Comprehensive Approach to patients with

hyperglycemia

Dr . Samia A Ali Elmiladi

Consultant physician, Diabetes & Endocrinology
Hospital, Associated professor
Diploma in Diabetes

6/1/ 2024
 Diabetes
FPG=126mg/dl
RPG=200
Pre-diabetes
FPG=100-125mg/dl HBA1C=6.4g%
RPG=140-199mg/dl
HBA1C=5.9-6.3 g%
Normal
FPG<99MG/DL
RPG<139
HBA1C<5.8G%
 Assessment and initial management of new-onset hyperglycemia

Patient un well and /or marked symptom of hyper and /or

Keto +Refer for immediate assessment

Inter-current illness No underlying cause ,patient

DKA HHS ,dehydration well

Commence IV insulin
&fluids Commence SC insulin

Continue SC insulin .Evaluate aetiology of DM

Likely Likely
T1DM T2DM

Glucose monitoring Education ,SC Glucose monitoring Education ±

insulin Specialist referral Glucose-lowering therapy
 Achieve and maintain :
B glucose levels in the normal range
Lipid profile that reduced risk for CVD
B Pr levels in the normal range
To prevent (or slow) the rate of
development of chronic complication by
modifying nutrient intake and lifestyle

MNT goal for DM

Address individual nutrition needs

Maintain pleasure of eating by only
(personal/cultural preferences and
limiting food choices when indicated by
willingness to change)
scientific evidence
 MNT Recommendations

❖ Monitor CHO intake for glycemic control

❖ Include a variety of CHO from fruit, vegetables,
whole grains, legumes, and fat –free/low-fat dairy
products
❖ The use the glycemic index may provide a modest
benefit.
❖ Avoid excess energy intake
Glucose-lowering Drugs
Overall Approach.
Management of diabetes & The glycemic targets should be individualized based on

Patient / Disease Features More stringent A1C 7% Less stringent

Risks potentially associated
With hypoglycemia and other low
drug adverse
High

Usually not modifiable

Disease duration
Newly diagnosed Long-standing
Life expectancy
long Short
Important comorbidities
Absent Few/Mild Severe
Established vascular
complication Absent Few/Mild Severe

Potentially modifiable
Patient attitude and
expected treatment Highly motivated, Less motivated, poor
efforts excellent self-care self-care capabilities
capabilities
Resources and
support system Readily available limited
 Efficacy and key
patient factors

Patient Comorbidities as
preferences (ASCVD), (CKD),
and (HF)

A patient
centered
approach Hypoglycemia
Cost
risk

Effects on body European Association for the

Side effects weight Study of Diabetes
 Normal or subclinical ESTABLISHED ACUTE
HEART
ENDOTHELIAL ATHERO- CORONARY
FAILURE
DYSFUNCTION SCLEROSIS SYNDROME

Metformin, SLGT2-I
stage I-II CKD Metformin, SGLT2-I, GLP-1 Insulin
Pioglitazone, DPP4-I, DPP4-I,
eGFR 90-60 RA, Pioglitazone, DPP4- I , DPP4-I,
GLP-1 RA, SGLT2-I, GLP-1 RA,
ml/min/1.73 m2 Insulin, Gliclazide GLP-1 RA
Insulin ,Sus Insulin
Metformin, Pioglitazone, SLGT2-I
Stage III CKD Metformin, GLP- 1RA, Insulin
SLGT2-I, GLP- 1RA DPP4-I,
eGFR 59-30 SGLT2-I. Pioglitazone, DPP4-I,
,DPP4-I, Gliclazide, GLP-1 RA,
ml/min/1.73 m2 DPP4-l, Insulin, Gliclazide GLP-1 RA,
Insulin Insulin
Stage IV CKD Pioglitazone,
Pioglitazone ,DPP4-I, DPP4-I, DPP4-I,
eGFR 29-15 DPP4-I,
Insulin Insulin Insulin
ml/min/1.73 m2 Insulin
Stage V CKD Pioglitazone, Pioglitazone
DPP4-I, DPP4-I,
eGFR <15 DPP4-I, DPP4-I,
Insulin Insulin
ml/min/1.73 m2 Insulin Insulin

Evidence of efficacy Evidence of safety Author consensus

Treatment algorithm based on cardiac and renal co-morbidities and CVOTs. 1To be used with caution because of the risk of Hypoglycemia
 comprehensive care of patients with diabetes
Standards of diabetes care

➢Initial patient assessment (History, physical examination & basic labs )

➢Addressing lifestyle changes (Follow up with educator & dietitian )

➢ Setting glucose targets (Glucose control ,Home glucose monitoring )

➢Screening for complications of diabetes (periodic exams/tests)

➢ Psychological care

➢ Vaccination
 Approach to DM: history

Duration of diabetes Social: smoking, work, alcohol

Medications and any side effects Social support (financial status)

Adherence to medications Lifestyle changes (diet, exercise)

Follow up Visits to educator

Presence of complications (acute or chronic) Visits to dietitian

Screening for complications (eye, foot, tests) Family history (DM, HTN, CVD)

Home glucose monitoring Vaccination

Comorbidities (HTN, dyslipidemia,…)

 Approach to DM: physical exam

Blood pressure

Weight, height, BMI

Skin

Foot

Baseline Lab. Tests

A1c ,Lipids ,Serum creatinine (eGFR) ,Serum potassium (if on ACEI, ARB, or diuretic) ,ALT, AST
,Urine albumin: creatinine ratio (UACR) ,

TSH for T1 DM
 Periodic exams & referrals

➢Dilated eye exam (yearly)

➢ Foot exam (yearly)

➢Dental exam

➢Family planning for women of reproductive age

 Periodic lab. Tests

1) A1c Every 6 months if controlled Every 3 months if not controlled

2) Urine albumin creatinine ratio, s. creatinine, e-GFR: Yearly More frequent if CKD or
changing medications/doses

3) Serum Potassium (if on ACEI, ARB or diuretic) Yearly More frequent if CKD or
changing medications/doses

4) Lipids - Yearly - More frequent if not at target or changing doses/therapy

5) ALT, AST – Yearly

6) Serum vitamin B12: - If on metformin for >4 years - Every year in such cases
Thank you