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Making Diabetes Easy 2013

Making Diabetes Easy 2013. Ian Sempowski MD CCFP (EM). You are so lucky…. The 2013 CDA guidelines are now finally here!!!!!!!!!! Go to CDA website print full text or browse executive summary or ppts Theme is “Individualization of therapy”. CDA Clinical Practice Guidelines.

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Making Diabetes Easy 2013

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  1. Making Diabetes Easy2013 Ian Sempowski MD CCFP (EM)

  2. You are so lucky….. • The 2013 CDA guidelines are now finally here!!!!!!!!!! • Go to CDA website print full text or browse executive summary or ppts • Theme is “Individualization of therapy”

  3. CDA Clinical Practice Guidelines www.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) you can pay for and order the bound guidelines www.diabetes.ca – for patients

  4. Case #1 Mary: 50 yr old obese female complains that she is thirsty, has urinary frequency and fatigue. Past medical history – none Medications- none Physical exam: BP 150/94 HR 90 Lab tests: glucose 15.0, total cholesterol 6.0, LDL 3.9, HDL .9, TG 3.9 urine dipstick negative for protein Questions: How do you diagnose DM? What is the role of the OGTT? Role of A1C

  5. Diagnosis Diabetes - 4 ways: • Two FPG > 7.0 • Random > 11.1 with symptoms • HbA1C >.065 • Using OGTT 2 hr 7r gm • Do 2 hr 75 gm OGTT if FPG 6-6.9 • Based on results determine if they are: • Normal • impaired fasting glucose • impaired glucose tolerance • diabetes • See the CDA guidelines for the table 2013

  6. Dx of prediabetes: 2013 * Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM

  7. Goals for Mary : What is the goal for BP ? Describe her lipid profile? What is her LDL goal? Chol/HDL goal? A1C goal? Lab frequency? She is overwhelmed and thinks you are prescribing too many medications. How do you convince her? What can you tell her in 5 minutes about diet Tx?

  8. Individualizing A1C Targets 2013 Consider 7.1-8.5% if: which must be balanced against the risk of hypoglycemia

  9. How often to test ???

  10. Regular SMBG is Required for:

  11. Increased frequency of SMBG may be required: Daily SMBG is not usually required if patient:

  12. She wants to know what she should be eating ???? Wait time is one month to see dietician Your next pt is due in 5 minutes What do you tell her……

  13. Tips Eat 3 meals/d, meal spacing 4-6hrs , healthy snack-possibly beneficial Limit sugars, sweets eg Limit amts high fat foods eg fried foods, chips, pastries Eat more high fibre foods eg If thirsty drink water Add physical activity Reasons Helps control BG levels Sugar increases BG. Artificial sweeteners OK High fat foods- may cause wt gain , SF reduce insulin receptor activity Increased fullness, lowers BG, chol Pop and fruit juice increase – BG Improves BG “Just The Basics”: (all from CDA website)

  14. Alcohol in diabetes: She wonders whether she can consume alcohol? What advice would you give her?

  15. Case #2 Bob: You are doing a PHE on a 43 yr old car salesman. He is sedentary. Wt is 109 kg waist circumference (WC) is 115 cm BP 146/93 Fasting glucose 6.2 Total cholesterol is 6.1, LDL-C 4.0 HDL-C 0.7, T chol/HDL 8.7, TG 4.1 Questions: 1. What is his diagnosis? 2. What are the diagnostic criteria for this condition? 3. What is the prevalence? 4. How would you treat this patient?

  16. Int D Fed Guidelines Central obesity (ethno- specific values*) plus≥ 2 other risk factors TG ≥ 1.7 BP ≥ 130/85 HDL–C M <1.0 F < 1.3 FPG ≥ 5.6 *Europids WC M ≥ 94, F ≥ 80 South Asian M≥ 90 F≥ 80 ATP-3 guidelines Any 3 of the following: WC M >102 F >88 cm TG ≥ 1.7 BP ≥ 130/85 HDL-C M < 1.0 F<1.3 FPG ≥ 5.6 Metabolic Syndrome- diagnostic criteria:

  17. Diet Refer Dietician and / or DEC Exercise prescription “ Consider medication” for non – responders – Metformin or Acarbose Glucometer – not needed as per 2013 guidelines Metabolic Syndrome- treatment: 2013

  18. Exercise prescription: • Exercise: • What information would you ask of Fred regarding exercise? • Recommendations? • CDA • Explanation, Negotiate, What does h he like to do?

  19. Case # 3 Fred: Fred is 62 and is here for a PHE. He has diabetes for 3 years. He has gained 4 kg in the past three years. PMH- gout, obesity (longstanding) FH- father MI at age 68, brother HT, sister DM O/E: BP 150/92 BP tru 5 readings, weight 94 kg, BMI 30, WC 106cm Fasting blood glucose 10.2 repeat 8.6 HbA1C.077 total cholesterol 6.7, LDL-C 2.9, HDL-C 1.0, TG 3.8 Meds Metformin 500 mg bid, ramipril 10 mg, asa 81 mg, crestor 10 mg. Questions: What is the plan?

  20. What will the dietician do?: • Meals: • balance- • regularity and spacing in meal consumption • consistency in CHO intake • replace high GI CHO’s with low GI CHO’s • Food composition and distribution: • Intact veg, fruit, legumes, whole grains • High protein food/meal • Low fat milk product/meal • Fats – emphasis MUFA omega 3’s - EPA/DHA • SF <7%, TFA’s – trace, PUFA <10%

  21. Acute Metabolic Effects High GI Foods: • 1-2 hrs BG conc 2x that of low GI >>insulin release, reduce glucagon Exagerates N anabolic response to early satiety- stimulates glycogenesis, lipogenesis • 2-4 hrs • Biological effects high insulin and low glucagon persist • Rapid fall BG – hunger, hypoglycemia Y/N • 4-6 hrs • counter regulatory hormone response to restore BG- stimulates glyconeolytic and gluconeogenic pathways - >> FFA levels vs low GI

  22. Omega 3’s- EPA/DHA: • EPA & DHA- fish & fish oils • Lowers : BP, TG’s, platelet aggregation • CDA – 2008 • American Diabetic Association 2008 • Include ≥ 2 svgs/wk fatty fish • All fish –BUT • Fish oil supplement (not cod liver oil) - 1000 mg/d • Adverse events- >3g/d • Alpha linolenic acid (ALA) - Flax, walnut, canola, soybean oils • Recommendation - no

  23. Snacks? • Active time of day – 2 hrs prior to meal • Elevated AC’s? • Night snack – protein food/milk product- modest amts low GI food • Sweeteners? • Alcohol- advice varies – Coingestion of CHO- mixes • Secretagogues or insulin – take with food • Reduces nocturnal hypoglycemia • Tips – food diary and log blood sugars AC’s PC’s – negotiate frequency of monitoring

  24. More pharmocatherapy for Fred • What do we choose???

  25. Pharmacotherapy in T2DM checklist 2013 • CHOOSE initial therapy based on level of glycemia • START with Metformin +/- others • INDIVIDUALIZEyour therapy choice based on characteristics of the patient and the agent • REACH TARGET within 3-6 months of diagnosis

  26. AT DIAGNOSIS OF TYPE 2 DIABETES L I F E S T Y L E Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin A1C <8.5% A1C 8.5% Symptomatic hyperglycemia with metabolic decompensation If not at glycemic target (2-3 mos) Start metformin immediately Consider initial combination with another antihyperglycemic agent Initiate insulin +/- metformin Start / Increase metformin If not at glycemic targets Add an agent best suited to the individual: Patient Characteristics Degree of hyperglycemia Risk of hypoglycemia Overweight or obesity Comorbidities (renal, cardiac, hepatic) Preferences & access to treatment Other Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other 2013 See next page…

  27. From prior page… L I F E S T Y L E If not at glycemic target • Add another agent from a different class • Add/Intensify insulin regimen 2013 Make timely adjustments to attain target A1C within 3-6 months

  28. Drugs -Metformin: • The wonder drug!!!! • Liver- Decreases hepatic gluconeogensis • Skeletal Muscle- Facilitates glucose transport • Adipose tissue- inhibits fatty acid production and oxidation

  29. Metformin: • Start with 250 or 500mg od • Max 2500mg/day • Long acting metformin available but not covered • Lower if renal impaired (egfr 30-60), stop if egfr <30 • GI side effects • Doesn’t cause hypo

  30. Statins:

  31. Dyslipidemia in adults with DM. 2008 CDA Clinical Practice Guidelines

  32. Who Should Receive Statins? 2013 • ≥40 yrs old or • Macrovascular disease or • Microvascular disease or • DM >15 yrs duration and age >30 years or • Warrants therapy based on the 2012 Canadian Cardiovascular Society lipid guidelines

  33. ACE inhibitors: • Target is 130/80 and most will not meet • Three benefits: • HOPE trial • Renal protection • BP reduction • I personally try to get all to Ramipril 10 mg od

  34. Who Should Receive ACEi or ARB Therapy? 2013 • ≥55 years of age or • Macrovascular disease or • Microvascular disease At doses that have shown vascular protection [perindopril 8 mg daily (EUROPA), ramipril 10 mg daily (HOPE), telmisartan 80 mg daily (ONTARGET)] EUROPA Investigators, Lancet 2003;362(9386):782-788. HOPE study investigators. Lancet. 2000;355:253-59. ONTARGET study investigators. NEJM. 2008:358:1547-59

  35. Wt loss as part of treatment: Mary was been diagnosed with Type 11 DM 5 yrs ago when she was 49. She is a single mother and has limited financial resources and no drug plan. She was seen by a dietitian 5 yrs ago and states she has been following a diabetic diet since then. She does very little exercise. BMI 36, WC 96 cm How can she lose weight? She has heard adds on TV for different weight loss programs all promising results. A number of her friends have lost weight on Dr Atkins diet.

  36. Weight Watchers: • Flex Plan – Point System • Core Plan – focus on balance and wholesome foods- Meetings – weigh in (45 min) plus meeting time (30-40min) • Evidence – attending mtgs Costs – July 30 2008 Membership fee – adults 26.25 Meeting payment 8 wks 108.95 12 wks 157.50 Pay weekly 15.75

  37. Dr Atkins Diet: • 20 g CHO/d in veg + other acceptable food choices. NO bread, fruit, rice, pasta, grains, sugar • Permitted- liberal amts eggs, meats, poultry, fish, shellfish – eat until full don’t gorge • Cheese- limit 3-4 oz (90 - 120g) hard cheese/d • Liberal amts – butter ,olive oil • May eat 3-4 C loosely packed leafy greens/d, others 1 C/d plus 2 C leafy greens • Limited amts: olives, avocado, lemon and lime jc/d • 8 250 ml glasses water/d, unlimited herbal, decaf tea coffee/d • Avoid aspartame, alcohol • Allows 3 pkg Splenda/d • Exercise

  38. LA Weight Loss Program: • Center based program, personal counselling, exercise and diet/behaviour modification • Claims: wt loss 1.5-2 lbs/wk, indiv support, eat real food, low cost $6-7/wk • Drawbacks: Pay fees upfront: initiation fee $88. plus $/wk to goal wt. Hard sell- supplements – LA Lites, Nu Lite Bars, Vit/Min Supplements, Jump Start Program, Juice Diet, Counsellors- company trained focus weigh-in • No published evaluations of program

  39. Dr Bernstein Diet: • Promotes avg wt loss – 7-8 kg/mo, stored fat. Low E diet plus injections B6, B12 3X/wk, MD supervised + ,medical personnel evaluations • Reality: E intake 650 (33% pro)-850 kcal, ketogenic diet. Restrictive food choices. Exercise optional. Costly - ~ 160./wk • Unsafe- not recommended

  40. Bottom Line with diets: Emphasize healthy eating and glycemic index! Beware: • On off mentality to eating and foods • External vs internal regulation • Self esteem • Healthy habits • Eating disorders??

  41. Bariatric surgery: • Bypass surgery vs stomach reducing surgery • Often combined together • BMI > 40 • > 35 with serious comorbidities • Beware long term nutritional, immune and other effects….

  42. Treatment BP diabetes: • ACE Ramipril 2.5, 5, 10 mg (ARB if cough) • HCTZ (12.5, 25 mg od) • CCB dihydropiridine class (Amlodipine 2.5, 5, 10 mg od) more emphasis • B Blocker (metoprolol, atenolol 50, 100, 150 od) • Alpha blocker (terazosin 1mg , 2, 5, 10, 20 mg, doxasosin) 2013

  43. What if diet exercise, wt loss and metformin aren’t enough?????? • Sulfonylureas • DPP-4 inhibitors (Januvia) • GLP-1 agonists (Victoza???) • Prandase • Insulin

  44. Case study: • 55 yr old obese, type 2 DM 2years • BMI 37, A1C down from .095 but can’t get below .078 for last year • Working hard on diet and exercise • On metformin 1500 mg / day

  45. Options: • Increase metformin to 2500 mg/day • Add Diamicron or Diamicron MR • Add Januvia (Sitagliptin) • Add Victoza (Liraglutide) • Add Prandase

  46. Sulfonylureas: • They just release insulin • Glyburide is the old standby mostly being replaced by new agents • Diamicron (glicazide) less hypoglycemia- 80 mg bid to 160 mg bid • Diamicron MR 30mg-120mg od • Amaryl (glimepiride) is once daily but not covered ODB

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