Treatment algorithm for DM; factors to consider while prescribing medication: Dr. V Mohan
M3 India Newsdesk Oct 03, 2019
Dr. V Mohan emphasises that diabetes is not a single disorder but a syndrome consisting of several types of diabetes all of which have in common raised blood glucose levels. Here he provides a quick treatment algorithm and details on the necessary factors to consider before planning treatment.
What is Diabetes? Is it a single disease?
The question may seem a bit strange, when I am writing this article for doctors. However, the more we learn about diabetes, the more humbling it becomes. I have been working in the field of diabetes from the age of 18, ever since I joined my father Prof. M. Viswanathan who is widely considered as ‘Father of Diabetology’ in India. In all humility I must say that even after working for nearly 47 years in this field, I still really do not understand what diabetes is.
The only thing we are sure is that people with diabetes have a raised blood glucose level. The normal fasting blood glucose levels are below 100 mg/dl in the fasting state and below 140 mg/dl, 2 hours after the glucose load. When the fasting blood sugar is above 126 mg/dl or the 2 hour value is above 200 mg/dl, we call this as ‘Diabetes’.
Values in between, ie, a fasting between 100 to 125 mg/dl and a 2 hour value in the OGTT between 141 and 199 mg/dl are referred to as ‘Pre-diabetes’. This much we all agree on. However, there could be people with values within the diabetic range, but who have completely different forms of diabetes.
I would like to state that there are at least 40 varieties of diabetes to be considered in the differential diagnosis of diabetes.
- Most of us know and treat type 2 diabetes which is the commonest form of diabetes that we see in our practice. It is widely believed that 90 to 95% of all diabetes belongs to type 2 diabetes.
- Type 1 diabetes is the most severe form of diabetes which usually affects children and young adults. These individuals require insulin on a lifelong basis to maintain life and good health.
- There are other forms of diabetes like secondary diabetes (eg, diabetes secondary to chronic pancreatitis), gestational diabetes which comes due to pregnancy and the Monogenic forms of diabetes like Maturity Onset Diabetes of the Young (MODY) or Neonatal Diabetes Mellitus (NDM) which are caused by single gene mutations.
- Apart from these there are several other genetic syndromes which are associated with diabetes.
Thus, as we can see, diabetes is not a single disorder but a syndrome consisting of several types of diabetes all of which have in common raised blood glucose levels. The story gets even more complicated if we consider that type 2 diabetes itself is not one homogeneous condition but consists of several heterogeneous subtypes.
SAID: Leif Groop and colleagues from Sweden recently identified five clusters or sub types of type 2 diabetes. The first one is called SAID or Severe Autoimmune Diabetes. In this form patients are usually lean and severely insulin deficient. GAD antibodies and other antibodies are positive. This subtype more closely resembles type 1 diabetes and some people refer to it as type 1.5 diabetes. These patients invariably require insulin for control of the diabetes.
SIDD: The second variety is a Severe Insulin Deficient Diabetes (SIDD) where insulin deficiency is the main pathology and insulin resistance is less marked. They may not be metabolic syndrome. Insulin secretagogues like sulphonylureas and DPP4 inhibitors would work best in this group.
SIRD: The classical prototype of type 2 diabetes is the third form which is the SIRD or Severe Insulin Resistant Diabetes. Here patients are obese, have severe diabetes and evidence of metabolic syndrome with dyslipidemia and hypertension. These patients invariably respond well to insulin sensitizers like metformin.
MOD: A fourth one is Mild Obesity-related Diabetes (MOD). These patients usually obese and have no insulin resistance.
MARD: A fifth variety is called the Mild Age Related Diabetes (or MARD) which usually comes after 60 or 70 years of age and patients do not need to be treated very aggressively. It has been shown that the proneness to complications also varies between these various subtypes. Hence the next time, when the patient comes to our clinic, it is worth mentally thinking which type of diabetes are we dealing with. This has particular significance in young patients with diabetes.
Case discussion
I had a 16 year old girl who came to me with severe diabetes, she was thin. She was seen by a physician and was immediately diagnosed to have type 1 diabetes and was told that she has to take four insulin injections per day without which she would die.
When we examined her, we found that she had a strong family history of diabetes going through three generations. Her C-peptide assay showed that she was secreting enough insulin. Both GAD antibody and Zinc transporter antibodies were negative.
Based on this we did a genetic testing to rule out Maturity Onset Diabetes of the Young or MODY and we found that she had MODY 3 (HNF1a) mutation which responded well to sulphonylureas. We were able to stop the insulin completely and treat her with sulphonylureas to which she is responding even after 10 years. This is the classical example of how by accurately diagnosing a patient one can offer the correct treatment to the patient.
Algorithm to treat diabetes
When a patient comes to you it is always worth asking,
- Does the patient have diabetes? Yes / No
Very often patients who do not have diabetes are wrongly diagnosed and hence it is worth even asking this fundamental question.
- If the answer is ‘Yes’, then ask, is this ‘Type 1 diabetes’, ‘Type 2 diabetes’, ‘Monogenic form of diabetes’ or any other form of diabetes.
This should be the next question which comes to our mind.
- If it is ‘Type 2 diabetes’, then we can ask the question which form of type 2 diabetes is it? Is it SAID, SIRD, SIDD, MOD or MARD?
Based on this, we can plan what type of treatment one should give.
Factors to consider while prescribing treatment
- Age of the patient
- Renal function and EGFR
- Presence of co-morbidities like heart diseases or stroke
- Expected life span of the patient
- Patient preferences and motivation levels
All these factors should be taken to consideration before we prescribe a particular treatment to a patient. This will ensure that our patients are happy, have good quality of life and also help them eventually live a long and healthy life despite diabetes.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
The author, Dr. V Mohan is the Chairman & Chief of Diabetology at Dr. Mohan’s Diabetes Specialities Centre & Madras Diabetes Research Foundation, Chennai, India
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