1. Diabetes Update for registrars
PART 1- Type 2 Diabetes-an
overview
C McNamara

2. Learning objectives:
 Understand progressive nature of DM
 Aim for early diagnosis & patient empowerment –
(better self-management)
 Screen for complications (and treat if +ve)
 Optimise function (ie. keep patients well and
informed)
 Understand treatments, how to uptitrate and move
to insulin where necessary
 Understand the difference between Type 1 & Type 2
DM

3. Progressive Decline of
B Cell Function in UKPDS
100
80
%
Function 60
40
Cell B 20
0
Years 100
80
60
40
20
““IInnssuulliinn
RReessiissttaannccee
uunncchhaannggeedd””
““5500%% ooff ppaattiieennttss
nneeeedd iinnssuulliinn aafftteerr
66 yyeeaarrss””
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
Years
B Cell Function %
PPrrooggrreessssiivvee DDeecclliinnee ooff
BB CCeellll FFuunnccttiioonn iinn UUKKPPDDSS
0
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
DDiiaaggnnoossiiss

5. Type 2 Diabetes
A growing epidemic
Approximately 200,000 in New Zealand
and 25,000 plus in WDHB.
A growing epidemic
Approximately 180,000 in New Zealand
and 20,000 plus in WDHB.
 5% in European NZ
 10-13% in Maori and Pacific Island people.

6. Risk factors for Type 2 Diabetes
 Ethnicity- twice as common in Maori, Pacific
Island and Indian (South-East Asian)
 Positive family history
 Obesity and sedentary life-style
 Mainly occurs at age>50y BUT THE OBESITY
EPIDEMIC IS MAKING TYPE 2 DIABETES COMMON
IN KIDS.
 Evidence of other vascular risk factors

7. What to do following a screening test for
type 2 diabetes
Result Action
HbA1c ≥ 50mmol/mol
and, if measured,
Fasting glucose ≥7.0
mmol/L
Or
Random blood glucose
≥11.1mmol/L
No further tests required Diabetes is confirmed
Symptomatic

8. What to do following a screening test for type 2
diabetes
Result Action
HbA1c ≥ 50mmol/mol
and, if measured,
Fasting glucose ≥7.0
mmol/L
Or
Random blood glucose
≥11.1mmol/L
Repeat HbA1c
or a fasting plasma glucose
Two results above the
diagnostic cut-offs, on
separate occasions are
required for the
diagnosis of diabetes*
asymptomatic

9. Prediabetes?
Result Action
HbA1c 41-49
mmol/mol
and, if measured,
Fasting glucose 6.1–
6.9 mmol/L
Advise on diet and lifestyle
Redo test in 6-12 m
Results indicate ‘pre-diabetes’
or impaired
fasting glucose
asymptomatic

11. HbA1c reporting (% to mmol/mol)
NPS

13. Lifestyle Education Prevention and early detection
and support:
(see www.nzssd.org.nz)
•Self Management education(DSME)
•Smoking cessation
DIAGNOSIS
•Dietary advice
(HbA1c>50mmol/mol)
•Exercise/Green RX
•Family support
•Psychological support
(see www.nzssd.org.nz
•Dental Health
for guidelines)
•Diabetes NZ Support Groups
WEIGHT
Target BMI <28
(or 5-10% weight
loss)
Dietitian
Refer:
Consider
bariatric surgery
if BMI > 35
LIPIDS
Target
TG <1.7; LDL < 2
Total <4; HDL>1
Statin
Combine with
ezetimibe or nicotinic
acid if predominately
hypercholesterolaemia
Combine with fibrate if
predominately
hypertriglyceridaemia
CV Risk >15%:
consider aspirin, statin
and antihypertensive
Refer:
If not attaining
targets despite
dietician and maximal
therapy
GLYCAEMIC
CONTROL
Target 50 –60
mmol/mol (but
individualise)
Metformin (caution
if eGFR < 40 and
stop if eGFR<30)
Add
Sulphonylureas (or
pioglitazone or
gliptin if not
tolerated) See
useful tips
Insulin (see
Insulin initiation
algorithm)
Refer:
If unable to initiate
insulin or target
not reached within
3 - 4months
RENAL
FUNCTION
Micro/ macro
albumniuria or low
eGFR for age
ACEI or ARB
initially targetting
BP
Consider Intrinsic
renal disease or
raised BP if not
improving and no
retinopathy
Refer:
•eGFR < 60 and
age <50years
•eGFR < 40
•20% reduction
eGFR over 3
months
Progressive
increase in ACR on
therapy
•BP target not
achieved with
multiple agents
FOOT CARE
NEUROPATHY
Annual foot check
Refer Podiatrist for
at risk/high risk foot:
Previous amputation,
ulcers or Charcot foot
Peripheral arterial
disease
Peripheral neuropathy
Foot deformity,
significant callous
formation or
preulcerative lesions
Refer to High risk Foot
clinic and/or relevant
speciality:
Active ulceration
Suspected Charcot
Non-responsive painful
peripheral neuropathy
Urgent admission:
Severe or spreading
infection
Critical limb ischaemia
BLOOD
PRESSURE
Target usually < 130/80
(but individualise)
ACEI or ARB
Add calcium channel
blocker (CCB), thiazide
diuretic or
chlorthalidone
Add another thiazide
diuretic or CCB
Add one of:
alpha, beta blocker or
potassium sparing
diuretic
Add another of above
Refer:
BP targets not reached
on multiple agents
Associated diabetes
nephropathy
EYE CARE
2 yearly retinal
screening if no
retinopathy
1 yearly retinal check
for those with
retinopathy
(especially if poor
glycaemic control)
(First trimester
retinal screening in
pregnant diabetes
patients)
Refer
Ophthalmology:
Acute changes in
vision
Type 2 Diabetes Algorithm
Northern Region Diabetes Clinical Network - 2012
Aim to reduce complications and morbidity. 3 monthly evaluation of BP, HbA1C, lipids,
ACR, creatinine, eGFR then lipids 12 monthly once controlled
Referral at
diagnosis:
•Severe hyperglycaemia ie
glucose > 25mmol/l or
ketonuria (urgent)
•Intercurrent severe illness
(urgent)
•Complications of diabetes at
diagnosis (semi-urgent)
•Pregnant or gestational
diabetes diagnosed (semi-urgent)
•Type 2 adults < 30 years old
(semi-urgent)

14. TTyyppee 22 ddiiaabbeetteess ((SSEEEE AAllggoorriitthhmm))
PPaarrtt ooff ““mmeettaabboolliicc ssyynnddrroommee””
· Vascular Disease
· Hypertension
· Proteinuria
· Raised lipids
· Obesity (apples vs pears)
Insulin Resistance

15. Be sure of Type of Diabetes
 Consider autoimmune diabetes
(adult Type 1) if slimmer, younger,
history of autoimmune disease.
 GAD Ab positive

16. SET TARGET for each patient
 HbA1c target depends on age,
co-morbidities, diabetes duration, e.g.:
 50-55 (6.7-7.2%) for younger fitter
 55-64 (7.2 – 8.0%) in others with vascular co-morbidities,
especially over 70 yrs
 LDL cholesterol to 2.5 or better
(TG <3.0)
 BP 130/80

17. Next step after Metformin
Diet & Exercise

Metformin
   

Sulphonylurea
e.g. Glipizide
Gliclazide
Glitazone
eg. Pioglitazone
Incretins
e.g.
Sitagliptin
Byetta
Liraglutide
Insulin

18. INCRETINS
a) Sitagliptin (Januvia) DPPIV inhibitor
 GLP is a gut hormone from the ileum which is reduced in type 2
diabetes. Restoring GLP levels leads to:
  insulin from ß cell -  Glucagon from α cell
  Gastric emptying; -  Appetite
 Sitagliptin is a DPPIV inhibitor which inhibits the enzyme that
breaks down GLP and therefore increases GLP levels
PPrrooss: CCoonnss::
 Once/day and tablet form
 No hypogylcaemia
 Weight neutral
 HbA1c 0.5-1.0%  on average
 COST
 Limited experience
so far

19. b) GLP-agonists
 Given by S.C. injection once or twice daily, possibly
soon once weekly
e.g. Exanatide B.D., Liraglutide once daily
PPrrooss: CCoonnss::
 HbA1c  1.0-1.5%
 Weight loss
 No hypoglycaemia
  B.P.
 May preserve ß cell
 As good as insulin in
some studies
 COST
 S.C. injection
 Nausea
(usually wears off)

20. Checklist ffoorr PPrree--iinnssuulliinn aasssseessssmmeenntt
 MMaaxxiimmuumm ttaabblleettss
 ddoo tthheeyy ttaakkee tthheemm??
 aatt tthhee rriigghhtt ttiimmeess??
 PPhhyyssiiccaall aaccttiivviittyy-- ccaann iitt bbee iinnccrreeaasseedd??
 FFoooodd-- CCaarrbbss//ccaallss
 BBlloooodd MMoonniittoorriinngg--ttoo llooookk ffoorr ppaatttteerrnnss aanndd uunnddeerrssttaanndd
hhooww lliiffeessttyyllee aaffffeeccttss bblloooodd gglluuccoossee
 UUnnddeerrssttaanndd
 ddiiaabbeetteess ‘‘rriisskkss’’
 HHbbAA11cc
 bblloooodd gglluuccoossee ttaarrggeettss