Diabetes Mellitus Medical Management and Latest Developments Dr - - PowerPoint PPT Presentation

Diabetes Mellitus

Medical Management and Latest Developments Dr Ahmad Abou-Saleh

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)

United Kingdom

• 6 – 8% of UK Population is Diabetic
• Approximately half a million undiagnosed Diabetics in the UK at any
• ne time
• 5 Million Diabetics in UK by 2025
• 10% of NHS Budget is spent on Diabetes care (~£10 Billion)

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

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)

Diabetic Complications

Eye Disease Kidney Disease Heart Disease Cerebrovascular Disease Nerve Disease Peripheral Vascular Disease Foot Disease

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

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

Risk Factors for Diabetic Foot Disease

• Neuropathy
• Peripheral ischaemia
• Swelling
• Skin breakdown
• Infection
• Deformity
• Callus

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

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

NICE Guidance on Type 2 Diabetes Mellitus

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

Diabetes and Insulin

how far have we come?

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

• 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

Glucose lowering agents

possible insulin regimens

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

Updates in Type 2 Diabetes Mellitus

Personalised Care

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

GLP-1 Analogue: Liraglutide injections

SGLT2 Inhibitor: Empagliflozin

SGLT2 Inhibitor: Canagliflozin

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

Updates in Type 1 Diabetes Mellitus

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

Closed-Loop System “Artificial Pancreas”

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

Glucose Monitoring now available on the NHS

Islet Cell Transplantation

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!