DM Treatment How to Achieve Optimal Glycaemic Control The Tung Wah Eastern Hospital Experience of DM Share Care Experience Optimal glucose control Theorectically easy More challenging in the real world Political and social problems S C Siu HKEC 19..9 (HKMA) Glucose Control one out of many Smoking Blood Pressure Cholesterol Complications detection and management Psychosocial Co-existing diseases Many guidelines: Confusing USA, Canada, UK, Europe, Australia, Hong Kong, International Always changing 1
Difficult to achieve optimal glucose control Basic concept (I): BG as good as possible All around the world ~% reach target Stratton, I. M et al. BMJ ;31:- 1 Treatment goals - DHK Basic concept (II) A1C(%) Ideal (optimal) <. Fair <7. Poor >. Fasting PG (mmol/l) hpg (mmol/l).-. <. <. <1. >1. >1. Glucose control as early as possible During pregnancy, women should aim to keep -hour post-prandial blood glucose level < 7. mmol/l.
But treatment is not without side effects kg 7.... -. Change in Body W eight cross-sectional, mean values Intensive Conventional 3 9 1 1 Years from randomisation ukpds Proportion of patients (%) Hypoglycaemic episodes per annum 3 1 any episode 3 9 1 1 Actual Therapy analysis 3 1 Years from randomisation major episodes 3 9 1 1 ukpds Art of Negotiation DM education Patient and family Comes up with an Facts delineation Life situation Empathetic discussion individualized decision Diet and Exercise A must Most Vital Depressing news Healthy lifestyles declining in US NHANES, age -7 Over the last 1 years (-), adherence to healthy habits drops from 1% to % King et al. Am J Med 9 Would Hong Kong be spared? 3
Excessive hepatic glucose production is the main cause of fasting hyperglycaemia Start with Metformin right away!. Fasting plasma glucose (mmol/l) 1 1 Normal (n=73) TDM (n=77) Normal range Hepatic glucose output Hepatic glucose production (mg/kg.min) 3. 3... r=.7 p<.1 1. 1 3 Fasting plasma glucose (mg/dl) Adapted from DeFronzo R. Diabetes 19;37:7 7. Treating fasting hyperglycaemia lowers the entire -hour plasma glucose profile Prime patient Plasma glucose (mg/dl) 3 1 Meal Meal Meal TDM Hyperglycaemia due to an increase in fasting glucose Normal 1 1 1 1 1 Plasma glucose (mmol/l) To reach targets Need of finger prick monitoring Regular A1c, FG, every 3M Usually Require additional drugs (oral/injection) Time of day (hours) Comparison of -hour glucose levels in control subjects vs patients with diabetes (p<.1). Adapted from Polonsky K, et al. N Engl J Med 19;31:131 9. Frequent FU in the early stage of disease Step up medications till targets met Step up Metformin to 1g BD Support the patient/family
Targets not reached in 3 months Add nd drug ( Which is better? ) Sulphonylureas thiazolidinediones GLP1 agonists Insulin Alpha-glucosidase inhibitor Drugs combination Eg. Metformin + SU + glitazones Poor control 1 1 1 1 No hypos Hypos : A fact of life Oral drugs: Side effects Metformin GI, lactic acidosis 1 1 1 Mild Severe Type 1 /week 1/year Type 1-/week 1/1 year SU Hypoglycaemia Weight gain Thiazonidinediones Weight gain, oedema CHF Increase LDL Increase CHD? (Rosiglitazone Rosiglitazone) Alpha-glucosidase inhibitor GI But even UKPDS failed to achieve non diabetic range 9 H ba 1cc cross-sectional, m edian values HbA 1c (%) 7 Conventional Intensive.% upper limit of normal range 3 9 1 1 Years from randomisation u k p d s
7 Not True Actions Meal Glucgagon like pepetide 1 (GLP 1) Glucose dependent insulinotropic peptide (GIP) A1c % Insulin, gastric emptying glucagon, satiety Nauck et al. Diabetologia 1993 time The Incretin Effect Control (n=) Type Diabetes (n=1) IR Insulin, mu/l Incretin Effect....3..1 nmol / L IR Insulin, mu/l Incretin effect diminished....3..1 nmol/l Incretins Degraded by Dipeptidyl peptidase (DPP) 1 Time, min 1 1 Time, min 1 Oral glucose load Intravenous (IV) glucose infusion Adapted from Nauck M et al. Diabetologia. 19;9:. Copyright 19 Springer-Verlag. Permission pending. DDP I Consideration Preferable in obese patient less hypo, no weight gain, Headache, GI upset, nasopharyngitis,, LBP Safe in the long term? Expensive GLP1 analogues Glucose dependent, decrease hypoglycaemia Decrease BW, improved LDL/TG, decrease BP, Stop beta cell failure (?) Sc injection twice daily (exenatide( exenatide), liraglutide (daily) GI upset, pancreatitis (?), thyroid tumours Preferable in obese patients Expensive, CI : gall stones, alcoholism, raised TG Long term safety?
Insulin Therapy liberal use Start early Noctunal or morning injection small dose Step up dose accordingly New agents Dual peroxisome proliferator- activatedα/γreceptor agonists (PPARα/γ) Weekly GLP1 Inhaled/Oral insulins Discussed in another talk DM Team Doctors Nurses Dietitians Podiatrists Psychologists Ophthalmologists Dentists Social workers Administration and supporting staff Great demand of service 9 7 3 1 199 9 DM pt x 1 Year Structured service Patient education & empowerment programmes Patient participation Case meeting Nurse clinic Community engagement Break Clinical Inertia Reach all targets Clinical protocols Red-flag system Difficult case clinic 7
Shared Care Programme with Primary Care If any problems Newly enrolled DM patients Support from NGOs & Self help group Assessment by DM Nurse Perform DM Cx Sc Diabetic patients outcome 7.3% of patients satisfied admission criteria of Shared Care Programme at a mean FU 1. months Back to primary care Periodic Cx Sc Receive DM education Siu SC et al. DM Research & Clin Pract Manage all problems Reach the targets Consultation by doctors Shared Care Programme 9 7 3 1 DM pt x 1 199 9 year Total GOPD GP Working with GPs and Training GP Certificate Course GPs Meeting Visiting Professorship PPI WIN/ WIN/ WIN GP Certificate Courses e-pr Many issues unresolved Conclusions Optimal glucose control - individulized Active treatment Break clinical inertia Patient, family & community participation Private & public health services should work together