Type 2 diabetes
Goals of therapy in Type 2 Diabetes
Primary Goals of Type 2 Diabetic Therapy
- Smoking Cessation (NNT = 11 over 10 years)
- Blood Pressure Control (NNT 15 over 10 years for mortality, 6 over for complications)
- Metformin Therapy (NNT = 15 over 10 years, NNT = 10 over 10 years for complications)
- Lipid Reduction (NNT 10-15 over 10 years - Decreases Cardiac Events, Extends life by 2-3 years)
B12 Deficiency in Metformin NNH ~9-13 BMJ 2010. Long Term Rx w/ Metformin...B12 Def
Secondary Goal of T2DM Therapy with targets discussed with patient
- Glycemic Control (No effect on mortality or clinically relevant outcomes)Glycemic control should be considered a secondary endpoint for treatment of microvascular outcomes (ie renal protection and eye protection). Glycemic control is directly associated with the onset and progression of retinopathy and nephropathy. White blood cells fight infection best when Glucose is < 180.
Management of Inpatient Hyperglycemia
Basal Bolus Regimen Recommended, Goal Control between 140-180 mg/dL
Think Basal-Prandial vs Basal-Correction(for older, questionable PO intake)
1. Calc Total Daily Dose(TDD) of Insulin in units 0.3 to 0.5 units/kg/day as an estimate (lower for CKD/older >70yo , higher for younger with centripetal obesity)
2. 1/2 of TDD as Basal Insulin = 0.15 to 0.25 units/kg/day given as Basal Dosing
3. 1/2 of TDD split into 3 short acting doses given prior to meals // Alternatively, you can just give correction doses if you think they have poor intake (as in Basal-Correction)
4. Next day, if fasting is >140mg/dL, considering increasing by 2 units. Review prandial or 2 hour post-prandial sugars to adjust prandial/correction doses as needed.
5. Calculate "Insulin Sensitivity Factor" Reasonable worksheet, 3/2018
AAFP "Lending a Hand"Am Fam Physician. 2014 Feb 15;89(4):256-258.