CPG DM 2015

5th edition
Screening
 Asymptomatic Symptomatic

• First degree relative with

symptoms suggestive of
diabetes
diabetes (tiredness, lethargy,
• hx CVD (ACS/TIA/CVA)
polyuria, polydipsia,
• HPT
polyphagia, weight loss,
• IGT/IFT
pruritus vulvae, balanitis
• HDL <0.9 or TG>2.8
• Morbid obesity
• Hx GDM
• PCOS
1. How to screen for diabetes in symptomatic
patient? Asymptomatic patient?
2. What are the tools for diabetic screening?
Screening &
Diagnosis
 Symptomatic

Venous plasma glucose

Fasting Random

<7.0 ≥7.0 ≥11.1 <11.1

OGTT Diabetes mellitus OGTT

• Asymptomatic
Capillary blood glucose

<5.6 >5.6

RBG FBG
normal

<7.8 7.8- >11.1 <6.1 6.1-6.9 ≥7.0

11.1

2nd Normal OGTT 2nd

Normal OGTT
RBG FBG
 OGTT
Category 0 hour (fasting) 2 hour
Normal <6.1 <7.8
IFG 6.1-6.9
IGT - 7.8-11.0
DM ≥ 7.0 ≥11.1
 A1c as screening test for DM
• A1c more convenient to do and therapeutic decisions also based
on A1c value.

• But
A1c not appropriate for diagnosis DM in:

- Adolescents <18years old

- on medication cause rapid glucose rise: steroids, antipsychotic
- on iron supplements
- acute pancreatic damage including pancreatic surgery
- genetic,hematologic and illness related factor that influence
HbA1c (haemoglobinopathies, rheumatoid arthritis, chronic liver
disease, post splenectomy)
- anemia due to iron, B12 or erythropoeitin deficiency
 Normal Pre- diabetes Diabetes

A1c < 5.6 5.6-6.2 ≥ 6.3

If, A1c ≥ 6.3%, repeated HBa1c after 4weeks required in

asymptomatic patient
 Cardiovascular Risk Estimation
• Assessment of risk of developing
cardiovascular complication once diabetes
diagnosed  Aggressive and closer
monitoring
• - Framingham risk score
- systemic coronary risk evaluation(SCORE)-
validated only for men
• Both test valid for adult age 40-65years old.
 Targets for control
Parameters Levels
Glycaemic control Fasting 4.4-6.1
Non Fasting 4.4-8.0
A1c <6.5%
Lipids TG <1.7
HDL >1.1
LDL <2.6
Blood pressure <130/75
Body weight If overweight or obese,
reduction 5-10% in 6/12
Individualised targets and
patient profile
Tight (6.0-6.5%) 6.6-7.0% Less tight (7.1-8.0%)
- Newly diagnosed All others - comorbidities (coronary
-younger Age disease, heart failure, renal
- Long life expectancy, no failure, liver failure)
cvd complication - short life expentancy
- low risk hypoglycemia -prone to hypoglycemia
 Treatment
• Weight reduction ( 5-10% from initial weight in 6/12)
• Diet
- take low GI diet
- consistent CHO intake on a day to day basis
- protein 15-20%
- fat 25-35%
• Exercise: 5days a week preferably most days of the
week with no more than 2 consecutive days without
physical activity
Medications
• Biguanides (Metformin)

- ↓ hepatic glucose production

not stimulate insulin secretion

- ↓ A1c 1.5%

- side effects: nausea, diarrhea, anorexia

to reduce side effect  take together or after meal, start

500mg OD first than titrate weekly, or extended release
formulation.

- benefit: weight stability or mild weight loss

* low dose MTF safe for lactating mother
 Sulphonylureas

• Reduce plasma glucose by increasing insulin secretion

• ↓ A1c 0.4-1.6%

• Adverse effect: - hypoglycemia (esp: renal impairment, liver cirrhosis,

elderly)
- weight gain

• 2nd generation are preferred – gliclazide and glimepiride

• Glibenclamide should not be used for pt age > 60y.o

• SU if combine with NSAIds, antithyroid, anticoagulant, α- blocker,

sulpha drugs  increase risk hypoglycemia

• Should be taken 30minutes before meal

Alpha glucosidase Inhibitor
• Acarbose reduce rate of polysaccharide in
proximal intestine
• Take with main meals
• Lower PPG without causing hypoglycemia
• ↓A1c: 0.5-0.8%
• Can combine with insulin
• Adverse effect: bloating, diarrhoea, flatulence
DPP4-i
• Lower A1c 0.5-0.8%
• Weight neutral and low risk hypoglycemia

GLP-1
• Two forms: immediate release and extended release
• Given subcutaneous.
• Reduce A1c 0.5-1.0%
• If pt on MTF + SU with A1c <10% addition of GLP-1 may
give similar glycaemic control compare to insulin glargine
without any increase risk of hypoglycemia and weight gain
• Progressive weight loss seen
• SGLT2 inhibitor
- inhibit transporter in proximal tubule thus
reduce glucose reabsorption
- Reduce A1c 0.2-0.8%
- Benefit: weight loss
- *not suitable for CKD GFR <60mL/min/1.73
 Onset of action Peak action(hours) Duration of action(hours) Timing of administration of
Prandial insulin
Short acting 30-60 min 2-4 6-10 30min before meal
Actrapid
Humulin R
Insuman R
Insugen R

Rapid analogue 0-20min 1-3 3-5 5-15min before or immediately

Aspart(Novorapid) after meals
Lispro(Humalog)
Glulisine(Apidra)

Basal
Intermediate acting, NPH 1-2hour 4-8 8-12 Prebreakfast/prebed
Insulatard
Humulin N
Insuman N
Insugen N

Long acting analogue Same time everyday

Glargine 30-60min less peak 16-24 flexible once daily injection
Detemir 30-60min less peak 16-24
Gegludec 30-90min less peak 24-40

Premixed insulins
Mixtard 30/70 30min Dual 16-18 30-60min before meal
Novomix 30 10-20min 1-4 16-20 5-15min before meal
Diabetic Emergencies
• Hypoglycemia defined as either one of:
- plasma glucose level <4.0
- autonomic or neuroglycopenic symptoms which are reversed
with caloric intake
Autonomic Neuroglycopenic
• Trembling • Difficulty concentrating
• Palpitations • Confusion
• Sweating • Weakness
• Hunger • Drowsiness
• Nausea • Vision changes
• tingling • Difficulty speaking
• Dizziness

Severity of hypoglycemia
Mild Autonomic symptoms
Moderate Autonomic and neuroglycopenic sx
but patient able to self treat
Severe Require assistance of another
person.
May become unconscious
• Mild to moderate ingest 15g of simple carb (1 tbs honey, ¾
cup of juice, 3 tea spoon of sugar)
repeat GM 15 minutes later if <4.0 mmol/L ingest another
15g of carbohydrate

• Severe  if still conscious ingest 20g carb then repeat GM

if unconscious:IV 20-50ml of D50% over 1-3minutes

• Once hypoglycemia reversed, pt should have usual meal that

is due at that time
• **repeated hypoglycemia may blunts symptomatic and
hormonal responses to subsequent episodes that lead to
hypoglycemia unawareness (↑17 fold risk of severe
hypoglycemia)
• Need to avoid another hypoglycemia attack in several weeks
to reverse hypoglycemia unawareness.
• Hypoglycemia cause increase risk of CVD risk
and sudden cardiac death
• It also induce changes in conduction system of
heart  prolong QTc interval, lengthening
repolarization and causing ST wave changes
 DKA
• Diagnostic criteria: (all 3 must be met)
1. GM >11 mmol/L
2. Capillary ketone >3 mmol/L or Urine ketone
≥ 2+
3. Venous pH <7.3 and/or bicarbonate
<15mmol/L
• HDU admission may be required for pt below:
1. Elderly
2. Pregnant ladies
3. Heart or kidney failure
4. Severe DKA
- venous bicab <5mmol/L
- blood ketones >6 mmol/L
- Venous pH <7.1
- Hypokalemia
- GCS <12
- SPO2 <92%
- Systolic BP <90mmHg
- Pulse >100 or <60
- Anion Gap >16
Immediate management:
• IV 0.9% NS drip using large bore branula
If SBP ≥ 90mmHg  1000mL 0.9 NS for 1hour
SBP ≤ 90mmHg
- 500mL 0.9% NS over 10-15minutes until SBP
≥ 90mmHg.
Once SBP ≥ 90 give 1000mL 0.9 NS over 1hour
• Commence fixed rate IV insulin infusion
HHS (hyperglycaemic hyperosmolar State)

• Diagnosis criteria:
1. Hypovoluemia
2. Marked hyperglycaemia >30 mmol/L
3. Osmolality >320 mosmol/kg
No significant hyperketonemia (<3.0 mmol/L) or
acidosis
 Aspirin for primary prevention of
cardiovascular disease ??
• Aspirin low dose (100mg) not recommended in
patients with diabetes unless age ≥ 65years old.

• Six well controlled trials failed to show significant

effect on cardiovascular disease endpoint.
However risk of fatal coronary or cerebrovascular
events was significantly decreased in those age
65y.o above with aspirin.
Diabetes in pregnancy
• GDM

• MGTT:
Diagnosis FPG 2HPP
GDM ≥ 5.1 ≥ 7.8

• Blood sugar target in pregnancy

Timing of blood glucose Target value
Fasting ≤ 5.3
1 HPP ≤ 7.8
2HPP ≤ 6.7
• Metformin in GDM not associated with any
birth defects, pre eclampsia or any adverse
fetal or maternal outcomes
• It may lead to better maternal outcomes in
terms of total weight gain, postprandial blood
glucose, pregnancy induced hypertension
(maternal) fetus  reduce risk of severe
neonatal hypoglycemia
• For pt pregnant and PCOS  reduce risk of
early miscarriage, excessive weight gain, fasting
serum insulin level and incidence of gdm
• Insulin should be initiated if BSP not
maintained between 4-7mmol/L
Diabetes in elderly (≥ 60y.o)
DM in Ramadhan
 CASE DISCUSSION
• 42Y.O female para 3 DM type 2/hypertension/dyslipidaemia for 8 years. Current
medication:
• Metformin 1g bd
• Sc actrapid 22u tds
• Sc insulatard 24u on
• Hctz 12.5mg od
• Perindopril 8mg od
• Amlodipine 10mg od
• Simvastatin 20mg ON
BSP: 15.9/10.3/6.1/6.7/7.2
BP: 140/89
BMI: 20

What are the main issues for this patient?

• Latest blood ix:
Hba1c: 14.9
Creat: 181 (creatinine trend since 2016: 119-120-127-
181)
Urea: 8
Total chol: 6.6
LDL:4.82
TG: 3.73

Any other investigation should be done for this patient?

Other assessment tools to assess risk of CVD
 Case 2
• Mr Y 40 y.o male come for CVD screening. He
has s/sx hyperglycemia. strong family history-
parent are diabetic.

• GM: 15

• How to confirm diabetes for this patient?

• FBS: 18

• What kind of medications patient should be

treat with?