Treatment in type II diabetes.

1. Diet/weight/exercise control
2. Oral hypoglycemics - metformin is first line. Over time additional therapy is requried. add a 2nd drug, sulfonylureas. Beware thiazolidinediones ( especailly rosiglitazone - associated fluid retention. some studies show that it is associated with coronary artery disease)
3. Consider use of alpha-glucosidase inhibitors(acarbose), lipase inhibitors (orlistat) [ not good for weight loss but indicated for glycemic control], DPP-IV inhibitors (sitagliptan (Januvia)-oral [prevents incretin break down], GLP-1 receptor agonist(exenatide (byetta)-s/c [ increases incretin levels] This new class increases insulin secretion and decreases glucagon secretion. Lowers post-prandial sugar levels and keeps pre-prandial levels low.
4. once per day insulin is added to oral hypoglycemic therapy in patients with type 2 diabetes, either insulin NPH or detemir given at bedtime or insulin glargine given in the morning or at bedtime. Start low at 10 units and vary by 10-20% over 2-4 days.
5. Total daily dose of 1unit/BMI of insulin.
   
6. Consider pre-mixed insulin or NPH + a short acting. twice a day. Not recommended in type I diabetics.
7. More complex insulin regimens are recommended when needed. Similar to type I diabetes. (long-acting basal bolus in the night+ pre-meal short or rapid acting insulin)
8. Target of 4-6mmol pre-prandial and 4-7.7 post-prandial. HbA1C of 6-7% (reflects past 3 months glucose levels)
   

ALWAYS REMEMBER PATIENT EDUCATION! insulin injections, warnings on hypoglycemia - in relation to illnesses, missed doses, exercise, diet.

Types of insulin

Ultra-short acting: insulin aspart(novorapid), insulin lispro
Onset:15min Peak: 1hr duration: 4hrs

Short-acting: actrapid, hypurin neutral
Onset:30min Peak: 4hrs duration:8hrs

Intermediate: Protaphane, Humulin NPH, Hypurin Isophane (bovine), Hypurin Isophane (porcine) via SAS.
Onset:1.5hrs Peak: 8 hrs duration: 16hrs

Long-acting: glargine(constant output), detimir
Onset: 2hrs Peak: No peak Duration: 24hrs (less for detimir)

Mixed insulin: mixtard 70/30. novomix 70/30
Both contain a short-acting(30%) and a long-acting (70%), given twice a day.

http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Diabetes_insulin_choices?OpenDocument

Differences between DM type 1 and type 2

1. Genetics- type 1 has only a 30% concordance between identical twins unlike type 2 which is 80%. HLA-DR3/DR4 are also associated with type 1.
2. Epidemiology- type 1- affects the young. consider late onset autoimmune diabetes(LADA). type 2- affects the middle age obese population. consider maturity onset disease of the young(MODY).
3. Presentation-

• Type 1 - polyuria, polydipsia, polyphagia, weight loss, nocturia, ketoacidosis(ketones on dipstick)
  
• Type 2- asymptomatic

4. Aetiolgy- type 1 - beta cell destruction. anti-islet cell Ab, anti-glutamic acid decarboxylase Ab type 2- insulin resistance. beta cell dysfunction.

Diagnosis of diabetes + relevant history questions.

Diagnosis is made by one of the following and must be confirmed on a subsequent day unless unequivocal hyperglycemia or metabolic decompensation.

1. random glucose of >11mmol/L
2. fasting glucose of >7.0mmol/L
3. OGTT>11mmol/L 2 hours after 75g of glucose after 3 days of fasting.

Diagnosis alogoritham

1. Do a random or fasting.
2. If <5.5, diabetes unlikely
   
3. If fasting 5.5-7.0, random 5.5-11.0 unequivocal, proceed to OGTT.
   
4. If F>7.0, R>11.0, diabetes likely
5. OGTT, between 7.8-11.0 impaired glucose tolerance, >11.0 diabetes likely.

Screen diabetes in pple >45 age.

CVD(AMI, stroke, PVD)
Hypertension
Obesity (>30kg/m2)
PCOS
Ethnic groups - aboroginal, torres strait, chinese (>35 age)