UPDATE ON MANAGEMENT OF

TYPE 2 DIABETES MELLITUS

CLINICAL PRACTICE
GUIDELINE (6TH EDITION)
*IMPORTANT UPDATES??
Dr Norhayaty Sharman Bt
Khamis@Roslee
FMS KK BALOK
 BACKGROUND
• T2DM is the most common form of diabetes , accounting for > 90% of
all cases of adult-onset diabetes in Malaysia.

• Both prediabetes and diabetes commonly coexist with other non-

communicable diseases namely hypertension, dyslipidaemia and
obesity.
• T2DM is an important risk factor for CVD and microvascular
complications such as nephropathy, retinopathy and neuropathy.
Other non-vascular complications include infective complications.

• Non-alcoholic fatty liver disease ( NAFLD), obstructive sleep apnoea

(OSA) and increased risk of certain malignancies are common
co-morbidities that are associated with T2DM.
 PREVALENCE

Prevalence rate of diabetes in adult has

increased in Malaysia from 13.4% in
2015 to 18.3% in 2019, with diabetes
defined as having fasting sugar levels
7.0 mmol/L or above
• There is evidence that reversal or remission of
T2DM may be possible in some individuals with
short duration of disease, following reversal of
insulin resistance through significant and
sustained weight loss by either caloric
restriction or bariatric surgery.
 (6th edition)

(5th edition)
VLCD with Diabetic Formula
● 800 kcal/day
● 3x meals with diabetic formula
● 1x meal : 200 – 300 kcal or 1 serving
Contoh Menu 1600 Sarapan (7.00 – 8.00 pagi) Pertukaran Karbohidrat
kcal/day Roti 2 keping @ Oat 6 sudu makan
+ Telur 1 Biji
2

( may need to half + Susu Tepung Skim 4 sudu makan 1

the intake) Minum Pagi (10.00 – 10.30 pagi)

Biskut 3 keping @ Roti 1 keping 1
Makan Tengahari (12.30 tghari – 1.30 ptg)
Nasi 1 ½ cawan 3
Ayam / Ikan / Daging 1 ketul
Sayur 1 cawan
Epal 1 biji 1
Minum Petang (3.30 – 4.30 ptg)
Biskut 3 keping @ Roti 1 keping 1
Kopi / Teh
+ Susu Tepung Skim 4 sudu makan 1
Makan Malam (6.30 ptg – 7.30 mlm)
Nasi 1 ½ cawan 3
Ayam / Ikan / Daging 1 ketul
Sayur 1 cawan
Epal 1biji 1
Minum Pagi (9.30 – 10.00 mlm)
Biskut 3 keping @ Roti 1 keping 1
Jumlah Pertukaran Karbohidrat 15
#2 NAFLD
Recommendations : Treatment of
NAFLD

1. Lifestyle intervention is the mainstay of treatment of NAFLD

2. Statins should be prescribed for treatment of dyslipidaemia in

NAFLD patients, when indicated, to reduce the risk of CVD

3. GLP1-RA and/or SGLT2-i should be considered for the treatment of

T2DM in patients with suspected or confirmed NASH and/or
advanced liver fibrosis
#3 MANAGEMENT
Managing Type 2 Diabetes
An evolutionary concept
Recommendations

1. Lifestyle measures remain important ; attainment of appropriate weight,

increased physical activity and smoking cessation.

2. Aspirin should be used for 2⁰ prevention in T2DM. For patients with

ASCVD and documented aspirin allergy, clopidogrel 75mg/day should be
used.

3. Primary prevention of ASCVD with low dose aspirin (75-100mg OD) is

only recommended in patients at increased CV risk after discussion with
patient on benefits vs risk of bleeding.
4. In patients with T2DM with established atherosclerotic CVD,
consider adding SGLT2-i / GLP1-RA with demonstrated CV benefit as
part of the glucose lowering regimen.

5. Among patients with ASCVD with pre-existing or at high risk of

heart failure (HFrEF) SGLT2-i should be considered, even if HbA1c is
at target.
 Updates & Recommendations
1. DKD is the new term used to refer to kidney disease caused by T2DM.

2. Optimise glucose and BP control and use RAS blockade to slow progression of DKD.

3. BP target should be ≤ 130/80 mmHg in DKD regardless of level of albuminuria

4. ACEIs or ARBs should be initiated in patients with albuminuria, regardless of BP, as

tolerated.

5. SGLT2i have been proven to be renoprotective, beyond glucose-lowering. SGLT2-i

should be considered in patients with eGFR ≥ 30 ml/min/1.73m², particularly in those
with albuminuria to reduce risk of DKD progression.

6. GLP1-RA should be considered in patients with DKD and at high CV risk. GLP1-RA have
been shown to reduce albuminuria progression in DKD with high CV risk.
 Updates

• Diabetic ketoacidosis
 Weight- based fixed rate intravenous insulin infusion ( FRIII) is the
current standard recommendation and the use of ‘sliding scale’
insulin should no longer be practised.

• Euglycaemic ketoacidosis
 Although this has been known in T1DM, it can occur in patients with
T2DM treated with SGLT2-i , precipitated by stress, and/or omission
of insulin.
Individualised
DM Refresher course 2021 at Cathayana
Hotel (18 Dec2021)
Important take home message:
• Insulatard/Basal maximum dose (0.4-0.5unit/kg) for obese pt can up to (0.7unit/kg)
• Add actrapid/Bolus if has prandial issue- (0.2-0.3unit/kg) each dose-titrate slowly
• Don’t adjust the bolus/prandial if fasting still not targetted
• Fix the fasting first
• Relative hypo-treat as true hypo-to advice pt to take ‘simple sugar’- reduce
treatment- give time up to one month for body adjustment-target higher sugar
level.. Then pt will slowly achieve non sx euglycaemia
• To avoid congenital teratogenicity- need to get Aic ≤ 6.5% before POA 7weeks
• To anticipate of the needs of insulin dose increment at 2 nd to 3rd trimester due to
more insulin resistant at this period
• Assessment by 3Ds formula: Diet, Delivery, Dose
 Whooley)

6, 2022
DOSE,
DELIVERY
THANK YOU