Diabetes Mellitus (Prediabetes and Type 2)

1. Prediabetes: lifestyle

Prediabetes is reversible; otherwise you are one step away from diabetes.

• Reduce 10% of body weight (delays diabetes by 10 years)
• Brisk walk 30 minutes per day, 5 times per week
• Reduce diet (carbohydrates) by 50%; reduce half of the rice and roti
• No refined sugars and bakery products like biscuits, cakes, sweets (Urdu: stop sweets and begin bitter gourd)
• Monitor RBS once a week, fasting
• Say no to a sedentary lifestyle: eat less and walk more
• Encourage fruits with fibre and vegetables; no bed after eating

2. Prediabetes: oral hypoglycaemic

• Metformin 500 mg BD (Tab Glucophage 500 mg, 1+1)

Prescription

3. Diabetes: lifestyle

• Similar to prediabetes; 100 mg/dL can be reduced

4. Diabetes, Step I: overweight patient

• Most type 2 diabetics are overweight, so metformin is the first-line drug in overweight patients
• Start with 500 mg BD: Tab Glucophage 500 mg 1+1; continue for 2 weeks and monitor RBS (fasting) two times a week; target 130 mg/dL
• If the target is achieved, continue lifestyle modification
• If not, increase: Glucophage 500 mg 1+1+1; then Glucophage 850 mg 1+1+1; maximum dose 3 g/day
• If the target is still not achieved, add a second-line drug

Prescription

5. Diabetes, Step I: underweight and newly diagnosed

• Sulfonylureas are drugs of choice
• Tab Getryl 1 mg BD (1+1); monitor for 2 weeks; target 130 mg/dL
• If not achieved: Tab Getryl 2 mg 1+1; maximum dose 4 mg BD

Prescription

6. Step II: combination therapy

• If cardiovascular risk factors are present (angina, transient ischaemic attack, peripheral vascular disease): sitagliptin + metformin, Tab Treviamet 50/500 1+1; monitor for 2 weeks
• If no cardiovascular risk factors: metformin + sulfonylurea, Tab Glucovance 2.5/500 (glibenclamide + metformin) 1+1 morning and evening; monitor RBS; if the target is achieved, continue

Prescription

7. Step III: three-drug combination

• Combination of sulfonylurea, metformin, Trevia (sitagliptin), and dapagliflozin / empagliflozin; the choice is the doctor's (side effects or contraindications)
• Three of the four groups can be combined, e.g. Tab Glucovance 2.5/500 1+1 plus Tab Dapagliflozin 5 mg once daily; OR Tab Treviamet 50/500 1+1 plus Tab Getryl 2 mg 1+1

Prescription

8. Step IV: insulin

Indications: periods of stress (DKA, surgery, infections); deranged renal parameters (serum creatinine above 1.5 mg/dL); type 1 diabetics; treatment failure by oral hypoglycaemics; HbA1c above 9.5%.

• Choice: Mixtard 70/30
• If newly diagnosed: 0.5 U/kg, two-thirds in the morning and one-third in the evening. Example for a 70 kg patient: 70 × 0.5 = 35 U, so Inj Mixtard 70/30: 24 units in the morning and 12 units in the evening
• Dose adjustment: monitor RBS in the morning and evening. If fasting RBS in the morning is more than the target (130 mg/dL), increase the evening dose by 2 units. If RBS in the evening is more than the target, increase the morning dose by 2 units, and vice versa

Prescription

9. Patient education and supplements

• Awareness about hypoglycaemia
• Awareness about diabetes: it is a controllable disease
• Multivitamins are recommended: Cap Polybion Z once daily with food (Urdu)

Prescription

10. Complications and referral

• Diabetic ketoacidosis: refer to the nearest government hospital
• Diabetic neuropathy
• Diabetic retinopathy
• Diabetic nephropathy
• Diabetic foot: care of the foot (Urdu: just as you look at your face daily, look at your feet daily; try to keep the feet bare/soft, not tight shoes — partly legible)
• Consultant opinion