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Diabetes

May 6, 2017

Patient task list:

  • Have HbA1C tested every 3 months
  • Annual eye examination
  • Annual foot examination
  • Intermittent cholesterol levels, ECG, kidney function
  • DASH diet if no kidney disease
  • Quit smoking
  • Exercise at least 150 minutes per week (moderate-intensity exercise) and resistance training (three times per week)
  • Prioritize at least 7 hours of sleep per night

Intervention Targets

  • The traditional HbA1C target is <7%
  • An HbA1C target ≤6.5% will decrease the risk of eye disease (retinopathy), kidney disease (nephropathy), and nervous system disease (neuropathy).
  • The blood pressure target is <130/80 mmHg
  • LDL-Cholesterol target is <2 mmol/L
  • Patients with a BMI ≥25 should aim for reduction of body weight by 5 to 10%

Patient resources: http://www.diabetes.ca


Doctors secrets …

Pre-diabetes is associated with a 5-fold increased risk for future type 2 diabetes. Metformin reduces the risk of future diabetes in pre-diabetic patients by 25 to 30%

Step 1 Rx = start metformin (if GFR >45 and monitor B12 in chronic use), stop if GFR <30

If the A1C is >7.5%, the patient will likely need dual treatment. If HBA1C >9%, start dual treatment. If the A1C is >8% despite dual treatment, the patient likely needs basal insulin. Consider insulin when HBA1C >10% and symptomatic.

Add additional agent if not in target >3/12 e.g SU, TZD, (edema, HF, bone fracture, weight gain risks), DPP-4-i (avoid if Hx of pancreatitis), SGLT-2-i, thiazolidinedione, GLP-1-RA( avoid if FH of medullary thyroid carcinoma, MEN2, pancreatitis, gastroparesis), basal insulin. CVS outcomes reduced with Liraglutide (GLP-1), empagliflozin (SGLT-2). Watch for euglycemic DKA in SGLT-2 inhibitors. Watch for CCF with saxagliptin, alogliptin (DPP-4); (if pre-existing CCF or CKD). Avoid dpp4-i + GLP-1-RA.

 

– Insulin

Start 10U (or 0.1 to 0.2U/kg) of basal and increase dose by 10-15% (or 2-4U) once or twice weekly until FBG in target. NPH is cheapest. If HBA1C <8% or hypoglycaemia- decrease dose by 4U (or 10-20%). If insulin does >0.5U/kg and not at target, need to start adding basal

– Rapid insulin

Start 4U per meal (0.1U/kg, or 10% of basal dose)- consider decreasing basal dose by same amount of starting mealtime dose. Increase 1-2U (10-15%) once or twice weekly. Hypoglycemia- decrease 2-4U (10-20%)

– Premixed insulin

divide basal dose into 2/3am and 1/3 pm. Increase 1-2U (10-15%) once or twice weekly to target. Hypoglycemia- decrease 2-4U or 10-20%. Can increase to TID dosing if failure to control.

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