Diabetes Mellitus: Its Goals Of Therapy!

 GOAL OF THERPY

The goals of treatment of DM includes;

• Reducing, controlling and managing long-term microvascular, macrovascular and neuropaathic complications.
• Preserving beta cell function.
• Preventing acute complications from increased Blood glucosel level.
• Minimizing hypoglycemic episodes.
• Maintaining patient quality of life.

--Two landmark trials, THE DIABETES CONTROL AND COMPLICATION TRIAL (DCCT) and THE UNITED KINGDOM PROSPECTIVE DIABETES STUDY(UKPDS), showed that lowering blood glucose levels decreased the risk of developing chronic complications.

--A near normal blood glucose level can be achieved with appropriate patient education, lifestyle modification and medications.

--Proper care of DM requires goal setting and assessment for glycemic control, self-monitoring of blood glucose (SMBG) monitoring of blood glucose pressure, and lipid levels, regular monitoring for the development of complications, dietary and exercise lifestyle modifications and proper medication use 

Proper care of DM requires goal setting and assessment of Glycemic control by; 

• Monitoring daily blood glucose levels.
• A1c monitoring 
• Estimated Average Glucose values (eAG) monitoring.
• Blood pressure.
• Lipid levels.

                         1.MONITORING OF BLOOD GLUCOSE LEVELS

                      1. By SMBG.                                                       2. By Glucose sensors.

• The ADA premeal plasma glucose levels goals are 70-130 mg/dL and peak post-prandial plasma glucose level goals are <180mg/dL. 
• The American Association of Clinical Endocrinologists (AACE) supports tighter SMBG controls with premeal glucose level goals of < 110mg/dL. and post-prandial glucose level goals of < 140mg/dL.
• For patients using multiple daily insulin injections or Insulin pumps therapy, the ADA recommends that SMBG be performed at least 3 times daily.

a) SMBG: It is a standard method that enables patient to obtain their current blood glucose levels at any time and is relatively inexpensive.

• Each patient should be educated regarding how often and when to perform SMBG. 
•  Typically, in SMBG, a drop of blood is placed on the blood sample size required to as small as 0.3 micrometers, provided the capability of alternate site testing and allowed for the delivery of readings in as few as 5 seconds. 

b) Glucose sensors: Several continuous glucose sensors are now available that works with or independently of insulin pumps. These monitors provide blood glucose readings, primarily through the interstitial fluid (ISF). 

• A small sterile disposable glucose sensing device called a SENSOR is inserted into the subcutaneous tissues. The sensor then measures the change in glucose in ISF, and sends the information to a monitor, which stores the results.

 2.MONITORING OF HAEMOGLOBIN A1c:

Glucose interacts spontaneously with Hb in RBCs to form glycated derivatives. The most prevalent derivative is A1c because Hb has a life span of approx. 3 months, level of A1c provide a marker reflecting the average glucose levels over this time frame.

• The ADA goals for persons with DM is less than 7% whereas AACE supports a goal of less than or equal to 6.5% 
• Testing A1c levels should occur at least twice a year for patients who are meeting treatment goals and 4 times for patients who are not meeting goals 

3.ESTIMATED AVERAGE GLUCOSE eAG:

Estimated Average Glucose is used to correlate A1c values with readings that patients obtain from their home glucose monitors. 

• The equation to convert from A1c to eAG is.

                                                   eAG(mg/dL) = 28.7*A1c- 46.7 

• The goal for eAG is 154mg/dL which corresponds with an A1c of less than 7%.
•  In standardized assay, a 1% rise in A1c translates into 35mg/dL increase in mean glucose.

4.KETONE MONITORING URINE AND BLOOD KETONE TESTING

• It is important in people with T1DM, in pregnancy with pre-existing diabetes and in GDM. 
• People with T2DM may have positive ketones and develop into Diabetic ketoacidosis if they are ill.
• When there is a lack of insulin, peripheral tissues cannot take up and store glucose. this causes the body to think it is starving and because of excessive lipolysis, ketones, primarily Beta-hydroxybutyric acid and aceto-acetic acid, are produced as by-product of free fatty acids metabolism in liver.
• Glucose and Ketones are osmotically active and when an excessive amount of ketones is formed, the body gets rid of them through urine, leading to dehydration. 
• Patients with T1DM should test for ketones during acute illness or stress or when blood glucose levels are consistently elevated above 300mg/dL 
• Women with pre-existing diabetes before pregnancy or with GDM should check ketones using their first morning urine sample or with any symptoms of Diabetic ketoacidosis such as nausea, vomiting or abdominal pain are present

• Blood ketone testing methods that quantify Beta-hydroxybutyric acid are available and are a preferred way to diagnose and monitor DKA.