causing nocturnal hypoglycemia & morning hyperglycemia (rebound hyperglycemia)

• To overcome this problem: either decrease NPH dose, or give NPH at bedtime instead of pre-dinner, why?

Method 1

AM Noon PM Bedtime

Reg/NPH -- Reg NPH

Reg/Lente -- Reg Lente

Lispro/NPH -- Lispro NPH

Lispro/Lente -- Lispro Lente

Aspart/NPH -- Aspart NPH

Aspart/Lente -- Aspart Lente

Method 2 This method is used to overcome disadvantages

of method 1

How can method 2 overcome method 1 disadvantages?

• By shifting NPH or lente dose to bedtime the peak action will occur in early morning (5-7 am) when the patient is awake & ready to eat

Method 2

AM Noon PM Bedtime

Reg Reg Reg NPH

Reg Reg Reg Lente

Reg Reg Reg Glargine

Reg Reg Reg Ultralente

Method 3

• More flexibility in meals

• If regular insulin was replaced by lispro must add with it NPH, why?

• If glargine replaces either NPH or lente the dose should be decreased by 20%

Method 3

AM Noon PM Bedtime

Lispro/NPH Lispro Lispro NPH

Lispro/Lente Lispro Lispro Lente

Aspart/NPH Aspart Aspart NPH

Aspart/Lente Aspart Aspart Lente

Method 4

• The problem with lispro or aspart is post-prandial hyperglycemia due to short duration of action

• If glargine replaces either NPH or lente the dose should be decreased by 20%

Method 4

AM Noon PM Bedtime

Reg/Ultralente Reg Reg/Ultralente --

Lente/Ultralente Lispro Lente/Ultralente --

Aspart/Ultralente Aspart Aspart/Ultralente --

Method 5

• Why ultralente is given twice daily?

• If glargine replaces ultralente give it once daily

• The main disadvantage here is fasting hyperglycemia, why?

Method 5

AM Noon PM Bedtime

Reg/Ultralente Reg Reg NPH

Lente/Ultralente Lispro Lente NPH

Aspart/Ultralente Aspart Aspart NPH

Method 6

• It overcomes the problems in method 5, why?

Method 6

Testing FrequencyTesting Frequency

Ideally patients should test their blood glucose in the following times:

• Before meals

• After meals

• Bedtime

• At 2-3 am

This means 8 times/day!!

But at least the patient should measure blood glucose in the following times:

• Before meals

• Bedtime

• At 2-3 am

• Patients should evaluate blood glucose level when they are not feeling well, or in case of increased physical activity, large meal, final examinations or family crisis

This means 4 times/day

3 times/week

• Testing blood glucose at these times corresponds with the peak action of short & intermediate acting insulin administered at different times of the day

• This enables the clinician to evaluate the effect of various insulin components on meals & to identify nocturnal hypoglycemia

• GlucoWatch?

Interpreting SMBGInterpreting SMBG

Test Time Target Insulin Dose Target Meal/Snack

Fasting (pre-breakfast) Pre-dinner/bedtime intermediate or long acting insulin

Bedtime snack

Pre-lunch Pre-breakfast regular insulin Breakfast

Pre-dinner Pre-breakfast intermediate acting insulin or pre-lunch regular acting insulin

Bedtime Pre-dinner regular insulin Dinner

3 am Pre-dinner intermediate acting insulin

Dinner/bedtime snack

Case 1:

• J.F is a 20 year old female recently diagnosed with type I DM, she was prescribed NPH insulin twice daily: 16 units am & 8 units PM. Her initial goal of therapy was to achieve a pre-prandial blood glucose concentration <180 mg/dl. After being on this regimen for 1 week, trends in her blood glucose concentrations were: (occasional 3 am tests was 160 mg/dl)

Examples

Time SMBG (mg/dl)

7 am 160-200

Noon 220-260

5 pm 130-180

11 pm 140-180

How to solve case 1?

• Increase TDD because her overall control is poor (increase dose to 0.6 U/kg)

• Split this dose to provide 2/3 in the morning & 1/3 at evening

• Add regular insulin to her regimen by 2:1 ratio, how?

Examples

Fasting HyperglycemiaFasting Hyperglycemia

• Insufficient insulin dose

• Somogyi effect

• Dawn phenomenon

• Examples

Insufficient Insulin DoseInsufficient Insulin Dose

• In which there is at least 3 reading values of blood glucose are high

• The 3 am value must be high or normal (not low), why?

• Example:

7 am 190

12 pm 220

5 pm 200

3 am 140

• Solution: increase the TDD of insulin

Fasting Hyperglycemia

Somogyi EffectSomogyi Effect

• Also called rebound hyperglycemia; posthypoglycemic hyperglycemia

• Fasting hyperglycemia but normal blood glucose at bedtime, low at 3 am with symptoms of hypoglycemia (nightmares, sweating, hunger & morning headache)

• Example:

7 am 190

12 pm 120

5 pm 100

3 am 80

• It occurs after severe hypoglycemia & its 2nd to excessive increase in glucose production by the liver that is activated by counter regulatory hormones

• The evening dose of NPH is responsible for this effect

• It is the cause of morning hyperglycemia in >10% of diabetic patients

Solutions:

• Decrease NPH dose by 2-3 units, or

• Shift the pre-dinner NPH dose to bedtime (preferred than twice daily injection)

• Switch NPH to glargine, give it at bedtime & decrease the dose by 20% (remember glargine cannot be mixed with regular insulin)

Dawn PhenomenonDawn Phenomenon

• A rise in blood glucose concentration that occurs between 4-8 am

• It is due to natural increase in growth hormone levels in the early morning (not rebound effect)

• Example:

7 am 180

12 pm 120

5 pm 110

3 am 110

Dawn PhenomenonDawn Phenomenon

Solutions:

• Increase evening NPH by 1-2 units

• If patient on glargine switch to something with peak as NPH or lente

• Decrease bedtime snack

ExamplesExamples

• Example 1: Patient on NPH/Reg am & NPH/Reg pm

7 am 160

12 pm 130

5 pm 90

10 pm 100

3 am 60

Somogyi effect

Solution:1.Decrease evening NPH by 1-2 units2.Give NPH at bedtime3.Give a snack

Solution:Increase regular insulin in breakfast

ExamplesExamples

• Example 2: Patient on NPH/Reg am & NPH/Reg pm

7 am 160

12 pm 130

5 pm 90

10 pm 100

3 am 100

Down phenomenon

Solution:1.Increase evening NPH by 1-2 units2.Decrease amount of dinner or bedtime snack

Solution:1.May not need to do anything, why?2.Increase regular insulin in breakfast

ExamplesExamples

• Example 3: Patient on NPH/Reg am, Reg pm, & NPH bedtime

7 am 100

12 pm 60

5 pm 90

10 pm 100

3 am 110

Post-prandial hypoglycemia

Solution:1.Snack at morning2.Change from regular to lispro3.Decrease morning dose of regular insulin

Supplemental InsulinSupplemental Insulin

• After establishing the basic dose of insulin, each patient must be educated on supplemental insulin in case of increase or decrease in blood glucose level according to SMBG

• Two methods

1. Compensatory insulin doses

2. Anticipatory insulin doses

Compensatory insulin doses

• These doses are used to compensate for high blood glucose levels

• It assumes that there is no unusual changes in patient’s overall diet & exercise patterns

• Given as regular or short acting insulin (lispro & aspart are preferred due to shorter duration of action)

• Usually for each 30-50 mg/dl elevation above the target level 1-2 units of supplemental insulin is required

• To be more accurate must determine the supplemental dose of insulin by using the sensitivity factor

• Sensitivity factor is determined by using the 1500 or 1800 rule

1500/TDD = sensitivity factor

• If TDD is 30: 1500/30 = 50 mg/dl (each unit of insulin will decrease blood glucose level by 50 mg/dl)

• Example for algorithm for the previous patient:

Blood glucose mg/dl Regular insulin

<80 1 unit less

80-120 Usual dose

120-170 1 unit extra

170-220 2 units extra

• If the patient requires more than 4 units must seek medical advice

• Also in case of ketones in urine must go to hospital

• If supplemental doses of insulin are required for ≥3 days, insulin dose should be adjusted

• Example: if patients is usually taking lispro before meals and NPH at bedtime, and 3 days in a row he required 2 units of lispro before lunch, so increase lispro morning dose by 2 units

Anticipated insulin doses

• Prescribed in anticipation of an immediate event that is likely to alter a patient’s response to insulin

• This include an unusual large or small meal or exercise

• Increase lispro, aspart or regular insulin by 1 unit for each additional 15 g of carbohydrates

• Decrease lispro, aspart or regular insulin by 1 unit for smaller meals

Sliding ScaleSliding Scale

• Algorithmic method for adjusting doses of short or regular acting insulin according to blood glucose test results

• Used for hospitalized patients in which their insulin requirements may vary significantly due to stress (infection, surgery or acute illnesses), inactivity or variable caloric intake

• Blood glucose levels are measured every 4 hours if given SC, & every hour if given IV

• Sliding scale should be individualized by using each patient sensitivity factor

Sliding ScaleSliding Scale

• If sensitivity factor is not use the alternate method is for each 30-50 mg/dl elevation above the target level 1-2 units of insulin is given

• After sliding scale or upon hospital discharge what to do?

Sick Day ManagementSick Day Management

1. Continue insulin even if food intake is decreased

2. Maintain fluid intake

3. Test blood glucose every 4 hours at a minimum

4. Test urine for ketones

5. Administer supplemental dose of insulin according to a prescribed algorithm (ex. 1-2 units for every 30-50 mg/dl over 120 mg/dl)

6. Seek medical attention if : Urine ketones, blood glucose > 300 mg/dl or mental status changes

Principles of ManagementPart II: B. Oral anti-diabetic agents

Oral Anti-Diabetic AgentsOral Anti-Diabetic Agents

1. Alpha – glucosidase inhibitors

2. Biguanides

3. Non-sulfonylurea insulin secretagogues (Meglitindes)

4. Sulfonylureas

5. Thiazolidnediones

α – Glucosidase Inhibitorsα – Glucosidase Inhibitors

• Acarbose – precose® & Miglitol – Glyset ®

Mechanism of action

• Competitive reversible inhibition of intestinal α – glucosidase

• Delays glucose absorption & lower postprandial hyperglycemia

• Dose not enhance insulin secretion

• No effect on weight or lipids

Adverse effects

• GI: flatulence, diarrhea & abdominal pain. Can decrease this side effect by slow titration in dose

• Elevated liver function test: monitor liver enzyme every 3 months for 1st year of therapy then periodically. Because miglitol is not metabolized through liver there is no liver toxicity

Contraindications & precautions

• GI conditions: not recommended for patients with malabsorption, or inflammatory bowel disease

• Renal impairment: not studied in sever renal impairment so should be avoided

Drug interactions

• May decrease the bioavailability of digoxin

• Miglitol decreases the bioavailability of ranitidine & propranolol

• Charcoal decreases the absorption of these drugs

Dosing & clinical application

• As an adjunct to diet and exercise in type 2 diabetes

• In combination

• Titrate the dose:

25 mg QD with meal for first 7-14 days

25mg BID week 3-4

25mg TID week 5-12

50mg TID (max dose if wt < 60 kg)

100mg TID (max it wt > 60 kg)

BiguanidesBiguanides

• Metformin ( Glucophage C. ®)

Mechanism of action

• Antihyperglycemic agent

• Improve insulin sensitivity (they do not stimulate insulin release from pancreas & they do not cause hypoglycemia)

• Increase tissue uptake & utilization of glucose by muscle

• Decrease hepatic production of glucose

Advantages

• Useful in obese patients because decreases insulin resistance

• Improves lipid profile

• Produces some weight loss

• No hypoglycemia

Adverse effects

• GI: diarrhea, abdominal discomfort, metallic taste, nausea & anorexia. Can decrease this side effect by slow titration in dose & by giving it with meals

• Lactic acidosis: it may decrease conversion of lactate to glucose & increase lactate production in gut & liver. Symptoms include weakness, malaise, myalgias, abdominal distress & heavy labored breathing

• Lactic acidosis only happen in patients with predisposing factors

Contraindications & precautions (For lactic acidosis)

• Renal impairment (not recommended if CrCl <60 ml/min)

• Hepatic disease

• CHF

• Alcoholic

• Shock

• Dehydration

• Surgery

• Chronic metabolic acidosis or a history of lactic acidosis

Drug interactions

• Cimetidin , nifedipine , furosemide – all can increase metaformin levels

• As an adjunct to diet in type 2 patient that are uncontrolled

• In combination

• Initial dose is 500 mg po BID or 850mg Po QD, with meals to decrease side effects

• Titrate dose weekly and increase by 250-500mg

• Maximum dose 2550 mg OD or 850 mg TID

Non-Sulfonylurea Insulin SecretagoguesNon-Sulfonylurea Insulin Secretagogues

• Meglitindes ( Repaglinide – Prandin ® and Netaglinide – Starlix ®)

Mechanism of action

• Stimulates release of insulin from the pancreatic beta cells (like sulfonyurea)

• The advantage over sulfonyurea is that they have rapid onset & shorter duration of action

Adverse effects

• Mild hypoglycemia

• Weight gain (mild)

• Not given in patients with no pancreas (or type 1)

• Caution in liver dysfunction

• No dose adjustment is required in renal impairment

Drug interactions

• CYP450 3A4 Metabolism , so potential for interactions exist

• As an adjunct to diet & exercise to patients with uncontrolled type 2 diabetes

• In combination (not with sulfonylurea, why?)

• Rapid Onset & short duration of action, so given with meals to enhance postprandial glucose utilization

• If HgbAIC is < 8 % start 0.5 mg repaglinide or 60 mg netaglainide

• If HgbAIC is > 8 % start 1-2 mg or 120 mg netaglinide

• Adjust doses at weekly intervals

• Take 15-30 minutes prior to each meal

• Instruct patients who skip a meal to skip a dose

• Instruct patient who eat an extra meal to add a dose

SulfonylureasSulfonylureas

First generation

• Acetohexamide, chlorpropamid, tolazamide, & tolbutamide

• Not used commonly today duo to increase adverse effects, active metabolites, some prolonged half lives , & increase drug interaction

Second generation

• Glyburide, glipizde, & glimepiride

• 100 times more potent than first generation

Mechanism of action

• Stimulate insulin release from pancereatic beta cells

• Normalize hepatic glucose production & partially reverse insulin resistance

Adverse effects

• Hypoglycemia & weight gain

Renal/hepatic insufficiency patients

Elderly or malnourished patients

Concurrent hypoglycemic drugs

• Hypothyroidism

• GI disturbances

• Hematologic

• Allergic skin reactions/photosensitivity

• Hepatotoxicity (Increase liver enzymes)

• Type 1 DM

• Pregnancy & breast-feeding except glyburide

• Documented hypersensitivity to sulfonylurea

• Severe hepatic or renal dysfunction

• Severe, acute intercurrent illness (e.g. infection or MI), surgery, or other stressful conditions

Drug interactions

• Increased hypoglycemic effect

• Warfarin, azole antifungals, gemfibrozil, clofibrate , sulfonamides, MAOIs, tricyclic antidepressant, alcohol, cimetidine, aspirin & concomitant agents for diabetes

• Decreased hypoglycemic effect

• beta – blockers, CCBs, cholestyramine, Glucocorticoides, phenytoin, oral contraceptives, rifampin, thiazides, niacin

• Adjunct to diet and exercise in type 2 patients

• Used in combination therapy with insulin, metformin, thiazolidinediones or alpha – glucosidase inhibitors

• Start at low end of the dosing range, especially in the elderly

• Increase dose every 1-2 weeks until maximum dosage

• Exceeding the maximum dosage increases side effects, but does not decrease blood glucose

• Use cautiously in patients with increase risk of hypoglycemia

Treatment failure

• 15 % will have primary failure (poor blood sugar control after a trial of 6-12 weeks on medication & diet)

• After 5 years, ~ 50 % may experience secondary failure (failure of medicine to work after initial good glycemic control)

Glipizde:

• Dose 10 mg/day (maximum 40 mg/day)

• If not respond to 10 mg/d give combination not increase dose

Glyburide:

• Maximum dose 20 mg/d (maximum effect occur at 10 mg/d)

• Advantage over others is that food does not delay extent of absorption (can be given without relation to meal)

Glimepiride :

• Has the advantage of once daily dosing

ThiazolidinedionesThiazolidinediones

• Rosiglitazone – Avandia ® & Pioglitazone – Actos ®

Mechanism of action

• Improves cellular response to insulin W/O increasing pancreatic insulin secretion

• Decrease insulin resistance

• Decreases hepatic glucose production

• Results in reduction in exogenous insulin dosage when used in combination

• May have favorable effect on HDL

Adverse effects

• Hepatotoxicity

Troglitazone pulled from the market secondary to hepatic fatalities

Do not start therapy in patients with baseline LFTs> 2.5x

Check LFTs every 2 months for the first year

Monitor nausea vomiting, abdominal pain, fatigue, anorexia, dark urine

Adverse effects

• Hematologic effects

Decrease hemoglobin & hematocrit

• Cardiovascular effects

Can cause edema

• Weight gain

Fluid & fat accumulation

• Type 1 DM

• Hepatic disease

• Severe CHF

• History of hypersensitivity to TZD

Drug interactions

• Pioglitazone induces the hepatic enzyme CYP 3A4, may affect the following drugs: estrogen, cyclosporine, tacrolimus & HMG-CoA reductase inhibitors

• Rosiglitazone does not appear to inhibit any CYP enzymes

• As an adjunct to diet and exercise

• In combination

• Dose:

• Rosiglitazone 4-8 mg/day

• Pioglitazone 15-30 mg/day

Pharmacological Effects of Anti-Diabetic Agents

Therapeutic Class Increases peripheral glucose uptake

Decrease hepatic glucose secretion

Increase insulin secretion

Delay CHO absorption

Target Organ

a-glucosidase x GIT

Biguanide x x Liver & intestine

Thiazolidinediones x x Muscle, adipose tissue & liver

Sulfonylureas x x x Islet cells of pancreas

Meglitinide x Islet cells of pancreas

Combination ProductsCombination Products

• Glucovance ® : glyburide / metformin

• Metaglip ® : glipizide / metformin

• Advadamet ® : rosiglitazone / metaformin

Type 2 DM Under Special CircumstanceType 2 DM Under Special Circumstance

Patients with decreased renal function:

• Consider: glipizide, glimerpiride, insulin, repaglinide, thiazolidinediones

• Avoid: first generation SUs, glyburide, metformin, acarbose

Patients with decreased hepatic function:

• Consider: insulin, repaglinide (cautious dosing), miglitol

• Avoid: thiazolidinediones, metformin, acarbose, glyburide, first generation sulfonylurea

Obese patients:

• Consider: metformin, acarbose, miglitol

• Avoid: SUs, insulin (unless you are at the end stage of disease), repaglinide, thiazolidinediones

Patients experiencing hypoglycemia due to irregular eating patterns

• Avoid: insulin & long acting SUs

Prevention & Management of Diabetes Complications

Complication of DMComplication of DM

• CVD

1. Hypertension/blood pressure control

2. Dyslipidemia/lipid management

3. Antiplatelet agents

4. Smoking cessation

5. CHD screening and treatment

• Nephropathy

• Retinopathy screening & treatment

• Neuropathy screening & treatment

• Foot care

Complication of DMComplication of DM

Goal Endpoint Assessment

Blood pressure < 130/80 mmHg Every visit

Lipid control LDL < 70 mg/dlTG < 150 mg/dlHDL > 45 mg/dl

Yearly

Urine protein Microalbuminuria< 30 mg/24 hours

Yearly

Principles of ManagementTreatment Algorithm for DM

1. Diagnose Your Patient1. Diagnose Your Patient

Criteria for the diagnosis of diabetes

1FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h

Symptoms of hyperglycemia & 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 hyperglycemia include polyuria, polydipsia, & unexplained weight loss

2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water

2. Type 1 or Type 22. Type 1 or Type 2

3. Set Your Goals3. Set Your Goals

A1C < 7%

Preprandial plasma glucose 70–130 mg/dl (3.9–7.2 mmol/l)

Peak postprandial plasma glucose

<180 mg/dl (<10.0 mmol/l)

4. Start Treatment for Type 1 DM4. Start Treatment for Type 1 DM

Chose your initial dose 0.5

U/kg Chose types of insulin to be used

Honeymoon phase?

Acute illness?Remember you will need 1

short/regular acting & 1 intermediate/long acting

Split the dose between both insulin types

70:30 or 50:50

Chose the method of insulin delivery

According to ADA guidelines MDI is the preferred method of therapy

But remember to see is your patient is welling to take MDI

Educate your patient on interpreting SBGM

Tell him the frequency of monitoring & the goals he has

to achieve

Supplemental insulin doses if patient is not

meeting his goal

Remember the method of calculation

(insulin sensitivity

factor)

Other things to remember when your dealing with a type 1 patient:

1.Fasting hyperglycemia (including simogyi effect & dawn phenomenon)

2.Insulin sliding scale

3.Sick day management

Life style interventions

Check HgbA1C

This includes diet & exercise specially for obese patients

>7%Add metformin or

sulfonylurea

Obese patient: metforminLean patient: sulfonylurea

If goals not achieved switch to combination

<7%Continue on same mode

of therapy

Check HgbA1C

Use combination of metformin + one of the followings: • Rosiglitazone or pioglitazone • Sulfonylurea• Basal insulin (bedtime intermediate acting or bedtime or morning long-acting)

Check HgbA1C

<7%Continue on same mode

of therapy

Add glitazone or sulfonylurea or insulinOr intensify insulin for those on insulin

HgbA1C >7%In patients not yet receiving insulin, add basal insulin or

intensify insulin in those receiving insulin

• When prandial rapid acting insulin is added, sulfonylureas or glinides should be DC

• Consider insulin as initial therapy (with lifestyle modification) in patients with fasting glucose >250 mg/dL or HbA1C >10% or those with ketonuria or symptoms of hyperglycemia

• When initiating insulin, start with a bedtime dose of an intermediate-acting or once-daily long-acting

• Initiate with 0.2 units/kg

• Monitor HgbA1c every 3 months

6. Educate Your Patient6. Educate Your Patient

• Group discussion

Thank youThank you

Diabetes Mellitus (DM) Part II PHCL 442 Hadeel Al-Kofide MSc 1.

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