Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice...
Transcript of Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice...
![Page 1: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/1.jpg)
Current Evidence and Best Practice in the Management of Diabetes
Ganesh ArunagirinathanConsultant Physician
Western General HospitalEdinburgh
![Page 2: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/2.jpg)
Diabetes mellitus
• Coined by the Greek Physician Aretaeus-Diabetes meaning siphon
• Mellitus meaning Honey in Latin
• Group of metabolic diseases characterised by high glucose levels in blood (hyperglycemia)
• Defects in insulin secretion or insulin action or both
• Long term damage, dysfunction and failure of various organs
![Page 3: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/3.jpg)
![Page 4: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/4.jpg)
![Page 5: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/5.jpg)
Classification of Diabetes
• T2 Diabetes Mellitus
• T1 Diabetes Mellitus
• Gestational Diabetes Mellitus
• Monogenic Diabetes
• Secondary diabetes- pancreas, hormonal/endocrine including steroids
• Rare & related to syndromes
![Page 6: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/6.jpg)
![Page 7: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/7.jpg)
UK-Diabetes data (Facts & Figures, Diabetes UK 2015)
• More than 1 in 16• 4 Million in UK (90% T2DM, 10% T1DM)• 56% Men, 44% Women• I person is newly diagnosed every 2 minutes
• Undiagnosed 549000• Impaired Glucose Tolerance prevalence 5.9%
• Scotland 271,312
![Page 8: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/8.jpg)
Ethnicity
• South Asians upto 6 times higher risk of diabetes than Caucassians
• Black African/Carribean have upto 5 times higher risk
• Children of Asian origin are 8.9 times & black African origin 5.8 times more likely to have T2DM than Caucassian children
![Page 9: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/9.jpg)
Children & Diabetes(DUK)
• Prevalence of T1DM - 22.8/100,000
• Peak age of onset is 9 to 14
• 95% T1DM
• 1.9% T2DM
• 2.73% Monogenic & others
![Page 10: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/10.jpg)
Gestational DM
• 5% of all pregnancies in UK
• 7.5% T1DM, 5% T2DM
• Manifest in the 2nd or 3rd trimester
• 7 fold higher risk of diabetes in later life
• Children born to women with GDM are usually overweight & have 6 times higher risk of T2DM later in life
![Page 11: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/11.jpg)
HbA1C
Glycosylated Haemoglobin Marker of glucose control
![Page 12: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/12.jpg)
DCCT to IFCC conversion
![Page 13: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/13.jpg)
![Page 14: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/14.jpg)
Burden of the disease
• T1DM• By age 20, life expectancy reduced by 11 years in
men and 14 years in women
• T2DM• Life expectancy reduced by 6 years around age 50
• 10% of NHS budget spent on diabetes(1 million an hour)
![Page 15: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/15.jpg)
Diabetes Control &Complications Trial(DCCT) T1DM
• 1983-1993
• US & Canada
• Age 13-39
• T1DM between 1 to 15 years from diagnosis, no or minimal retinopathy
• 1441
![Page 16: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/16.jpg)
![Page 17: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/17.jpg)
![Page 18: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/18.jpg)
DM diagnostic criteria
![Page 19: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/19.jpg)
DCCT- EDIC 30 year MACE follow upLegacy effect-Metabolic memory
Diabetes Care 2016
![Page 20: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/20.jpg)
United Kingdom prospective Diabetes Study (UKPDS) T2DM
• 1977 to 1997
• 23 UK centres
• 5102 patients with median follow up of 10 years
• Intensive vs conventional glucose control
![Page 21: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/21.jpg)
UKPDS Summary
• There is a direct relationship between the risk of complications of diabetes and glycaemia over time
• No threshold of glycaemia was observed for a substantive change in risk for any of the clinical outcomes examined
• The lower the glycaemia the lower the risk for complications
• The rate of increase of risk for microvasculardisease with hyperglycaemia is greater than that for macrovascular disease
![Page 22: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/22.jpg)
UKPDS
0
2 0
4 0
6 0
8 0
0 5 6 7 8 9 1 0 1 1
Myocardial
infarction
Microvascular
disease
Updated mean HbA1c (%)
Incid
ence p
er
1000 p
atient-
years
![Page 23: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/23.jpg)
UKPDSIntensive (SU/Ins) vs. Conventional glucose control
HR (95%CI)
![Page 24: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/24.jpg)
![Page 25: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/25.jpg)
UKPDS
BP 154/87 vs 144/82
![Page 26: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/26.jpg)
Risk for macrovascular disease
• Hypertension
• Dyslipidaemia
• Insulin resistance
• Obesity
• Smoking
• Higher HbA1C
• Synergistic interaction of above factors
![Page 27: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/27.jpg)
Pathophysiology
• Similar to non-diabetic population
• More extensive, diffuse, aggressive, distal & multivessel involvement
• Higher rate of hypertension(50%) and dyslipidaemia(30%) at diagnosis
• HbA1C is an independent risk factor for vascular disease
![Page 28: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/28.jpg)
MRFITStamler J et al, Diabetes Care 1993
![Page 29: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/29.jpg)
“Diabetes is Coronary Artery disease equivalent”
MRFIT study- Haffner SM et al, NEJM 1998
![Page 30: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/30.jpg)
![Page 31: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/31.jpg)
Statins- Metaanalysis CTT collaborators, Mar 2012, Lancet
![Page 32: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/32.jpg)
STATINS sign 116
• 1mmol/L reduction in LDL = 21% reduction in risk of CVD
• CARDS study- Benefit noted irrespective of baseline cholesterol concentration
• Simvastatin 40mg or atorvastatin 10mg daily for T2DM over 40 years (consider in T1DM)
• Statin should be recommended in <40 age group with higher risk eg microalbuminuria
• In established CVD/ACS, atorvastatin 80mg/day
![Page 33: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/33.jpg)
Smoking- Nurses Health Study
![Page 34: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/34.jpg)
Management of T1DM
• Structured education- Carbohydrate counting and insulin dose adjusting
• DAFNE (Diet Adjustment For Normal Eating)
• Insulin pumps- special features like low glucose suspend etc.
• Monitoring devices- Continuous glucose monitor, Flash sensors
![Page 35: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/35.jpg)
Insulin pens and regimens
![Page 36: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/36.jpg)
Pumps, sensors and data
![Page 37: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/37.jpg)
SIGN 116- Psychosocial• Regular assessment of a broad range of psychological and
behavioural problems in children and adults with type 1 diabetes is recommended
• In children this should include eating disorders, behavioural, emotional and family functioning problems
• In adults this should include anxiety, depression and eating disorders
• Children and adults with type 1 and type 2 diabetes should be offered psychological interventions (including motivational interviewing, goal setting skills and CBT) to improve glycaemic control in the short and medium term.
![Page 38: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/38.jpg)
Acute complications
• Hypoglycemia
• DKA
• HHS
![Page 39: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/39.jpg)
Hypoglycemia treatments
![Page 40: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/40.jpg)
T2DM
• Diet
• Lifestyle
• Oral meds- metformin, sulphonylureas, pioglitazone, acarbose, Gliptins, SGLT2 inhibitors
• Injectable- GLP1 analogues(daily, weekly)
• Insulins
• Weight management and bariatric surgery
![Page 41: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/41.jpg)
DESMOND
• Diabetes Education and Self Management for Ongoing and Newly Diagnosed patients with Type 2 Diabetes
• Within the 1st year of diagnosis
![Page 42: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/42.jpg)
![Page 43: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/43.jpg)
![Page 44: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/44.jpg)
![Page 45: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/45.jpg)
Bariatric surgery
• Interventions –individualised lifestyle, pharmacological and surgical- should be offered SIGN 116
• Body Mass Index above 35 with diabetes or other comorbidities
• Benefit in reversing T2DM or reducing medication requirements
![Page 46: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/46.jpg)
Bariatric surgery
![Page 47: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/47.jpg)
Retinal photography
![Page 48: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/48.jpg)
Slit lamp biomicroscopy
![Page 50: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/50.jpg)
Optimal Coherence Tomography (OCT)
Normal Macular oedema
![Page 51: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/51.jpg)
EDIC Retinopathy progression
Risk factors for Diabetic Retinopathy
Duration of disease- severity
Poor glycaemic control
Renal disease – risk factor for onset and progression
Hypertension-linked to PDR & established risk factor for macular oedema
Dyslipidaemia associated with hard exudates
Pregnancy, puberty, smoking, obesity
![Page 52: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/52.jpg)
Retinopathy prevention & treatment
• Tight glycaemiccontrol
• BP, weight, lifestyle
• Lipids- fenofibratesuseful
• Smoking cessation
• Pre-pregnancy counselling- screen during each trimester
Scatter photocoagulation to peripheral retina
Focal laser photocoagulation for Clinically Significant Macular Oedema
Macular Grid laser for diffuse macular neovascularisation/ leak
Pars plana Vitrectomy for fibrovascularproliferation, severe retinal disease not amenable to laser
![Page 53: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/53.jpg)
Structure of a kidney and nephron
![Page 54: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/54.jpg)
Management of nephropathy
• ACEI/ARB- withhold if dehydration, contrast
• BP- as low as tolerable; 130/80 & below
• Glucose
Statins-
• May preserve renal function over time and reduce microalbuminuria
• Reduce albuminuria even if EGFR <30ml/mt
• avoid fibrates in CKD- 4 & 5
![Page 55: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/55.jpg)
• Smoking cessation
• Avoid nephrotoxics eg NSAIDs
• Hb – check from CKD-3
• Refer to Nephrology if rapid decline in EGFR, Blood in dipstik, CKD 4 ,5 OR atypical presentation
![Page 56: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/56.jpg)
Peripheral nerve anatomy
![Page 57: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/57.jpg)
![Page 58: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/58.jpg)
Clinical presentation of Diabetic NeuropathiesPickup J, Williams G, Textbook of Diabetes Vol 1, 1997
![Page 59: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/59.jpg)
![Page 60: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/60.jpg)
Diabetic Neuropathy
• Varied
• Silent, non-specific or mimic other diseases
• Diagnosed by exclusion
• Grossly under diagnosed
• Complications are equal in type 1 and type 2 DM
• Symptomatic Autonomic neuropathy has 25-50% mortality in 5 to 10 years
![Page 61: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/61.jpg)
Evidence for achieving good glycemiccontrol
• DCCT- 50% reduction in neuropathy over 5 years with intensive insulin therapy
• UKPDS -“Legacy Effect”- despite worsening control later neuropathic symptoms improved
• EDIC study confims Legacy Effect
• STENO trial showed 0.32 reduction in ODDs ratio for development of autonomic neuropathy with treatment of all metabolic comorbidities
![Page 62: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/62.jpg)
Diabetic foot ulcers
• 1.7 to 3.3% in <50 yrs; 5 to 10% in >50 yrs
• 50% annual risk in those with previous ulcers
• Lifetime risk of getting diabetic foot ulcer is 25%
• Amputation performed in 3 per 1000 diabetics
![Page 63: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/63.jpg)
Risk factors for Diabetic foot ulcers
• Neuropathy as such does not cause ulcers
• Callus, deformity & high foot pressures
• Ill fitting shoes
• Foot trauma
• Combination with ischaemia
• Retinopathy, CKD & dialysis
• Previous ulcers
![Page 64: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/64.jpg)
Foot ulcers
![Page 65: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/65.jpg)
Peripheral Vascular Disease
![Page 66: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/66.jpg)
Osteomyelitis
![Page 67: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/67.jpg)
Charcot foot
![Page 68: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/68.jpg)
Aircast, scotch cast, Total Contact Cast, Removable Cast walker
![Page 69: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/69.jpg)
SIGN 116
• Running-style, cushion soled trainers should be used by those with foot disease
• Custom-built footwear or orthotic insoles should be used to reduce callus severity and ulcer recurrence
• Active foot disease to be referred to MD footcare Team
• Cardiovascular risk management should be addressed for anyone with foot disease
![Page 70: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/70.jpg)
![Page 71: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/71.jpg)
![Page 72: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/72.jpg)
![Page 73: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/73.jpg)
Pregnancy planning
• GDM Prevalence 19.8%
• GDM 171300
• Preconception contraception
• Need HbA1C to be very well controlled ideally below 53mmol/mol
• Folic acid 5mg daily upto 12 weeks
• STOP ACE inhibitors/ARBs/Statins
![Page 74: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/74.jpg)
Older people with diabetes
• Diet- minimal restriction in care homes
• Nutritional assessment and individual advice
• Risk of dehydraion/HHS
• Ensure physically active
• Hypo risk is high
• Mental health issues /depression/dementia
• Continence issues
![Page 75: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/75.jpg)
Standards of medical care for older adults, Diabetes Care Jan 2016
![Page 76: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/76.jpg)
Diabetes UK statement• The 15 Healthcare Essentials is the minimum level of healthcare everyone
with diabetes deserves and should expect.
• 1. Get your blood glucose levels measured (HbA1c blood test)2. Have your blood pressure measured3. Have your blood fats measured4. Have your eyes screened for signs of retinopathy5. Have your feet and legs checked6. Have your kidney function monitored7. Get ongoing, individual dietary advice8. Get emotional and psychological support9. Be offered a local education course10. See specialist healthcare professionals11. Get a free flu vaccination12. Receive high-quality care if admitted to hospital13. Have the chance to talk about any sexual problems14. If you smoke, get support to quit15. Get information and specialist care if you are planning to have a baby
![Page 77: Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and](https://reader031.fdocuments.in/reader031/viewer/2022022613/5b9eea9a09d3f2083f8c5c55/html5/thumbnails/77.jpg)