a case presentation about diabetes mellitus with the guidelines in managing diabetes mellitus in the philippines

1. DIABETES MELLITUS
Ma. Bernadette S. Viado
PGI

2. PERSONAL DATA
• J.C.
• 65/F
• ComVal
• Retired gov’t employee
• Roman Catholic

3. CHIEF COMPLAINT
Body weakness

4. HISTORY OF PRESENT ILLNESS
1day PTC
Body malaise and fatigue
-hgt level of18.7 mmol/L
Hrs PTC
• random checking hgt-
19.7 mmol/L
Persistence of symptoms-
Consultation

5. PAST MEDICAL HISTORY
• DM x 19 years (Glucovance 500mg/ 2.5 mg OD)
• HPN x 27years (unrecalled meds; poor compliance)
• (-) stroke
• (-) BA
• (-) kidney disease
• (-) thyroid disease

6. PERSONAL AND SOCIAL HISTORY
• College Graduate
• Retired government employee

7. OBSTETRIC HISTORY
• G3P3 (3003)
• NSVD
• Home delivery
• No complications
• Menopause- 50

8. FAMILY HISTORY
• unremarkable

9. REVIEW OF SYSTEMS
General:
(-) weight loss
(+) weakness
(-) fever
(+) fatigue
(-) sweats
(-) insomnia
(-) anorexia
Endocrine:
(-) heat cold
intolerance
(-) thyroid problems
(-) neck surgery
(-) irradiation
Eyes:
(-) visual dysfunction
(-) itching
(-) lacrimation
(-) redness
(-) scotomata
(+) BOV

10. Ears:
(+) deafness
(-) tinnitus
(-) discharge
Nose:
(-) epistaxis
(-) discharge
(-) postnasal drip
Mouth:
(-) bleeding gums
(-) dental carries
Throat:
(-) tonsillitis
Neck:
(-) stiffness
(-) limited motion
Respiratory:
(-) dyspnea
(-) hemoptysis
(-) wheezing

11. Cardiac:
(-) palpitations
(-) hypertension
(-) edema
Vascular:
(-) phlebitis
(-) varicosities
(-) claudication
Gastrointestinal:
(-) nausea
(-) vomiting
(-) hematemesis
(-) abdominal pain
(-) diarrhea
(-) constipation
Genito-Urinary:
(-) dysuria
(-) hematuria
(-)urinary frequency

12. PHYSICAL EXAMINATION
• General
• conscious, coherent, and cooperative, not in respiratory distress
• Vital Signs:
• Blood Pressure: 170/90 mmHg
• Cardiac Rate: 89 bpm
• Respiratory Rate: 20 cpm
• Temperature: 36.9 º C
• Weight: 187 lbs
• Height- 5’3
• BMI= 33.9 kg/cm2 (obese)

13. • Skin:
• I – Fair; hyperpigmented macules over the upper and lower
extremities
• P – Moist and warm to touch
• Head: I- Normocephalic, black; no chloasma
• Eyes: pink palpebral conjunctiva, Sclera white, Pupils equally round,
opaque lens, OD
• Nose and Sinuses: nasal mucosa pink, septum midline, tenderness
upon palpation of frontal sinuses

14. • Mouth & Throat: Oral mucosa pink; tongue midline, dry; pharynx
without exudates; tonsils not enlarged
• Neck- (-) mass, supple, trachea midline, thyroid gland not enlarged,
no palpable lymph nodes
• Chest: symmetrical, (-) no lesions nor scars; Equal bilateral chest
expansion, Resonant on percussion, clear breath sounds

15. • Cardiovascular: AP, NCRR, (-) heaves or thrills, (-) murmur
• Breast: symmetric, no palpable masses, (-) tenderness
• Gastrointestinal: Flabby, NABS (10 BS/minute), (-) dullness, nontender
• Extremities: (-) edema, (-) pallor, warm, (+) clammy, CRT <2 secs
• Musculoskeletal: (-) deformities; fair range of motion on all joints
• Neurological Exam
• Mental status: Alert; thought coherent; oriented to person, place & time;
• Cerebellar: slow alternating movements, point-to-point movements intact
• Sensory: pinprick, light touch, position sense, vibration sense intact

16. 4/54/5
100% 100%
100% 100%
5/5 5/5

17. IMPRESSION
DM II, Uncontrolled

18. SALIENT FEATURES
Pertinent History Pertinent Physical Examination
Fatigue
Body weakness
Hgt monitoring level of 18-19.7 mmol/L
History of diabetes x 19 years
History of hypertension, poorly controlled
69 years old
BP of 170/90 mmHg
BMI of 33.9 kg/cm2
opaque lens, OD
Clammy skin

19. DIFFERENTIAL DIAGNOSIS

20. DISCUSSION

21. DIABETES MELLITUS
• chronic disease
• pancreas does not produce enough insulin, or when the body cannot
effectively use the insulin it produces  increased concentration of
glucose in the blood (hyperglycemia). (WHO, 2014)
• group of common metabolic disorders that share the phenotype of
hyperglycemia.
• Reduced insulin secretion, decreased glucose utilization, and
increased glucose production (Harrisons, 2012)

22. PREVALENCE
 U.S.
Diagnosed: 26 million people—8.3% of
population (90%+ have Type 2)
79 million people have pre-diabetes
CDC 2011

23. PREVALENCE
 Philippines
- 1 out of every 5 Filipinos have diabetes
- Children as young as 5-years old have been
diagnosed with type 2 diabetes
- - Over 7 million Filipinos will have diabetes by
2030
Philippine Diabetes Statistics,2012

24. CLASSIFICATION
• Type 1 diabetes mellitus
• from auto-immune beta-cell destruction, leading to absolute insulin deficiency.
Typically but not exclusively in children
• Type 2 diabetes mellitus
• from a progressive insulin secretory defect on the background of insulin
resistance
• Gestational diabetes mellitus (GDM)
• Secondary diabetes

25. SPECTRUM OF GLUCOSE HOMEOSTASIS AND
DIABETES MELLITUS

27. Differentiation between Type 1 and Type 2 Diabetes Mellitus
Characteristics Type 1 Diabetes
Mellitus
Type 2 Diabetes Mellitus
Onset Acute-symptomatic Slow-often-asymptomatic
Clinical Picture Weight loss, polyuria,
polydipsia
If symptomatic, similar picture as T1 DM- weight
loss, polyuria, polydipsia
 Obese
 Strong family history of T2DM
 Acanthosis NIgricans
 Polycystic ovary syndrome (PCOS)
Ketosis Almost always present Usually absent
C-Peptide Low/absent Normal/elevated
Antibodies  ICA positive
 Anti-GAD positive
 ICA 512 positive
 ICA negative
 Anti-GAD negative
 ICA 512 negative
Therapy Insulin Lifestyle, oral anti-diabetic agents, insulin
Associated auto-
immune diseases
Yes No
•Adapted from Alberti Diab Care, 2004.8. ICA – islet cell antibodies; Anti-GAD – glutamic acid decarboxylase antibodies

28. ACUTE COMPLICATIONS OF DM
Diabetic Ketoacidosis
Hyperglycemic hyperosmolar state

30. MANIFESTATIONS OF DKA
Symptoms
Nausea/vomiting
Thirst/polyuria
Abdominal pain
Shortness of breath
Precipitating events
Inadequate insulin
administration
Infection
(pneumonia/UTI/Gastroenteritis/
sepsis)
Infarction
Drugs (cocaine)
Pregnancy
Physical Findings
Tachycardia
Dehydration/hypotension
Tachypnea/ Kussmaul respiration
Abdominal tenderness
Lethargy/obtundation/ coma

31. CHRONIC COMPLICATIONS OF DM
Microvascular
Macrovascular
Others

33. CRITERIA FOR THE DIAGNOSIS OF DIABETES
 A1C > 6.5%
or
 FPG > 126 mg/dl (7.0 mmol/l)
or
 2-h plasma glucose > 200 mg/dl (11.1 mmol/l) during an OGTT
or
 Random plasma glucose >200 mg/dl (11.1 mmol/l) + classic symptoms
of hyperglycemia

34. CATEGORIES OF INCREASED RISK FOR DIABETES
(PREDIABETES)
 Impaired fasting glucose (IFG) - FPG levels 100–125 mg/dl
[5.6–6.9 mmol/l]
Or
 Impaired glucose tolerance (IGT) - 2-h PG values in the OGTT
of 140 –199 mg/dl [7.8 –11.0 mmol/l]
Or
 A1C 5.7–6.4%

35. SHOULD UNIVERSAL SCREENING BE DONE AND
HOW SHOULD SCREENING BE DONE?
• All individuals being seen at any physician’s clinic or by any
healthcare provider should be evaluated annually for risk factors for
type 2 diabetes and pre-diabetes.
• Universal screening using laboratory tests is not recommended as it
would identify very few individuals who are at risk.

36. DEMOGRAPHIC AND CLINICAL RISK FACTORS FOR TYPE 2 DM
• Testing should be considered in all
adults > 40 yo
• Consider earlier testing if with at least one
other risk factor as follows:
• History of IGT or IFG
• History of GDM or delivery of a baby
weighing 8 lbs or above
• Polycystic ovary syndrome (PCOS)
• Overweight: Body Mass Index (BMI)2 of
> 23 kg/m2 or
• Obese: BMI of > 25 kg/m2 ,or
• Waist circumference > 80 cm
(females) and > 90 cm (males), or
• Waist-hip ratio (WHR) of > 1 for males
and > 0.85 for females
• First degree relative with Type 2
diabetes
• Sedentary lifestyle
• Hypertension (BP > 140/90 mm Hg)
• Diagnosis or history of any vascular
diseases including stroke, peripheral
arterial occlusive disease, coronary
artery disease
• Acanthosis nigricans
• Schizophrenia
• Serum HDL < 35 mg/dL (0.9 mmol/L)
and/or
• Serum Triglycerides > 250 mg/dL (2.82
mmol/L)

37. SCREENING FOR AND DIAGNOSIS OF GDM
 Perform a 75-g OGTT, with plasma glucose measurement fasting
and at 1 and 2 h, at 24–28 weeks of gestation in women not
previously diagnosed with overt diabetes.
 Performed in the morning after an overnight fast of at least 8 h.
 The diagnosis is made when any of the following plasma glucose
values are exceeded:
• Fasting 92 mg/dl (5.1 mmol/l)
• 1 h 180 mg/dl (10.0 mmol/l)
• 2 h 153 mg/dl (8.5 mmol/l)

38. GLUCOSE MONITORING
 Patients on multiple-dose insulin (MDI) or insulin pump therapy
should do self-monitoring of blood glucose (SMBG):
• prior to meals and snacks
• postprandial
• at bedtime
• prior to exercise
• when they suspect low blood glucose
• after treating low blood glucose until they are normoglycemic
• prior to critical tasks such as driving.

39. A1C MONITORING
• at least two times a year - patients who are
meeting treatment goals/ stable glycemic
control
• quarterly- patients whose therapy has
changed or who are not meeting glycemic
goals

40. Therapeutic management of DM

41. INSULIN THERAPY FOR TYPE 1 DIABETES
 MDI injections or continuous subcutaneous insulin infusion (CSII).
 Use insulin analogs to reduce hypoglycemia risk.
 screening those with type 1 diabetes for other autoimmune diseases
(thyroid, vitamin B12 deficiency, celiac) as appropriate.

42. PHARMACOLOGICAL THERAPY FOR
HYPERGLYCEMIA IN TYPE 2 DIABETES
 Metformin
 Insulin therapy
 If noninsulin monotherapy at maximal tolerated dose does
not achieve or maintain the A1C target over 3–6 months,
add a second oral agent, a glucagon-like peptide-1 (GLP-1)
receptor agonist, or insulin.

43. TYPES OF INSULIN
• Basal insulin
• Faster-acting insulins
• Premixed insulins

44. INSULIN
Insulin
Preparation
Onset Peak Duration
Short Acting
Regular 30-60mins 2-3 hrs 4-6hrs
Rapid Acting
Lispro 5-15mins 30-90mins 3-4hrs
Aspart 5-15mins 30-90mins 3-4hrs
Glulisine 5-15mins 30-90mins 3-4hrs

45. Insulin Preparation Onset Peak Duration
Intermediate Acting
Isophane/NPH
(intermediate)
2-4hrs 4-10hrs 10-18 hrs
Long Acting
Glargine (long) 4-6hrs Minimal peak
activity
Up to 24hrs
Detemir (long) 2-3hrs 6-8 hrs Up to 24 hrs

46. Insulin Preparation Onset Peak Duration
Combination
Humulin/Novolin
70/30
30-60 mins 2-10 hrs 10-18 hrs
Novolog Mix
Humalog Mix
<15 mins 1-2 hrs 10-18 hrs

47. ADMINISTRATION OF INSULIN
o RI = 30-45 mins before meals.
o Short/rapid-acting insulin (Lispro, Aspart, glulisine) = within 20
mins or immediately before meals.
o Intermediate-acting insulin = in portions of 2/3 in the AM and 1/3
in the PM
o No insulin regimen produces the precise insulin secretory pattern
of the pancreatic islet
o S/E: hypoglycemia and weight gain

48. SC INSULIN ADMINISTRATION
abdomen
Thighs
Buttocks
Upper arms
Rotation of injection sites
Exercise or massage

49. INITIATING INSULIN THERAPY IN TYPE I DM
Insulin requirement: usually 0.5-0.8 U/kg per day
A conservative daily dose of 0.4U/kg/day is given initially to a
newly diagnosed pt, then the dose is adjusted, using SMBG
values

50. INITIATING INSULIN THERAPY IN TYPE II DM
 Initiation of basal bolus insulin regimen in T2DM: calculate insulin requirement
at 0.3 to 0.5 units/kg/day
 50% is given as basal insulin (2/3 given pre-breakfast and 1/3 given
pre-dinner)
- ex: intermediate- 20-0-10 ( 20 units pre-breakfast + 10 units pre-dinner)
 50% is given as pre-meal insulin in divided doses prior to meals ( short
or rapid acting insulin pre-breakfast, pre-lunch, pre-supper)
- ex: regular – 4-4-4 ( 4 units pre-breakfast, 4 units pre-lunch, 4 units pre-supper)

51. Differentiation between Type 1 and Type 2 Diabetes
Mellitus, especially in younger individuals
Characteristics Type 1 Diabetes
Mellitus
Type 2 Diabetes Mellitus
Onset Acute-symptomatic Slow-often-asymptomatic
Clinical Picture Weight loss, polyuria,
polydipsia
If symptomatic, similar picture as T1 DM- weight
loss, polyuria, polydipsia
 Obese
 Strong family history of T2DM
 Acanthosis NIgricans
 Polycystic ovary syndrome (PCOS)
Ketosis Almost always present Usually absent
C-Peptide Low/absent Normal/elevated
Antibodies  ICA positive
 Anti-GAD positive
 ICA 512 positive
 ICA negative
 Anti-GAD negative
 ICA 512 negative
Therapy Insulin Lifestyle, oral anti-diabetic agents, insulin
Associated auto-
immune diseases
Yes No
•Adapted from Alberti Diab Care, 2004.8. ICA – islet cell antibodies; Anti-GAD – glutamic acid decarboxylase antibodies

52. Drug Dose Range Notes:
Glyburide (DiaBeta
®
,
Micronase
®
)
1.25 to 20 mg QD or divided BID Glipizide is best absorbed when taken 30 minutes
prior to meals. Elderly patients and those with
decreased renal function should be started on lowest
doses.
Glyburide SR (Glynase
®
) 1.5 to 12 mg QD
Glipizide (Glucotrol) 5 to 40 mg QD or divided BID
Glipizide SR (Glucotrol
®
XL) 5 to 20 mg QD
Glimepiride (Amaryl
®
) 1 to 8 mg QD
Metformin (Glucophage
®
) Initial dose: 500 BID
Maximum dose: 2550 mg/day divided BID or TID WM
Note cautions in renal impairment. Note cautions for
patients undergoing procedures requiring contrast
media. Higher doses of Glucophage
®
may be the best
tolerated given TID.
Glucophage
®
XR Initial dose: 500 QD
Maximum Dose: 2000 mg/day
Conversion from Glucophage
®
to Glucophage
®
XR: Same total daily
dose, but once a day up to maximum daily dose of 2000 mg/day
Pioglitazone (Actos
®
) 15 to 45 mg QD Onset of action 2 weeks, maximum effects in 2 to 3
months. Thiazolidinediones may cause resumption of
ovulation.
Rosiglitazone (Avandia
®
) 4 to 8 mg QD or divided BID
Nateglinide (Starlix
®
) 60 to 120 mg TID WM Do not take dose if meal skipped.
Repaglinide (Prandin
®
) 0.5 to 4 mg TID to QID WM Maximum dose: 16 mg/day
Acarbose (Precose
®
) 25 to 100 mg TID WM Take with first bite of meal. Initial dose 25 mg QD and
titrate upward to minimize gastrointestinal effects.
Miglitol (Glyset
®
) 25 to 100 mg TID WM
Glyburide/Metformin
(Glucovance
®
)
Initial dose: 1.25 mg glyburide/250 mg metformin QD,
Maximum dose: 10 mg glyburide/2000 mg metformin divided BID WM
See above notes for glyburide and metformin

53. ORAL DRUGS FOR DIABETES

54. MONITORING OF RESPONSE
Drug Peak Effect
Sulfonyloreas 1-2 weeks
Meglitinide 1-2 weeks
Metformin 2-3 weeks
Acarbose 2-4 weeks
Thiazolidinediones 1-2 months
DDP-IV Inhibitors 2 weeks (?)

55. RECOMMENDED ANNUAL LABORATORIES
 Lipid profile
 Liver function tests
 Urinalysis
 Serum creatinine
 TSH in T1DM, dyslipidemia and women > 50 y/o
 Dilated eye exam

56. WHO SHOULD UNDERGO LABORATORY TESTING
FOR DIABETES/PREDIABETES?
• individuals with any of the risk factors for Type 2 diabetes
mellitus.

57. Previously identified IGT or IFG
both IFG and IGT RR* 12.13 (4.27-20.00)
isolated IGT RR 5.52 (3.13-7.91)
isolated IFG RR 7.54 (4.63-10.45)
GDM RR 7.43 (4.79-11.51)
PCOS
OR for IGT (BMI-matched) 2.54 (1.44, 1.47)
OR for DM2 (BMI-matched) 4.00 (1.97, 8.10)
Overweight or obesity
BMI > 25 kg/m (OR men 1.52 women 1.59)
WC > 90 cm for males and > 80 cm for females (OR men 1.54 women 1.70)
Waist-hip ratio > 1 for males and > 0.85 for females (OR men 1.53 women 1.50)
First-degree relative with DM
(parents or siblings)
OR 2.13 (1.22-3.71)
Sedentary lifestyle
RR for DM based on average hours spent watching TV per week (0-1, 2-10, 11-20, 21-
40, >40): RR 1.00, 1.66, 1.64, 2.16, and 2.87
Conditions assoc with insulin
resistance (acanthosis nigricans)
OR 1.97 (1.18-3.27)
HPN
Increased blood pressure, per 1 SD:
Systolic: RR 1.56 (1.31-1.85)
Diastolic: RR 1.52 (1.27-1.83)
CVD DM as a CVD risk factor (age- and sex-adjusted): HR 2.5 (1.9 to 3.2)
Schizophrenia OR 2.07 (1.03 to 4.15)
High TG, low HDL or both
Increased triglycerides, per 1 SD: OR 1.70 (1.62-1.78)
Increased apolipoprotein A-I, per 1 SD: OR 0.76 (0.62–0.92)
•RR= relative risk

58. OTHER CORNERSTONES OF MANAGEMENT
 Medical nutrition therapy -registered dieticians
 Weight loss
 Primary prevention of T2DM
 Moderate weight loss – 7% TBW
 Exercise of 150 min/week
 Diet (reduced calories and fat)
 Fiber intake of 14g of fiber/1000 kcal
 Saturated fat intake - <7%
 Medications

59. IN WHAT SETTING/S SHOULD TESTING
FOR DIABETES BE DONE?
• Testing should ideally be carried out within the healthcare
setting
• clinics, hospitals, local health centers) because of the need
for follow-up and discussion of abnormal results by qualified
health care professionals (nurse, diabetes educator, physician

60. IF INITIAL TEST/S ARE NEGATIVE FOR DIABETES,
WHEN SHOULD REPEAT TESTING BE DONE?
• Repeat testing should ideally be done annually.
• at least at 3-year intervals –individual will develop significant
complications of diabetes within 3 years of a negative result
• ADA 2010 -repeat testing annually for those with IFG and/or IGT.
• CDA 2008 -more frequent testing in those with multiple risk
factors.
• AACE 2007 -annual testing for all those with risk factors.

61. SUMMARY OF RECOMMENDATIONS: SCREENING FOR DIABETES
AMONG ASYMPTOMATIC ADULTS
• All individuals -evaluated annually for risk factors for type 2 diabetes and pre-diabetes.
• Obesity, pre-diabetes, components of the metabolic syndrome, PCOS, previous GDM, family
history and schizophrenia
• Universal screening using laboratory tests is not recommended as it would identify very few
individuals who are at risk.
• Laboratory testing for diabetes and pre-diabetes is recommended for those who have risk
factors for Type 2 diabetes mellitus.

62. • Laboratory Testing - > 40 yo
• Earlier testing if with at least one other (other than age) risk factor for
diabetes.
• Testing -health care setting (clinics, hospitals, local health centers)
because of the need for follow-up and discussion of abnormal results
by qualified health care professionals (nurse, diabetes educator,
physician).
• Testing at any setting should be supervised by a qualified health care
professional.

63. THANK YOU FOR LISTENING!