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type 2diabetes diagnosis and treatment pitfalls

Pitfalls in the diagnosis and treatment of type 2diabetes

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type 2diabetes diagnosis and treatment pitfalls

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  1. Common pitfalls in diagnosis and treatment of type 2 diabetes Professor Mohammed Ahmed Bamashmoos (MB) Professor of Internal Medicine and Endocrinology Faculty of Medicine - Sanaa University

  2. Diagnostic criteria

  3. Diagnosing diabetes – common pitfall 1 - selecting appropriate diagnostic test • 2- problem of under diagnosis • The prevalence of undiagnosed DM was found to be 10.2% ; the majority of them has family history , obese , had history of HTN 3- asymptomatic diseases 4- fallacies in the test

  4. - selecting appropriate diagnostic test; • FDG , OGTT versus HbA1C • - FBG , OGTT ; • advantages ; • - it can be performed as single blood draw . Or after 2 hour in OGTT • - FBG is most commonly used , but OGTT is superior to it • - OGTT ; includes assessment of both FBG , and 2 hour • - identify assessment of individual with dysglycemia than FBG or HbA1C • dysglycemia ; means blood sugar are to low or to high ; • causes ;

  5. Disadvantage ; • - requires over night fast • - It has intra individual variability and poor reducibility due to the factors such as ; • 1- hypocaloric diet in the previous week • 2- duration of the fast • 3- level of activity during the test • 4- inter current illness • 5- reduction in glucose concentration in test tube during storage • -

  6. HbA1C ; Advantages ; • - diagnosis of choice according WHO • - important for choice of drugs regimen • - follow up • - reflects integrated glucose level over preceding 180 days • - convenient • - does not requires fasting or patients preparation • can be performed as single blood draw • - high reproducibility • - not effected by stress or illness • - chronic hyperglycemia is captured by HbA1C • - microangiopathic complication are associated with HbA1C • -A1c are better related to CVD

  7. Disadvantages ; • - less sensitive than FBG and 2-h PG but more specific ( 88-99%) • - factors that causes inappropriate high and low HbA1C • - weakly associated with diabetes pathophysiology ( insulin sensitivity , and B –cell function ) • - may be high or low relative to average glucose level • Which best test to diagnose type 2 diabetes • WHO recommended use of HbA1C • when to choice OGTT instead of HbA1C for diagnosis • - HbA1C is in aquarate or in reliable • - border line blood glucose value during screening or non fasting • - renal glycosuria • - screening high risk individuals • - unexplained neuropathy , retinopathy , PVD , CVD

  8. Other diagnostic test sued instead of HbA1C ; • - fructosamine ; • indication ; • - if HbA1C is inadequate • - it monitor glucose level over previous 2-3 weeks • - in pregnancy • - monitor the effect of changes in therapy • - glycated albumin ; • same as fructozamine

  9. problem of asymptomatic patients Diagnosis of type 2 diabetes in asymptomatic patients • 20 - 30% of type 2 diabetic patients remain asymptomatic and may present with complication. • Indication for screening type 2 diabetes in asymptomatic person: - All individuals ≥ 45 years old every 3 years. - Annual screening of adults with additional risk factors: - Family history of DM. - Obesity ( BMI ≥ 23). - Previous identified IFG /IGT. - Hypertension (≥ 140/90 mmHg). - TG ≥ 250mg , or HDL ≤ 35. - Women with PCOS. - History of GDM, or delivery of baby over 9Ibs. • Types of test: HbA1C is preferred.

  10. CONTINUE • Other diagnostic pitfalls: - Differentiating types of diabetes according to age at presentation. - Type 2 diabetes can be diagnosed in young aged 12-18 years. - About 50% of type 1 diabetes can occurs in patients above 30 years. - MODY diabetes. • Who to over come: • By the following investigations ; - Serological test. - Assessment of B- cell function. - C – peptide. - Serum insulin. - Urine creatinine to C- peptide ratio. • Investigation to know: - Which phase of type 2 diabetes. - Which subtype of type 2 diabetes. - By HOMA – IR.

  11. Treatment target • Blood glucose targets are individualized based on: - Duration of diabetes. - Age/Life expectancy. - Conditions a person may have. - Cardiovascular disease or diabetes complications. - Hypoglycemia unawareness. - Individual patient considerations. • Blood sugar target: - FBS. - PPBS. - HbA1C.

  12. Treatment types

  13. Antidiabetic medication • Types ; • 1-oral antidiabetic drugs • 2- injectable drugs • A-insulin • B- Glp1 receptor agonist • C- amylin agonist • Oral antidiabetic drugs

  14. Treatments pitfalls • Patients related pitfalls: - Eating immediately after drugs intake. - Negligence. - Time of use. - Injection of insulin at same site. • Physician related pitfalls:

  15. - Which type of antidiabetic drugs to start with ; Oral antidiabetic drugs versus insulin ; - when to start insulin ; 1- in newly diagnosed type 2 diabetes with HbA1C ≥9 and severe symptoms 2- severely insulin deficient type 2 diabetes Use of oral antidiabetic drugs ; Consider the following 1- safety profile Factors to consider when selection therapy 1- Efficacy ( degree of HbA1C reduction ) 2- Risk of hypoglycemia 3- Effect in weight 4- Contraindication 5- side effect 6- Long term CVS mortality and morbidity 7- cost

  16. 2- stage of type 2 diabetes • 3- subtype of type 2 diabetes • 3- effect in long term mortality and morbidity

  17. .

  18. Who to start theraby • step wise approach ; • 1- monotherapy ; if entry HbA1c ≤ 7.5 • 2- dual therapy ; • - if entry HbA1C ≥ 7.5 • - if patients does not reaching treatment target after 3-4 months • 3 - triple therapy ; • - if entry HbA1C ≥ 9 and no symptoms • - if patients does not reaching treatment target after 3-4 months • Consider all of the following when you choice appropriate drugs • - safety profile • - stage of type 2 diabetes • - subtype of type 2 diabetes • - effect in long term outcome • Start with metformin monotherapy

  19. 1- step 1 monotherapy ; • drugs to start ; metformin ; or SGLT type 2 inhibitor , or DPP type 4 inhibitor , or GLP 1 receptor agonist • 2- step 2 dual therapy ; • any of above drugs if not used as monotherapy or others as SU ,Glinide , or Thiazolidinidione • 3- step 3

  20. Treatment pitfalls • 1- use of drugs with poor safety profile • - drugs that has high hypoglycemic risk ; in those who are prone to hypoglycemia ( old age , chronic illness , malnutrition , CVD , chronic LD and CRD • as SU, glinide , insulin • - drugs that increase body weight in obese • as glinide , SU , insulin , TZD • - those with serious side effect • -avoid drugs that increase or c/ I in CVD • - metformin in stage 3-4 NYHA HF • - saxagleptin in HF • - ganafleflazone • - SU • - TZd increase risk of HF

  21. 2- use of drugs that increase insulin secretion in early stage of type 2 diabetes as SU and glinide 3- according to subtype of type 2 diabetes 4- drugs that increase long term diabetic mortality and morbidity

  22. indication of insulin • 1- newly diagnosed type 2 diabetes when entry HbA1C • 2- type 2 diabetic patients not responding to triple therapy • 3- contraindication • 4- severe insulin deficient type 2 • 5- certain illness • Who to choice ; • - avoid insulin with rapid onset • - avoid insulin with peak • - duration • Better regimen ; • - basal insulin • - pre meal insulin • - basal bolus

  23. THANK YOU

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