Nov 2020

Master Diabetes
Management
Dr. Mona Yehia M.
Family Medicine Specialist
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 Type 1 or
type 2?

DM2 DM1

BMI < 25 -
Obesity
Rapid wt loss
Signs of DKA may be 1st
insulin presentation
resistance
Children > 6m,
Age >50 adolescents,
young adults
FH of
Personal or
DM2
family h.o.
autoimmune dis.

Confirmation of
type 1

Early late

• Anti-insulin Antibodies Fasting insulin level < 5 mIU/L,

• Islet-cell antibodies or fasting C peptide < 0.6 ng/ml
• Anti-GAD65 antibodies
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 How do I
know if I have
gestational
diabetes?

Check at 24 – 28 wks

75 gm Oral glucose
tolerance test (OGTT)
FBS ≥ 92 mg/dl
Or 1 hr postprandial ≥ 180 mg/dl
Or 2 hr postprandial ≥ 153 mg/dl

50 gm Glucose
loading test (OLT)
No fasting required
If after 1 hr ≥ 140 mg/dl

100 gm Oral Glucose

At least 2 readings: tolerance test (OGTT)
FBS ≥ 95 mg/dl
1 hr postprandial ≥ 180 mg/dl
2 hr postprandial ≥ 155 mg/dl
3 hr postprandial ≥ 140 mg/dl
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 Management of type 2

Metformin is the preferred initial pharmacologic agent (unless

eGFR is less than 45 ml/min) + lifestyle intervention

Early combination in high A1c and presence of other conditions

Start with Insulin if A1c level > 10%, blood glucose level ≥ 300
mg/dl, or evidence of ongoing catabolism (wt loss)

Continue Metformin as long as tolerated, & eGFR ≥ 30 ml/min.

If after 3 months A1c is still above target, increase dose of

current medication, if not yet controlled; add another agent.

SGLT-2i, GLP-1 RA are good 2nd line choices in obese patient

GLP-1 RA is preferred in patients with established ASCVD

SGLT-2i is preferred in patients with HF or CKD. Do not start if

eGFR < 60 ml/min, STOP if eGFR < 45 ml/min
DPP4i is neutral regarding wt, and not causing hypoglycemia
(Glucose-dependent insulin secretion). Don’t use with GLP-1 RA

SU, TZD if cost is major concern, or other agents not tolerated

If uncontrolled with oral agents, GLP-1 RA is preferred to insulin

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 Non-insulin agents

1-3 daily doses

Biguanides

Maximum 2550 mg Maximum 2000mg

One daily dose

SGLT-2i

Maximum 25 mg Maximum 10 mg

Metformin
- SGLT2i

One daily dose

Maximum 1.8 mg

Once weekly dose

Maximum 1.5 mg
GLP-1 RA

One daily dose

Maximum 14 mg

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DPP4i

Maximum: 5 mg 100mg 5mg 100mg

Metformin
- DPP4i

One daily dose

Maximum 120 mg Maximum 8 mg

SU

Twice daily

Maximum 320 mg Maximum 20 mg

One daily dose

TZD

Maximum dose 45 mg Maximum dose 8 mg

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 Is my patient
controlled?

Glycemic control is primarily

assessed with A1C test

if can be
In children achieved
and safely in
adolescent adults
s

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H.o. severe Appropriate

hypoglycemia In
goal in non-
, limited life pregnancy
pregnant adult
expectancy,
advanced
complications A1C tests can be affected by changes in red
, extensive blood cells or HGB, e.g. sickle cell anemia,
major bleeding, hemodialysis, chronic anemia,
comorbid
pregnancy, smoking, various infections, ..
condition

Self-monitoring of Continuous glucose monitoring

blood glucose (SMBG) is very effective in type 1
may help with
self-management and
medication adjustment, FBS 80- 2hrPP
particularly 130 < 180
in individuals taking mg/dl mg/dl
insulin.

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 Check patient adherence to management plan,
medication side effects or complex regimen

Enroll patient in Diabetes Self-Management

Education and Support (DSMES) program
What if
patient is Check other causes of hyperglycemia such as
anxiety, UTI, use of corticosteroids, ….
not
controlled Question the diagnosis, other type of DM?
Reassess glycemic target - revise plan

Intensification of regimen - Add basal insulin if

uncontrolled by 2-3 non-insulin agents

Sulphonyl urea (SU):

Hypoglycemia – wt gain

Biguanides: DPP4i:
Diarrhea, nausea, joint pain - risk of
vit B12 deficiency acute pancreatitis
Common Side
effects of Non-
insulin agents
TZD: GLP-1 RA:
Edema – CHF - wt NVD, injection site rn
gain - fractures thyroid C-cell tumor

SGLT2i:
Genitourinary infection – DKA -
volume depletion - LDL

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 Types of insulin analogue regimen

Basal Basal plus Premixed

Basal bolus
Types: aspart/aspart
Types: Glargine, Prandial insulin: aspart, protamine – lispro/ lispro
detemir, degludec lispro, glulisine
protamine
Starting dose: 10 Dose of prandial: 0.5 – 1.2
Dose: 0.5–1 unit/kg,
units, or 0.1-0.2 units/kg, divided on 1-3
divided on 1-2 doses, (2/3
units/kg once daily doses,~15 min. before meal
in the morning, 1/3
Maximum dose: Dosing: 50-60% prandial + evening) before meal
1.2 units/kg (Not > 40-50% basal]
Follow up: FBS for
80 units per day) Follow up of prandial: evening dose & pre-dinner
Follow up: FBS 2hrPP glucose level for breakfast dose

Initiate insulin in Type 1, pregnant, and type 2 if A1C > 10%

Monitor plasma glucose level 8 times daily, before and 2 weeks after
insulin initiation: pre and post prandial, bed time, and around 3 A.M.

“Fix fasting first”, start basal insulin, then add prandial gradually
(start by one dose prior to largest meal, or with highest PP reading)

Adjust dose gradually ( or by 2-4 units/3 days) until target reached

2-3 A.M. reading differentiate between Dawn phenomenon (where
glucose level is high → need to increase evening dose), and Somogyi
effect (glucose level is low, stimulating counter-regulatory hormones
causing morning hyperglycemia → need to reduce evening dose)

In pregnancy, Levimir is the only basal approved – Don’t use premixed

To change human insulin to analogue, decrease dose by 80% - to

change analogue to another analogue regimen, keep same total dose
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 Insulin Analogues

Basal

Prandial

Premixed

Basal +
GLP-
1RA

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 Screen and prevent complications

1. Control BP: below 140/90, and even < 130/90 if

patient has ASCVD or 10-year CVD risk ≥15%
2. lipid: monitor at time of diagnosis & every 5 yrs.
Start moderate-intensity statin at 40 to 75 yrs,
or with ASCVD risk factors, monitor annually.

Refer for dilated and comprehensive eye

examination at time of diagnosis in type 2,
or within 5 years of diagnosis in type 1,
then annually if no evidence of
retinopathy, more frequently if there’s.

Screen for diabetic nephropathy

(urinary albumin and eGFR) at time of
diagnosis in type 2, and after 5 years
in type 1, then at least once a year.
Monitor serum K level annually in
patients on ACEI, ARB or diuretic.

Perform a comprehensive foot evaluation

at least annually. Patients with evidence of
sensory loss or prior ulceration or
amputation should have their feet
inspected at every visit.

1. Screening of anxiety and depression every visit, Others

especially in uncontrolled cases.
2. Regular dental check up every 6 months.
3. Screen common comorbidities, such as OSA,
NASH, and autoimmune diseases in type 1.

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