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Management of diabetes mellitus (DM) WORKSHOP Dimitris Karanasios

Management of diabetes mellitus (DM) WORKSHOP Dimitris Karanasios. INTRODUCTION. The Importance of DM Management in Primary Care The role of the GP / FM in everyday practice. CONTENT. Diagnosis and management of DM Major complications resulting from DM

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Management of diabetes mellitus (DM) WORKSHOP Dimitris Karanasios

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  1. Management of diabetesmellitus (DM) WORKSHOP DimitrisKaranasios

  2. INTRODUCTION • The Importance of DM Management in Primary Care • The role of the GP / FM in everyday practice

  3. CONTENT • Diagnosis and management of DM • Major complications resulting from DM • Strategies for a patient-centred care approach to achieving intensive glycemic control • Patients’ empowerment through education about DM self-management

  4. Guidelines for DM management (ADA – AACE/ACE – EASD – IDF) and their differences “Despite the same objectives, these guidelines are substantially different in content.” Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more clinically relevant than the IDF recommendations? Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25

  5. Guidelines for DM management and their differences “ADA/EASD guidelines offer practical algorithms to help initiate and modify pharmacological therapy for diabetes with detailed descriptions of treatment options. IDF document, however, concentrates on the role of postprandial hyperglycemia and calls for a lower HbA1c target value of 6.5% as opposed to ADA/EASD guidelines advocating a value of 7%.’’ Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more clinically relevant than the IDF recommendations? Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25

  6. Guidelines for DM management and their differences “Careful analysis of the guidelines’ contents suggests that an ADA/EASD consensus might be more useful in everyday clinical practice than IDF recommendations, which do not offer a particular treatment algorithm”. Czupryniak L. Guidelines for the management of type 2 diabetes: is ADA and EASD consensus more clinically relevant than the IDF recommendations? Diabetes Research and Clinical Practice 2009 Dec; 8: s22-s25

  7. Guidelines for DM management and their differences “For example, having been developed by endocrinologists, ACE/AACE guidelines set more aggressive target A1C levels than the ADA/EASD guidelines(≤ 6.5% vs < 7%); they also stratify patients into treatment-nave and treated groups. In contrast, ADA/EASD guidelinesare unstratified and more general.” Robertson C. Translating Guidelines into Primary Care of Patients With Type 2 Diabetes: What's New About ADA/EASD Guidelines and the ACE/AACE Road Maps?Journal for Nurse Practitioners 2008; 4(9): 661-671. 

  8. Major complications of DM Complications: Macrovascular • Atherosclerotic Heart Disease • Myocardial Infarction • Peripheral Vascular Disease • Cerebrovascular Disease • Renal Artery Stenosis Complications: Microvascular • Diabetic Retinopathy • Diabetic Nephropathy • Occurs in 40% of Type I Diabetes Mellitus • Occurs in 20% of Type II Diabetes Mellitus • Peripheral Neuropathy • Autonomic Neuropathy • Gastroparesis • Impotence Family Practice Notebook, LLC, 2008

  9. Major complications of DM • Major complications of DM are: • Cardiovascular Disease • Diabetic Nephropathy • Diabetic Retinopathy • Family Practice Notebook, LLC, 2008

  10. CASE STUDY • A 58-year-old man, referred by his cardiologist, isfeeling very tired and fears that his heart disease has worsened. There are no indicators of a new coronary disease event. • History: • Stopped smoking 10 years ago (40p/y) • Drinks 1 glass of red wine per night • Underwent angioplasty 10 months previously • Current medication: Statin, beta-blocker, aspirin, ACE inhibitor and a diuretic • Physical examination: • BP 130/78 mmHg PULSE 88/min • WEIGHT 120 kg BMI 38.3 kg/m2 • Examinations: • Fasting Glu 220 mg/dl, HbA1c 8.4% • TC 212 mg/Dl, LDL 124 mg/dL, HDL 24 mg/dL and TG 320 mg/dL

  11. GROUP WORK - 3 GROUPS • Design a plan for: • Diagnosis, additional examinations(using current diagnostic criteria) • Lifestyle modifications – Medication (using current guidelines – treatment algorithms) • Patient education / self-management (use current guidelines)

  12. GROUP PRESENTATIONS • DM management plan – grouppresentations • Discussion

  13. SUMMARY • Goals of the workshop • Challenges in chronic disease management

  14. DM DIAGNOSTIC CRITERIA

  15. THERAPEUTIC CHANGES TO ONE’S LIFESTYLE – (TLC) ATPIII • Weight loss of 10% of BW in 6 months • Lowering the daily calorie intake (500 kcal-1000 kcal) • Moderate exercise 30 min. daily • Stress control, social and family support, smoking cessation • Medication lowering lipid levels in case of an inability to reach target levels within 6 months • http: // www.nhlbi.nih.gov • Copy for trainee

  16. Pharmacologic treatment of DM Heine RJ, Diamant M, Mbanya J-C, Nathan DM. Management of hyperglycaemia in type 2 diabetes: the end of recurrent failure?BMJ 2006; 333: 1200-1204

  17. Patient education in DM • Recommendations: • People with diabetes should receive DSME according to national standards when their diabetes is diagnosed and as needed thereafter. (B) • Self-management behaviour change is the key outcome of DSME and should be measured and monitored as part of care. (E) • DSME should address psychosocial issues since emotional well-being is strongly associated with positive diabetes outcomes. (C) • DSME should be reimbursed by third-party payers. (E) • Standards of Medical Care in Diabetes—2009. • Diabetes Care 2009 Jan; 32: S13–S61. doi: 10.2337/dc09-S013.

  18. EMPOWERING PATIENTS: WHAT PATIENTS SHOULD KNOW • Reducing Risk • What type 2 diabetes mellitus is: (a) insulin deficiency and resistance; (b) progression of the disease • The long-term effect of high blood sugar, emphasizing the importance of lowering blood sugar levels in order to prevent complications • What insulin is and why it is important • How lifestyle modification affects long-term complications • Healthy Eating and Activity • How lifestyle (diet and exercise) modification affects blood sugar, i.e., foods that raise blood sugar and the impact of activity on blood sugar • Monitoring • The importance of rigorous management of blood sugar levels—achieving desired blood sugar levels • The difference between fasting and postprandial sugar levels • Taking Medications • How various oral anti-diabetic agents affect blood sugar levels • Postprandial medications • When and why insulin should be administered • Which insulin? • Carolyn Robertson, Journal for Nurse Practitioners 2008; 4(9): 661-671

  19. Indicators of DM control • “Treatment involves control of hyperglycemia to improve symptoms and prevent complications while minimizing hypoglycemic episodes.” • Goals for glycemic control are: • Blood glucose between 80 and 120 mg/dl during the day • Blood glucose between 100 and 140 mg/dL at bedtime • HbA1c levels < 7% • Merck manuals online medical library

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