Diabetes Mellitus. Medical Management and Latest Developments Dr Ahmad Abou-Saleh

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1 Diabetes Mellitus Medical Management and Latest Developments Dr Ahmad Abou-Saleh

2 What is Diabetes Mellitus? A disease characterised by a state of chronic elevation of blood glucose levels due to: - The body s inability to produce insulin (insulin deficiency) And/Or - The body s inability to respond to insulin (insulin resistance)

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4 United Kingdom 6 8% of UK Population is Diabetic Approximately half a million undiagnosed Diabetics in the UK at any one time 5 Million Diabetics in UK by % of NHS Budget is spent on Diabetes care (~ 10 Billion)

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8 Type 1 Diabetes Mellitus A disorder of the immune system where the body s own ability to produce insulin is destroyed (nearly 100%) Immune system wrongly target and destroy β-cells in the Pancreas This can only be managed by immediately starting insulin therapy

9 Type 2 Diabetes Mellitus 95% of all Diabetics are Type 2 Combination of insulin deficiency (though not as much as Type 1 Diabetes Mellitus) and insulin resistance Associated with Obesity, Hypertension and Hypercholesteraemia Managed by a combination of diet, oral medications and injectable therapies (e.g. insulin)

10 Diabetic Complications Eye Disease Kidney Disease Heart Disease Cerebrovascular Disease Nerve Disease Peripheral Vascular Disease Foot Disease

11 Some of the potential outcomes of Diabetes! Cataracts Glaucoma Retinopathy Blindness End-Stage Renal Failure Dialysis Kidney Transplant Heart Attack Heart Failure Arrhythmias Mini-Stroke Stroke Sensory Ataxia Painful Peripheral Neuropathy Mononeuritis Multiplex Lumbosacral Plexopathy Muscle Infarction Intermittent Claudication Acute Ischaemia and Necrosis Foot Ulceration Toe Amputation Major Limb Amputation

12 Diabetic Foot Disease Definition: Localised injury to the skin and/or underlying tissue (below the ankle) in a person with Diabetes 10% of all Diabetics will be diagnosed with a foot ulcer in their lifetime 50% will die within 5 years of developing a diabetic foot ulcer 70% will die within 5 years of having an amputation Diabetes is the most common cause of non-traumatic limb amputation

13 Risk Factors for Diabetic Foot Disease Neuropathy Peripheral ischaemia Swelling Skin breakdown Infection Deformity Callus

14 Treatment for Diabetes Type 1 Diabetes Mellitus Multiple daily insulin injections Diet and Exercise Type 2 Diabetes Mellitus Diet, exercise and weight loss Oral and/or injectable anti-diabetic medications (including insulin) Treat Hypertension and Hypercholesteraemia

15 Aims of Treatment Prevent onset of complications Slow the progression or cause reversal of existing complications Prevent extremes of blood glucose levels (hyperglycaemia, hypoglycaemia) Manage other risk factors e.g. Hypertension, Hypercholesteraemia

16 NICE Guidance on Type 2 Diabetes Mellitus

17 Treatment for Diabetes Oral Medication Biguanides Metformin Improve insulin sensitivity Sulphonylureas Gliclazide Enhance insulin secretion Thiazolidinediones Pioglitazone Improve insulin sensitivity DPP4-inhibitors Sitagliptin Enhance effect of beneficial gut hormones GLP-1 Analogues Liraglutide (injection) Synthetic beneficial gut hormone SGLT2 inhibitors Empagliflozin Enhance excretion of glucose into urine

18 Diabetes and Insulin how far have we come?

19 Glucose lowering agents types of insulin available Mealtime insulins unmodified human soluble regular rapid-acting analogues Basal insulin NPH insulin protamine complex long-acting analogues Insulin mixes soluble + NPH rapid acting analogues + NPH

20 Glucose lowering agents possible insulin regimens Type 1 Diabetes Mellitus Fast-acting insulin with meals and 1-2 basal insulin injections optimal Twice daily mix insulin Type 2 Diabetes Mellitus Once Twice daily basal insulin Twice daily mix insulin Fast-acting insulin with meals and 1-2 basal insulin injections

21 Monitoring Diabetes Daily self-monitoring with use of blood glucose meters Glycosylated Haemoglobin (HbA1c): Spot blood test providing information on average blood glucose over last 2 3 months

22 Updates in Type 2 Diabetes Mellitus

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24 Personalised Care

25 New Glucose Lowering Agents GLP-1 Analogues (injection): Synthetic gut hormone which works to reduce weight as well as blood glucose SGLT2 inhibitors: Stimulates the kidney to allow more glucose to be removed in the urine also helping to reduce weight alongside blood glucose

26 GLP-1 Analogue: Liraglutide injections

27 SGLT2 Inhibitor: Empagliflozin

28 SGLT2 Inhibitor: Canagliflozin

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31 Diabetes reversal after <6 months low calorie diet Special formula diet (approximately 820 kcal/day) Nearly 50% had average blood glucose below the diabetic range (in remission ) versus 4% through conventional measures Progressively greater odds of successful remission of Diabetes with a higher amount of weight loss

32 Updates in Type 1 Diabetes Mellitus

33 Peptide Vaccine for newly Diagnosed Type 1 Diabetes Mellitus Similar principles to vaccines for infections! Newly diagnosed diabetics given subcutaneous injections every 2 4 weeks for 6 months Preserves insulin production and better diabetic control (and lower insulin doses) in treatment group

34 Closed-Loop System Artificial Pancreas

35 Benefits Improved diabetic control (glucose variability and average glucose values Reduced amount of time patients spent with low blood glucose values (hypoglycaemia) Automatic suspension of insulin delivery via pump when blood glucose drops too low

36 Glucose Monitoring now available on the NHS

37 Islet Cell Transplantation

38 Summary Diabetes caused by insulin deficiency and/or resistance Rising numbers UK and worldwide Managed by lifestyle modification, oral and injectable therapies Various developments ongoing!