Chronic Disease

Management-The
Diabetes Example

Dr Abeer Al Saweer
Chronic Disease
 Conditions with gradual  Cardiovascular disease
onset and lasting more  Cancer
than 6 months  Mental health problems
 Often develop over the  Diabetes
persons lifetime  Chronic respiratory
disease
 Tend to be progressive  Chronic muskulo-skeletal
and/or lead to conditions (OA, RA etc)
complications  Nervous system diseases
 Multiple factors cause  Renal disease
them and may be
symptom free early on
(insidious onset)
Aims of chronic care
 prevention or delay of manifestation(s), where possible
 improved functioning of patients
- reducing symptoms and complications
- prolonging lifespan
- improving quality of life
- living independently according own needs, demands and
preferences
 effective, efficient and safe health care delivery
Challenges of chronic care
 prevention & lifestyle
 effective and efficient care (delivery)
 co-morbidity and multi-morbidity
 tailoring to the needs of patients
 support of self-management
 care management support
 manpower
The Diabetes Epidemic: Global
Projections, 2010–2030

IDF. Diabetes Atlas 5th Ed. 2011

Impact of Intensive Therapy for Diabetes:
Summary of Major Clinical Trials
Study Microvasc CVD Mortality
UKPDS      
DCCT /
EDIC*      
ACCORD   
ADVANCE   
VADT   
Initial Trial

Long Term Follow-u

in T1DM *
Multiple, Complex Pathophysiological
Abnormalities in T2DM
pancreatic
incretin insulin
effect secretion
pancreatic
glucagon
_ secretion
gut
carbohydrate
?
& delivery HYPERGLYCEMIA
absorption

+ peripheral
hepatic renal glucose
glucose glucose uptake
production excretion
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Multiple, Complex Pathophysiological
Abnormalities in T2DM
GLP-1R Insulin
agonists pancreatic
Glinides S U s insulin
incretin
effect secretion
DPP-4 Amylin pancreatic
inhibitors mimetics glucagon
_ secretion DA
agonists
AGIs
gut
carbohydrate
?
& delivery HYPERGLYCEMIA
absorption
Metformin TZDs
_
Bile acid
sequestrants

+ peripheral
hepatic renal glucose
glucose glucose uptake
production excretion
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Initial Assessment-Medical
History
o Age and characteristics of onset of diabetes (e.g. DKA,
routine laboratory evaluation)
o Prior HBA1C records
o Eating pattern, nutritional status, and weight history,
growth and development in children and adolescents
o Review of previous treatment programs
o Current treatment of diabetes, including medications,
meal plan, and results of glucose monitoring and
patient's use of data
Initial Assessment-Medical
History
 Exercise history
 DKA frequency , severity, and cause
 Hypoglycemic episodes
Any severe hypoglycemia, frequency, severity
and cause
 History of diabetes- related complications
 Microvasular: eye, kidney ,nerve
 Macro vascular: cardiac, CVD, PAD
 Other: sexual dysfunction, gastroparesis
Initial Assessment- Physical
Examination
 Blood pressure determination, including
orthostatic measurements when indicated
 Fundosopic examination
 Thyroid palpation
 Skin examination
 Neurological / feet examination Inspection
 Palpation of DP and PT pulses
 Presence / absence of patellar or Achilles
reflexes
Initial Assessment- Physical
Examination
 Determination of proprioception, vibration and
monofilament sensation Laboratory evaluation
 HBA1C
 Fasting lipid profile , including total LDL and HDL
cholesterol and triglycerides
 Liver function tests
 Tests for micro-albuminurea
 Serum creatinine and calculated GFR
 Thyroid-stimulating hormone in patients with type 1
diabetes or dyslipidemia or women aged >50 years
 Screen for celiac disease in type 1 diabetes and as
indicated for type 2 diabetes
Stages of Chronic Kidney Disease
GFR (mL/min
per 1.73 m2
body surface
Stage Description area)
1 Kidney damage* with normal or ≥90
increased GFR
2 Kidney damage* with mildly 60–89
decreased GFR
3 Moderately decreased GFR 30–59
4 Severely decreased GFR 15–29
5 Kidney failure <15 or dialysis
GFR = glomerular filtration rate
.Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests *

ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S44; Table 12
 Definitions of Abnormalities in
Albumin Excretion

Spot collection
(µg/mg creatinine)
Category
Normal <30
Increased urinary albumin
excretion* ≥30

Historically, ratios between 30 and 299 have been called microalbuminuria and those 300 or greater have been called *
.macroalbuminuria (or clinical albuminuria)

ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S44; Table 11
Recommendations:
Nephropathy (4)

Treatment (3)
 Reasonable to continue monitoring urine albumin excretion to assess
both response to therapy and disease progression E
 When eGFR is <60 mL/min/1.73 m2, evaluate and manage potential
complications of CKD E
 Consider referral to a physician experienced in care of kidney
disease B
• Uncertainty about etiology; difficult management issues; advanced kidney
disease

ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S43

Initial Assessment- Referral
 Eye exam, if indicated
 Family planning for women of
reproductive age
 MNT
 diabetes educator if not provided by
physician or practice staff
 Goals for Blood Pressure, Lipids
and Microalbumin
Blood Pressure <140/90mmHg

Lipids (mg/dl)
LDL-C <100 (<70)
HDL C <40 (male)
HDL-C >50 (female)
Triglycerides <150

Microalbumin <30 (mg/g creatinine)

 Pharmacologic
Approaches to
Glycemic Treatment
 3. ANTI-HYPERGLYCEMIC THERAPY
• Glycemic targets
- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9
mmol/l])
- Pre-prandial PG <130 mg/dl (7.2 mmol/l)
- Post-prandial PG <180 mg/dl (10.0 mmol/l)
- Individualization is key:
 Tighter targets (6.0 - 6.5%) - younger, healthier
 Looser targets (7.5 - 8.0%+) - older, comorbidities,
hypoglycemia prone, etc.
- Avoidance of hypoglycemia
PG = plasma glucose Diabetes Care 2012;35:1364–1379; Diabetologia 2012;55:1577–1596
Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
 How to choose a drug ?
 Efficacy
 Hypo risk
 Weight change
 CV effect: ASCVD and HF
 Cost
 Oral/SQ
 Renal effect
 Adverse effects
 Durability of glycemic effect
 Anti-hyperglycemic drugs

Feature SU TZD DDP4i

Efficacy high high intermediate
Hypo risk high no no
Weight change gain gain neutral
CV effect Neutral? beneficial neutral
Renal effect neutral beneficial neutral
Cost low low high

Oral/SQ Oral Oral oral

 Anti-hyperglycemic drugs

Feature GLP1 analogs SGLT2i Insulin

Efficacy high intermediate high
Hypo risk No no high
Weight change Loss loss gain
CV Beneficial(ASCVD) Beneficial(BOT neutral
effect(ASCVD/H H)
F)
Renal effect beneficial beneficial neutral
Cost High High Low/
high
Oral/SQ S/Q oral S/Q
 Pharmacologic Therapy For T2DM: Recommendations

• Metformin, if not contraindicated and if tolerated, is the preferred initial

pharmacologic agent for the treatment of type 2 diabetes. A

• Once initiated, metformin should be continued as long as it is tolerated and

not contraindicated; other agents, including insulin, should be added to
metformin. A
 Pharmacologic Therapy For T2DM: Recommendations

• Long-term use of metformin may be associated with biochemical vitamin

B12 deficiency, and periodic measurement of vitamin B12 levels should be
considered in metformin-treated patients, especially in those with anemia or
peripheral neuropathy. B
 PHARMACOLOGIC THERAPY FOR T2DM:
RECOMMENDATIONS

• Early combination therapy can be considered in some patients at treatment

initiation to extend the time to treatment failure. A

• Consider initiating dual therapy in patients with newly diagnosed type 2

diabetes who have A1C ≥1.5% (17 mmol/ mol) above their glycemic target. E
 PHARMACOLOGIC THERAPY FOR T2DM:
RECOMMENDATIONS

• The early introduction of insulin should be considered if there is evidence of

ongoing catabolism weight loss), if symptoms of hyperglycemia are
present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose
level(≥300 mg/dL [16.7 mmol/L]) are very high. E

•
 PHARMACOLOGIC THERAPY FOR T2DM:
RECOMMENDATIONS

• In patients without atherosclerotic cardiovascular disease (ASCVD), if

monotherapy or dual therapy does not achieve or maintain the A1C goal
over 3 months, add an additional anti-hyperglycemic agent based on drug-
specific and patient factors . A
 PHARMACOLOGIC THERAPY FOR T2DM:
RECOMMENDATIONS

• A patient-centered approach should be used to guide the choice of

pharmacologic agents. Considerations include efficacy, hypoglycemia risk,
history of ASCVD, impact on weight, potential side effects, renal effects,
delivery method, cost, and patient preferences. E
 PHARMACOLOGIC THERAPY FOR T2DM:
RECOMMENDATIONS
• Among patients with type 2 diabetes who have established atherosclerotic

cardiovascular disease or indicators of high risk, established kidney disease, or

heart failure, a sodium–glucose cotransporter 2 inhibitor or glucagon-like

peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is

recommended as part of the glucose-lowering regimen independent of A1C and

in consideration of patient-specific factors. A

Pharmacologic Therapy For T2DM
 Pharmacologic Therapy For
T2DM: Recommendations

• In patients with type 2 diabetes who need greater glucose lowering than can
be obtained with oral agents, glucagon-like peptide 1 receptor agonists are
preferred to insulin when possible. B
 Pharmacologic Therapy For
T2DM: Recommendations
• Intensification of treatment for patients with type 2 diabetes not meeting
treatment goals should not be delayed. B

• The medication regimen and medication-taking behavior should be

reevaluated at regular intervals (every 3–6 months) and adjusted as needed
to incorporate specific factors that impact choice of treatment. E