Pitfalls in the management of

diabetes
Aly A Abdel Rahim, MD
 What is diabetes
• A syndrome of chronic hyperglycaemia.

• Associated with metabolic abnormalities

and micro and macro-vascular
complications
 Diagnosis
• The preferred test is:
– FBG
– PPG
– Random BG
– OGTT
– HbA1c
 Diagnosis
• A 48 years old man presented with
general fatigue increased frequency and
HTN, FBS 103mg/dl

• This man is:

– Not diabetic
– Diabetic
– Prediabetic
– Needs further investigations regarding BG.
 Diagnosis
• Normal FBS is up to:
– 100 mg/dl
– 110 mg/dl
– 120 mg/dl
– 125 mg/dl
– 140 mg/dl
• Diabetes is diagnosed if FBS is more than
– 100 mg/dl
– 110 mg/dl
– 120 mg/dl
– 125 mg/dl
– 140 mg/dl
• IFG
 Diagnosis
• Normal PPBG is up to
– 120 mg/dl
– 125 mg/dl
– 140 mg/dl
– 180 mg/dl
– 200 mg/dl
– 220 mg/dl
• Diabetes is diagnosed if PPBG is above
– 120 mg/dl
– 125 mg/dl
– 140 mg/dl
– 180 mg/dl
– 200 mg/dl
– 220 mg/dl
• IGT
 Diagnosis
• GDM is:
– DM in any pregnant women.
– DM discovered for the first time during
pregnancy.
– DM discovered in the first trimester.
– DM during pregnancy which disappears after
labor.
• Screening for GDM
• How to screen??
 Diagnosis
• A 15 years old young man with positive family history
of diabetes, body weight 118 Kg and height 169, FBS
145 mg/dl, BP 160/90.
• This man is
– Normal
– Type 1 DM
– Type 2 DM
– IGT
– Type 2 DM in the adolescent.
– Needs further investigations.
 Prevention of Diabetes
• Type 2 diabetes is:
– A preventable disease
– Non- preventable disease.
 Management
• In T2DM: initial evaluation should include:
– Glycaemic profile
– Lipid profile.
– PN
– Kidney functions
– ECG
– BP
– Fundus
• In T1DM
– Complications are unlikely at the time of diagnosis.
 Goals
• Fasting BG less than
– 100 mg/dl
– 120 mg/dl
– 125 mg/dl
– 130 mg/dl
– 140 mg/dl
– 160 mg/dl
– 180 mg/dl
– 200 mg/dl
 Goals
• PPBG less than
– 100 mg/dl
– 120 mg/dl
– 125 mg/dl
– 130 mg/dl
– 140 mg/dl
– 160 mg/dl
– 180 mg/dl
– 200 mg/dl
 Goals
• Hb A1c less than
–6
– 6.5
–7
– 7.5
–8
– 8.5
–9
– 10
 Goals
• LDL Cholesterol should be less than
– 100 mg/dl
– 120 mg/dl
– 140 mg/dl
– 150 mg/dl
– 160 mg/dl
– 200 mg/dl
– 250 mg/dl
– 285 mg/dl
 Goals
• TG should be less than:
– 100 mg/dl
– 120 mg/dl
– 140 mg/dl
– 150 mg/dl
– 160 mg/dl
– 200 mg/dl
– 250 mg/dl
– 285 mg/dl
 Goals
• HDL Cholesterol more than
– 30 mg/dl
– 35 mg/dl
– 40 mg/dl
– 45 mg/dl
– 50 mg/dl
– 60 mg/dl
 Goals
• Systolic BP should be less than
– 110 mmHg
– 120 mmHg
– 130 mmHg
– 140 mmHg
– 150 mmHg
– 160 mmHg
• Diastolic BP should be less than
– 70 mmHg
– 80 mmHg
– 90 mmHg
– 100 mmHg
 Management
Key concepts in setting Glycaemic goals:
• A1C is the primary target for Glycaemic control
• Goals should be individualized
• Certain populations require special considerations
• Less intensive Glycaemic goals may be indicated in patients
with severe or frequent hypoglycemia
• More stringent Glycaemic goals (i.e. a normal A1C, 6%) may
further reduce complications at the cost of increased risk of
hypoglycemia (particularly in those with type 1 diabetes)
• Postprandial glucose may be targeted if A1C goals are not met
despite reaching pre-prandial glucose goals
 BP control
• A target blood pressure goal of 130/80 mmHg is
reasonable if it can be safely achieved.
• Lowering BP with antihypertensive drugs,
including ACEI, ARBs, β-blockers, diuretics, and
calcium channel blockers, has been shown to be
effective in lowering cardiovascular events.
 BP management
• A 35 years old T1DM patient with BP 150/90,
microalbuminurea, and controlled on insulin. Regarding
his BP he needs:
– Just life style modifications
– ACE
– ARBs
– ACE or ARBs
– CCB
– BB
– Diuretic
– Vasodilator
– Centrally acting drugs
 BP management
• A 55 years old T2DM patient with BP 150/90,
microalbuminurea, and controlled on OHA.
Regarding his BP he needs:
– Just life style modifications
– ACE
– ARBs
– ACE or ARBs
– CCB
– BB
– Diuretic
– Vasodilator
– Centrally acting drugs
 BP management
• A 55 years old T2DM patient with BP 150/90,
macroalbuminurea, and controlled on OHA.
Regarding his BP he needs:
– Just life style modifications
– ACE
– ARBs
– ACE or ARBs
– CCB
– BB
– Diuretic
– Vasodilator
– Centrally acting drugs
 BP management
• A 32 years old T1DM pregnant patient with BP
150/90, microalbuminurea, and controlled on insulin.
Regarding her BP she needs:
– Just life style modifications
– ACE
– ARBs
– ACE or ARBs
– CCB
– BB
– Diuretic
– Vasodilator
– Centrally acting drugs
 Dyslipidaemia management.
Screening
• In adult patients, test for lipid disorders at least
annually and more often if needed to achieve
goals. In adults with
• For diabetics aged 40 years without overt CVD,
but at increased risk who do not achieve lipid
goals with lifestyle modifications alone, the
addition of pharmacological therapy is
appropriate and the primary goal is an LDL
cholesterol 100 mg/dl.
 Dyslipidaemia management.
Treatment recommendations and goals
• People with diabetes and overt CVD are at very
high risk for further events and should be treated
with a statin.
• A lower LDL cholesterol goal of 70 mg/dl using a
high dose of a statin, is an option in these high
risk patients with diabetes and overt CVD.
• Lower triglycerides to150 mg/dl and raise HDL
cholesterol to 40 mg/dl. In women, an HDL goal
10 mg/dl higher should be considered.
Nephropathy screening and
 Glycaemic control
• A 45 yeas old first discovery T2DM patient FBS
200 mg/dl, weight 115 Kg, height 172 cm, No
other medical disease, Initial Glycaemic
management should be:
– Life style modification
– Sulfonylureas
– Metformin
– Acarbose.
– TZDs
– Combination of OHA.
– Insulin.
– Combined insulin and OHA.
 Glycaemic control
• A 45 yeas old first discovery T2DM patient FBS 200
mg/dl, weight 115 Kg, height 172 cm, No other
medical disease, Initial Glycaemic management
failed, consider:
– Life style modification
– Sulfonylureas
– Metformin
– Acarbose.
– TZDs
– Combination of OHA.
– Insulin.
– Combined insulin and OHA.
 Glycaemic control
• A 45 yeas old first discovery T2DM patient FBS 200
mg/dl, weight 115 Kg, height 172 cm, No other
medical disease, Initial Glycaemic management
failed, second line failed, consider:
– Life style modification
– Sulfonylureas
– Metformin
– Acarbose.
– TZDs
– Combination of OHA.
– Insulin.
– Combined insulin and OHA.
 Glycaemic control
• A 45 yeas old first discovery T2DM patient FBS 200
mg/dl, weight 115 Kg, height 172 cm, No other medical
disease, Initial Glycaemic management failed, second
line failed, third line failed, consider:
– Life style modification
– Sulfonylureas
– Metformin
– Acarbose.
– TZDs
– Combination of OHA.
– Insulin.
– Combined insulin and OHA.
 Glycaemic control
• A 45 yeas old first discovery T2DM patient FBS 200
mg/dl, weight 115 Kg, height 172 cm, history of heart
failure, Initial Glycaemic management failed,
consider:
– Life style modification
– Sulfonylureas
– Metformin
– Acarbose.
– TZDs
– Combination of OHA.
– Insulin.
– Combined insulin and OHA.
 Glycaemic control
• Cautions with metformin

• Cautions with TZDs

• Caution in combining insulin and TZDs

 Glycaemic control
• A 50 years old diabetic patient had a rise
of FBG 150 mg/dl during stress which
improved without treatment after one
month, tell him:
– Forget about diabetes
– This is stress diabetes
– You are diabetic and must have therapy
– You may become diabetic and have to follow
up
 Glycaemic control
• A 30 years old lady who had GDM, she
asked what will happen to my diabetes
later, tell her:
– You’ll be diabetic for the rest of your life.
– 100% you will recover.
– Most probably you will recover.
– Most probably you will recover but may have
diabetes in later life.
 Glycaemic control
• A 12 years old boys presented with
abdominal pain, vomiting and malaise, on
urine test his acetone was +++ glucose –,
what is the provisional diagnosis:
– DM
– DKA
– Starvation ketosis
– Acute abdominal infection.
 Glycaemic control
• A 12 years old boys presented with
abdominal pain, vomiting and malaise, on
urine test his acetone was +++ glucose++
+, what is the provisional diagnosis:
– DM
– DKA
– Starvation ketosis
– Acute abdominal infection.
 Glycaemic control
• A 12 years old boys presented with abdominal
pain, vomiting and malaise, on urine test his
acetone was +++ glucose+++, RBG 600 mg/dl
what is the first step in management
– Give insulin to save his life.
– Give fluids.
– Investigate for the cause
– Trial of OHA.
– Hospitalize.
 Glycaemic control
• A 12 years old boys presented with abdominal pain,
vomiting and malaise, on urine test his acetone was
+++ glucose+++, RBG 600 mg/dl, after
hospitalization what is the first step in management
– Give insulin to save his life.
– Give fluids.
– Investigate for the cause
– Trial of OHA.
– Hospitalize.
– Give antibiotics.
 Glycaemic control
• A 12 years old boys presented with abdominal pain,
vomiting and malaise, on urine test his acetone was
+++ glucose+++, RBG 600 mg/dl, after
hospitalization what is the first step in management
– Give insulin to save his life.
– Give fluids.
– Investigate for the cause
– Trial of OHA.
– Hospitalize.
– Give antibiotics.
 Glycaemic control
• A 12 years old boys presented with abdominal pain,
vomiting and malaise, on urine test his acetone was +++
glucose+++, RBG 600 mg/dl, after hospitalization what is
the most important single investigation
– Serum glucose
– Serum insulin
– Blood gases
– CBP
– CXR, US abdomen
– Na
– K
– Urea and creatinine
 Glycaemic control
• A 60 years old man presented with urine test his
acetone was + glucose++, RBG 250 mg/dl, what is
the most probable diagnosis:
– T1DM
– T2DM
– DKA
– Stress condition (infection, CHD….)
 Glycaemic control
• A 65 old type 2 diabetic lady was controlled on
OHA, presented with drowsiness dehydration
fatigue no lateralization, there was urine sugar +
++ acetone – no acidosis, what should I suspect:
– Uncontrolled DM
– Early DKA
– Hyperglycaemic non ketotoic coma
– Renal failure
– Infection
– stroke
 Glycaemic control
• A type 1 diabetic patient under insulin treatment
presented with hypoglycaemia, he recovered with IV
glucose, what should I do regarding his next insulin
dose:
– Nothing, give as prescribed
– Omit
– Omit this day only
– Reduce
– Adjust according to the premeal BG.
– Adjust according to the PPBG.
 Glycaemic control
• A type 1 diabetic patient under insulin treatment
presented with hypoglycaemia, he recovered
with IV glucose, what should I do regarding his
previous insulin dose:
– Nothing, give as prescribed
– Omit
– Omit the next day only
– Reduce
– Adjust according to the premeal BG.
– Adjust according to the PPBG.
 Glycaemic control
• A 12 years old type 1 diabetic patient under
insulin treatment after classical DKApresented
with recurrent hypoglycaemia, he stopped insulin
for 5 days, FBG was 92 mg/dl, PPBG was 102
mg/dl
• This boy was:
– Wrongly diagnosed as diabetes and have to stop
insulin
– Needs further investigations
– Had transient diabetes due to stress and recovered.
– Should continue insulin anyhow.
Preparing for surgery
 The challenge is to
• Come as close as possible to normoglycemia
and reduce hypoglycemia.

47
Plasma Insulin and Glucose Profiles
in Normal Male Subjects
Plasma Glucose (mg/dL) Plasma Insulin (µ U/mL)

75

50

25

150

100

50
Breakfast
Breakfast Lunch
Lunch Supper
Supper
0
7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
A.M. Time P.M.
 Basal Bolus Therapy
Prandial insulin
eg: Lispro; Aspart;
HMR1964
Insulin levels

Basal insulin
eg: Lantus,
NPH,Lente

00.00 08.00 12.00 18.00 22.00

Thank you