Diabetes Management from Scratch PDF

 **Management of pre-diabetes** ============================== 1. People who screen-positive for prediabetes (FPG=100-125 mg/dL or 2-h PG in the 75-g OGTT=140-199 mg/dL or HbA1c=5.7%-6.4%) should be intervened with appropriate lifestyle modification. 2. 3 steps-...

 **Management of pre-diabetes** ============================== 1. People who screen-positive for prediabetes (FPG=100-125 mg/dL or 2-h PG in the 75-g OGTT=140-199 mg/dL or HbA1c=5.7%-6.4%) should be intervened with appropriate lifestyle modification. 2. 3 steps- - Advise to lose 10% of current body weight - Sleep 6-8 hours daily (Main reason for hyperglycemia is the cortisol stress response due to poor quality of sleep) - Exercise daily for minimum 1 hour/day 3. If at the end of 6 months HbA1c is still high, start Metformin 500mg OD Exercise advise =============== Treatment of Florid Diabetes ---------------------------- **HbA1C more than 6.5** **FBS/PPBS-\>\>126mg/dL/200mg/dL** STEP1- Always start Metformin 500mg BD Maximum dose of metformin is 2.5gm/day Start at low dose as giving higher doses straight-away is associated with increased risk of gastric side effects including diarrhea. Metformin dose can be hiked once weekly by 500mg/week up to a maximum of 2.5grams (dosed at 500mg 2-1-2). Always prescribe metformin with food to avoid GI side effects. Metformin is generally a very safe drug with very few side effects including gastrointestinal intolerance, Lactic acidosis and vitamin B12 deficiency Avoid if GFR is less than 30ml/min/m2 and in Decompensated liver disease (as increased risk of lactic acidosis!!) STEP2- at the end of 2-3 months, repeat HbA1C (we should target HbA1C as the treatment goal, instead of FBS/PPBS ideally, FBS.PPBS in resource poor settings) The ideal HbA1C target in young patients is 6-7, while in older patients a target of 7-8 is feasible because of the increased risk of hypoglycemia. Please study LEGACY EFFECT IN HARRISON!!! If HbA1C is 1.5 points higher than the target, that is for a target of 6, if the HbA1C level is 8 for a 40 year old patient, we shall initiate DUAL THERAPY. **Along with Metformin start either one of Glimepride/Sitagliptin/Voglibose/Pioglitazone/Dapagliflozin (Indian setting)** Drug Starting dose Maximum dose --------------- --------------- -------------- Glimepride 2mg OD/BD 4mg OD/BD Sitagliptin 50mg OD 50mg BD Voglibose 0.2mg TDS 0.3mg TDS Pioglitazone 15mg OD 30mg OD Dapagliflozin 10mg OD \- Glimepride(Sulfonyl urea) is associated with weight gain and increased risk of hypoglycemia while sitagliptin(DPP-4 inhibitor) is associated with increased satiety and weight loss, hence sitagliptin is more preferred in diabetes with metabolic syndrome and hyperlipidemia. Step 3- at the end of 2 months, if the HbA1C or FBS/PPBS levels are still not controlled, we shall start TRIPLE THERAPY **Metformin+Sitagliptin+Glimepride** up to maximum possible doses can be given for optimizing sugar control. Always we have to be careful in patients with deranged serum creatinine and it is better to stop the OHAs and shift to insulin therapy, because of the increased risk of OHA induced hypoglycemia in clinical practice! I usually avoid pioglitazone as it has side effects including osteoporosis, macular edema, bladder cancer and weight gain. It is preferred in patients with NASH(Non-Alcoholic steatohepatitis) where it decreases liver inflammation and prevents fibrosis. Up to maximum of 4 drugs can be given before considering Insulin GLP-1agonists are the revolution in the treatment of diabetes, but they are not yet available in oral formulations in Indian market (semaglutide) Step4- If the sugar levels are not controlled, and the HbA1C Levels are still persistently high consider starting insulin. PATIENT group Pre-prandial glucose Post-prandial glucose ---------------------------------------------- ---------------------- ----------------------- Normal \