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Basic management of DM2

Discussion in 'Family Medicine' started by LouisianaDoctor, Mar 17, 2012.

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  1. LouisianaDoctor

    LouisianaDoctor

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    Hi all, I'm starting residency in July. I'm having difficulty wrapping my head around the basic clinical management of DM2. I know the "boards" material, ie, metformin, if that's not enough then add another drug, perhaps a sulfonylureas, and that we'd rather use those drugs than insulin.

    But where do drugs like Actos, Avandia (or is this not even prescribed now due to the potential risks?), the meglitinides, GLP-1 analogs, the liptins, etc, come in to play? I'm counting 10-15 drugs at the bottom of this page (http://en.wikipedia.org/wiki/Glibenclamide - of course, ignoring the ones taken off the market.)

    Does anyone have a simple way to approach the management of DM2 in the clinic?

    Thank you
  2. teacherman84

    teacherman84

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  3. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    There's nothing simple about managing diabetes.

    Where NIDDM is concerned, the general approach can be summed up thusly:

    1) Educate, educate, educate. The more your patient knows and the more they are engaged in their treatment, the better. Use nutritionists, diabetes educators, etc. to the fullest.

    2) TLC (therapeutic lifestyle changes) - e.g., diet, exercise, and weight loss - are the foundation of therapy, and should never be considered "optional" by either the patient or the clinician. Push TLC to the max.

    3) Manage insulin resistance first. TLC will accomplish this, of course, but starting metformin early will also aid in weight loss. TZDs like Actos are being used much less these days due to safety concerns.

    4) Manage post-prandial hyperglycemia second. Diet is obviously the most important approach in this case, but select a DPP4 like Tradgenta or an injectable agent like Byetta over older sulfonylureas, as the latter carry a much higher risk of hypoglycemia, and will "burn out" the beta cells much faster. If you have to use a sulfonylurea for cost reasons, use a later-generation drug like Amaryl. Avoid older sulfonylureas entirely.

    5) Keep in mind that you aren't just treating blood glucose. You're preventing cardiovascular disease. Aggressively manage any cardiovascular comorbidities, including smoking, hypertension, hyperlipidemia, etc. Diabetes is a cardiovascular risk equivalent, meaning a diabetic is at the same risk for MI as someone who's already had one. Get BP <130/80, and LDL-p <1000.

    6) Monitor for end-organ damage. Regular foot exams, annual diabetic eye exams, etc. are key.

    7) Don't wait too long before starting basal insulin. I see this all the time in other people's patient who I inherit. Modern basal insulins like Januvia and Levemir are easy and painless to use. Don't let a patient's preconceived notions about insulin therapy delay the inevitable.

    Managing diabetes is complicated, but that's what makes it fun! Enjoy.
  4. newdude2009

    newdude2009

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    I know blue dog meant LDL<100.
  5. JustPlainBill

    JustPlainBill Attending

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    So, here's a place I use when attendings are beating the crud out of me about Evidence Based Medicine --- the first is a drill down link regarding diabetes care -- there's two articles on standards of care -- use with caution, your mileage may vary, standard disclaimers apply ---

    http://www.guideline.gov/browse/by-organization.aspx?orgid=159

    This is a little higher up the chain but has all sorts of interesting information from various societies -- you can find everything from warfarin prophylaxis to pre-op cardiac algorithms, etc....kinda neat and really more detail than you'll probably need/want -- but important for residency where you have to justify wiping a patient's toejam off when you inspect their feet based on the 'evidence' ---

    http://www.guideline.gov/browse/by-organization.aspx?alpha=A
  6. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    Nope. LDL particle number. http://www.theparticletest.com/

    At a minimum, I want a diabetic's LDL cholesterol (LDL-c) <70. LDL-p is a better predictor of risk, however, and is my primary therapeutic target where lipids are concerned.
    Last edited: Mar 17, 2012
  7. newdude2009

    newdude2009

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    I've never come across this. Thanks for the info, I'll look into it.
  8. LouisianaDoctor

    LouisianaDoctor

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    Thank you very kindly for this information.

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