Diabetes Management from

scratch!!!!

Management of pre-diabetes
1. People who screen-positive for prediabetes (FPG=100-125 mg/dL or 2-h PG in the 75-g
OGTT=140-199 mg/dL or HbA1c=5.7%-6.4%) should be intervened with appropriate lifestyle
modification.
2. 3 steps-
o Advise to lose 10% of current body weight
o Sleep 6-8 hours daily (Main reason for hyperglycemia is the cortisol stress response
due to poor quality of sleep)
o Exercise daily for minimum 1 hour/day
3. If at the end of 6 months HbA1c is still high, start Metformin 500mg OD
Exercise advise

Treatment of Florid Diabetes

HbA1C more than 6.5

FBS/PPBS->>126mg/dL/200mg/dL

STEP1- Always start Metformin 500mg BD

Maximum dose of metformin is 2.5gm/day

Start at low dose as giving higher doses straight-away is associated with increased risk of gastric side
effects including diarrhea. Metformin dose can be hiked once weekly by 500mg/week up to a
maximum of 2.5grams (dosed at 500mg 2-1-2). Always prescribe metformin with food to avoid GI
side effects.

Metformin is generally a very safe drug with very few side effects including gastrointestinal
intolerance, Lactic acidosis and vitamin B12 deficiency

Avoid if GFR is less than 30ml/min/m2 and in Decompensated liver disease (as increased risk of lactic
acidosis!!)

STEP2- at the end of 2-3 months, repeat HbA1C (we should target HbA1C as the treatment goal,
instead of FBS/PPBS ideally, FBS.PPBS in resource poor settings)

The ideal HbA1C target in young patients is 6-7, while in older patients a target of 7-8 is feasible
because of the increased risk of hypoglycemia. Please study LEGACY EFFECT IN HARRISON!!!

If HbA1C is 1.5 points higher than the target, that is for a target of 6, if the HbA1C level is 8 for a 40
year old patient, we shall initiate DUAL THERAPY.

Along with Metformin start either one of

Glimepride/Sitagliptin/Voglibose/Pioglitazone/Dapagliflozin (Indian setting)

Drug Starting dose Maximum dose

Glimepride 2mg OD/BD 4mg OD/BD
Sitagliptin 50mg OD 50mg BD
Voglibose 0.2mg TDS 0.3mg TDS
Pioglitazone 15mg OD 30mg OD
 Dapagliflozin 10mg OD -

Glimepride(Sulfonyl urea) is associated with weight gain and increased risk of hypoglycemia while
sitagliptin(DPP-4 inhibitor) is associated with increased satiety and weight loss, hence sitagliptin is
more preferred in diabetes with metabolic syndrome and hyperlipidemia.

Step 3- at the end of 2 months, if the HbA1C or FBS/PPBS levels are still not controlled, we shall start
TRIPLE THERAPY

Metformin+Sitagliptin+Glimepride up to maximum possible doses can be given for optimizing sugar

control. Always we have to be careful in patients with deranged serum creatinine and it is better to
stop the OHAs and shift to insulin therapy, because of the increased risk of OHA induced
hypoglycemia in clinical practice!

I usually avoid pioglitazone as it has side effects including osteoporosis, macular edema, bladder
cancer and weight gain. It is preferred in patients with NASH(Non-Alcoholic steatohepatitis) where it
decreases liver inflammation and prevents fibrosis.

Up to maximum of 4 drugs can be given before considering Insulin

GLP-1agonists are the revolution in the treatment of diabetes, but they are not yet available in oral
formulations in Indian market (semaglutide)

Step4- If the sugar levels are not controlled, and the HbA1C Levels are still persistently high consider
starting insulin.

PATIENT group Pre-prandial glucose Post-prandial glucose

Normal <115mg/dL <160mg/dL
Patients with increased risk of <130mg/dL <180mg/dL
hypoglycemia

While initiating insulin, doses of OADs should be modified as follows:

1) No change in metformin doses, DPP4i, SGLT 2 inhibitors, AGI and TZDs

2) Dose of sulphonylureas should be reduced when prandial insulin is introduced
3) Risk of unacceptable weight gain should be kept in mind while prescribing insulin with TZDs
and the latter should be withdrawn if such weight gain is seen.

Whom to initiate insulin upfront???

High glycemic parameters: HbA1c >9.0%, FPG >200 and/or PPG >300 mg/dL

Start with basal insulin-Basal insulin should be given preferably at bedtime to achieve adequate
suppression of Hepatic glucose production. 1st thing to control is morning fasting blood glucose

BASAL INSULIN Name of the INSULIN Dose in IU

GOVERNEMENT SETUP NPH(INSULATARD) 4-0-4 units
PRIVATE SETUP DEGLUDEC/GLARGINE (both of 10 UNITS IN THE NIGHT
equal efficacy) (If more than 30 units
shall divide and give as
 BD)

Usual dose for basal insulin is 0.1-0.2IU/kg/day or 10 units as a whole which should be given at night
before bed time for controlling morning fasting plasma glucose(decreased hepatic glucose
production)

For example for a person with bodyweight of 60kg we shall give 6 units of degludec in the
night(0.1*60)

How to titrate: check FBS after 2 days in the morning. Titration should be done every 2 days until the
target fasting plasma glucose is achieved!!

Fasting plasma glucose(mg/dl) Dose change

More than 180 Increase dose by 20%(if 6 IU, increase by 2 units
so 8 IU)
140-180 Increase by 10%(if 6 IU, increase by 1 unit to 7
units)
110-130 Add 1 IU
<70 Reduce dose by 20%, so give 4 units
<40 Reduce by 30%, shall give 3 units

Basal insulin takes care of the fasting state hepatic glucose production, but the prandial increase in
glucose levels will not be affected by it. Hence after initiating either NPH or Degludec / glargine in the
above doses, our next target should be to control post prandial glucose control.

Hence once the fasting plasma glucose is controlled by the above methods, post prandial glucose
should be controlled with short acting insulins/OHAS/Premixed insulins if they are higher.

What shall be given?

3 options are available

1)Short acting insulin- regular insulin (Human actrapid), Lispro, aspart etc.,

2)Premixed insulins with long acting and shorting acting insulins in the same vial (either 70/30 or
50/50 Combination)- Inj. human mixtard (NPH+ Regular insulin), Ryzodec (Aspart+Degludec). The
concept with pre-mixed insulin is that as they have short acting insulin they can be given as single
dose before the largest meal of the day, for Indians it is lunch!!Hence Ryzodec use is preferred in the
afternoon.

3)oral hypoglycemia agents- Glimepride, sitagliptin, vildagliptin, semaglutide(injectable),

Dapagliflozin

Most of the patients will be on either Glimepride or Gliptins or both for controlling prandial increase
in serum glucose. Since it is not controlled with these agents we are starting the next mode of
therapy that is insulin.

For the sake of simplicity we shall take short acting insulin now and details regarding pre-mixed
insulin shall be discusses in the upcoming classes!!
Coming to regular insulin, Human actrapid is the brand available in govt setup(taken half and hour
before food). Inj. lispro and aspart are ultra-short acting insulins (taken just before food intake)

How to start and what is the dose??

Start with 4 units or 0.1u/kg body weight dosing before the largest meal of the day(lunch) at starting
phase. Check Sugars every 3 days and It is better to do a six point sugar profiling if patient is
hospitalized.

So Human actrapid shall be given as 0-4-0 units. This is ideal if patient is taking OHAs for post
prandial glucose control in the morning and night

If there are any contraindications for OHAs (as in CKD) , or the morning and night time postprandial
glucose is not adequately controlled we can stop the OHAs and give short acting insulin in the
morning and night as well. So, the dosage will be Human actrapid 4-4-4 units s/c half and hour before
food (Lispro/aspart shall be taken just before food a they are ultra-short acting)

How to titrate- Check post prandial sugars (after 2-3 hours of meal) every 2 days and increase dose
by in increments of 2 units if glucose value is more than 140mg/dl.

The usual concept is 1 unit of insulin will decrease glucose by 50mg/dl in insulin sensitive patients,
and by 30mg/dl in insulin resistant patients (that is those requiring more than 1unit/kg body weight
of insulin)

So, if post prandial levels are 240mg/dl we shall add 2 units to decrease the sugar values by
100mg/dl, to a target value of 140mg/dl.

I Hope this is beneficial. If this needs any improvisation feel free to DM me and suggest your
feedbacks! Thank you!