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DIABETES MELLITUS
Management
IMPORTANT POINTS:IN HISTORY, EXAMINATION, INVESTIGATIONS AND TREATMENT
– Control: good / poor? Treatment?
– Complications
– Cardiovascular risk factors
HISTORY: special points
Introduction: ethnic group and age Presenting complaint
– E.g. admitted for control of diabetes History of presenting complaint
– Polyuria, polydypsia……blood glucose values, also indicates control, screening
Complications – systemic review esp. CVS, Neuro, Eye, Renal, Skin, Drug history – What medication? Duration, Side effects? Compliance? P/H/O complications esp. CVS, wound infections
F/H/O type 2 DM, IHD, CVA, HBP
Social history: smoking, diet, exercise, financial aspects
EXAMINATION: special points General examination
– skin infections, edema, waist CVS –
– BP, postural hypotension, JVP, cardiomegaly – peripheral pulses, bruits
RS– Infections - TB
Abdomen – Fatty liver, ascites with nephrotic syndrome
CNS– Ophthalmoscopy and cranial nerves– Mononeuritis– Amyotrophy– Autonomic (postural hypotension)– Peripheral neuropathy
• Muscle wasting• Early sensory signs: vibration sense, absent jerks• Romberg’s test
FEET– Skin, bact / fungal infections, gangrene, pulses, neuropathy, ulcers, osteomyelitis,
INVESTIGATIONS
Assess glycemic control
Extent of complications
Risk factors for CAD
INVESTIGATIONS
Assess glycemic control: blood glc levels, HbA1c, fructosamine
Extent of complications: ECG, A/B, Renal, CXR, ECHO,
Risk factors for CAD: BP, lipids, metabolic syndrome
PRINCIPLES OF TREATMENT
Good glycemic control Prevent or treat complications Manage risk factors for CAD
PRINCIPLES OF TREATMENTTYPE 2 DM
Good glycemic control Prevent or treat complications Manage risk factors for CAD
GLYCAEMIC CONTROL
A healthy lifestyle OHD Insulin
HEALTHY LIFE STYLE
Healthy eating Weight control Exercise Smoking and alcohol
HEALTHY LIFE STYLE
Healthy diet Exercise Weight control: BMI <23 kg / m2
Smoking and alcohol
DIET
Carbohydrates– 60% of calories– Low glycaemic foods preferred– Restrict refined sugars and high fiber– Non-nutrient sweeteners– Avoid alcohol
Fats– <30% of calories– <7% saturated– <200 g of cholesterol– Avoid trans-fatsEat fish twice a week
EXERCISE
Control of blood sugar Increases insulin sensitivity (danger of hypo) Weight loss Reduces body fat and maintains muscle bulk Lowers blood pressure Cardiovascular fitness
DRUGS
Decreased absorption
Decreased hepatic glc output Increased peripheral glc uptake
Stimulate insulin release
OHD
Decreased absorption
Decreased hepatic glc output Increased peripheral glc uptake
Acarbose
PioglitazonMetformin
Stimulate insulin releaseSulphonyluria, Repaglinide
OHD
Biguanides: metformin Sulphonyluria: glyclazide, glipizide Thiozolidinediones: pioglitazone Alpha glucosidase inhibitor: acarbose Non-sulphonyluria secretagogues: repaglinide
DRUG THERAPY
Asymptomatic
Life-style modification Drugs
DRUG THERAPY
Asymptomatic
Metformin
Life-style modification Drugs
DRUG THERAPY
Asymptomatic SymptomaticHigh HbA1C
High FPG
High RPG
Life-style modification Drugs
DRUG THERAPY
TYPE 2 D M Asymptomatic Type 2 DM ? Metformin
Symptomatic Type 2 DM HbA1c >8% FBS > 11.1 RBG > 14.0
TYPE 1 DM Insulin
TYPE 2 DM
Obese T2DM: Metformin If intolerant give acarbose or TZD HbA1C >10%: combination of metformin and
gliclazide (sulphonyluria)
Non-obese T2DM: Metformin or sulphonyluria
(gliclazide)
GOALS OF GLYCEMIC CONTROL
– FBS 4.4-6.1
– Non-fasting 4.4-8.0
– HbA1C <6.5%
Mono-therapy
Combination of metformin + gliclazide
OR metformin + acarbose / TZDs (esp in obese)
Then add third drug
Add insulin
ADD INSULIN
If not reaching target after 3 months of optimum combination therapy (metformin, gliclazide, acarbose, pioglitazone)
FBG> 7.0 mmol/L HbA1c>6.5% Maximum doses of OHD
INSULIN
Rapid-acting analogues Fast-acting insulin (short-acting) Intermediate-acting insulin Long-acting insulin Very long-acting analogues
Lancet 2006;367:847
INSULINS
Rapid-acting analogues: insulin lispro, Humalog (4-6 hours) Fast-acting: soluble insulin, Actrapid, Humulin R (6-10 hours) Intermediate-acting: (10-16 hours)
– isophane; NPH, Humulin N– Humulin L (Lente insulin)
Long-acting insulin: Ultralente 24 hours Very long-acting analogues: (24 hours)
– Insulin glargine (Lantus)– Insulin detemir (Levemir)
Lancet 2006;367:847
INSULIN REGIMES
Premixed (Mixtard) b.d. (30% soluble + 70% isophane)
Before meals rapid or short, with bedtime intermediate or long acting analog
Bedtime Long-acting or intermediate insulin, day time sulphonyluria + metformin
INSULIN REGIMES
Basal-bolus (T1DM) Insulin pumps (continuous subcutaneous)
Twice daily mixtard (Often for T2DM)– 2/3 of total dose in morning (2/3 long acting = e.g. 30:70
Mixtard)– 1/3 of total dose in evening (1/2 long acting = e.g. 50;50 Mixtard)
Lancet 2006;367:847
INSULIN PUMP
COMPLICATIONS OF TREATMENT
Hypoglycaemia Hypoglycaemia unawareness
NEWER DRUGS IN TYPE 2 DM
Exenatide– Stimulates insulin secretion
– Glucagon-like-peptide
– Given S.C
PREVENT COMPLICATIONS OF DIABETES
PREVENT COMPLICATIONS OF DIABETES
Nephropathy Neuropathy Retinopathy Cardiovascular: IHD, CVA/TIA. PVD Diabetic foot
PREVENT COMPLICATIONS OF DIABETES
Good glycaemic control Screen for complications Action to prevent specific complications
PREVENT COMPLICATIONS OF DIABETES
Good glycaemic control Screen: regular BP, lipids, eye and renal check up Action to prevent specific complications:
– ACEI or ARBs in early renal involvement– Aspirin if IHD, or high risk of IHD (microalbuminuria, metabolic
syndrome, >35, high-risk ethnic groups, family history) – Control hypertension (macrovascular, retinopathy and
nephropathy)– Treat hyperlipidaemia (macrovascular and nephropathy)– Stop smoking (IHD, CVA, TIA, PVD)– Diabetic foot
CONTROL HBP AND HYPERLIPIDAEMIA
– LDL <2.6
– TG <1.7
– HDL >1.1
– BP <130/80
– BP <120/75 (with renal impairment or gross proteinuria)
COMPLICATIONS: DIABETIC FOOT
Slides current until 2008
Diabetic neuropathyFoot education
Curriculum Module I I I -7cSlide 8 of 34
Wash, touch and look at feet every day
• Do not soak feet
• Test water temperature
• Wash and dry between toes
• Avoid herbs and ointments
• Examine feet in good light
COMPLICATIONS: DIABETIC FOOT
Slides current until 2008
Diabetic neuropathyFoot education
Curriculum Module I I I -7cSlide 15 of 34
How to care for toenails
• Do not to let nail grow too long
• Cut straight across
• File sharp edges
• Ask a friend or relative
COMPLICATIONS
Slides current until 2008
Diabetic neuropathyFoot education
Curriculum Module I I I -7cSlide 11 of 34
Learn to look for:
Hammer toe Clawed toes
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