Detailed management of diabetes patient

-surabhi desai

INTRODUCTION

• Diabetes is the common endocrine disorder.it is a disease marked by high level of blood glucose which results from defect in insuline production or insulin action or both.approx 135 million people worldwide have diabetes.

• Type1:insulin dependent diabetes mellitus• Type:non-insulin dependent diabetes mellitus

• Recently it is also classificed as:• Adult-onset• Juvenile-onset• GESTATIONAL DIABETES MELLITUS

AMMERICAN DIABETIC ASSOCIATION

• TYPE1:IMMUNE MEDIATED• IDIOPATHIC• TYPE2:GENETIC PANCREATIC BETA CELL

DEFECT,GENETIC DEFECT IN INSULIN RECEPTOR,PANCREATIC DISEASE:TRAUMA,INFECTION,INFLAMMATION,NEOPLASM

• ENDOCRINOPATHIES: growth hormone,cortisol,glucagon,epinephrine

Ammerican diabetic association

• Drug or chemical induced• Nicotinic acid,glucocorticoid,thyroid,phenyoid

thiazides• INFECTION• VIRAL,RUBELLA,CYTOMEGALOVIRUS,MUMPS,ADEN

OVIRUS• OTHER GENETIC

SYNDROME;DOWN,KLINEFELTER,TURNER• Impared glucose tolerance,impaired fasting glucose

Impaired fasting glucose….normal fasting glucose is taken as less than or equal to 110mg/dl,fasting plasma glucose level btw 110-126 is considered having impaired fasting glucose….Impaired glucose tolerance….postprandial glucose between 140-200mg/dl

HYPERGLYCEMIA

• etiology• WEIGHT GAIN• CESSATION OF EXERCISE• PREGNANCY• HYPERTHYROIDISM• EPINEPHRINE THERAPY• CORTICOSTEROID THERAPY• ACUTE INFECTION• FEVER• Skin is warm

HYPOGLYCEMIA

• etiology:• WEIGHT LOSS• INCREASED PHYSICAL EXERCISE• TERMINATION OF PREGNANCY• TERMINATION OF DRUGS• RECOVERY FROM INFECTION AND FEVER• Skin is cold

• Genetic factor• Environment factor..epidemic of

mumps,congenital rubella associated with type1

• Autoimmune factor:for type1• Type2• Three cardinal abnormalities…resistance of

action of insulin in peripheral tissue.particularly muscle,fat,liver

• 2..defective insulin secretion particularly in response to glucose stimulus.

• 3.increased glucose production by liver• Obesity• Insuline resistance• Insulin secretion

What to ask??????

Medical history……..

• Recent weight loss???• Fever night sweat???• Recurrent infection???• Excessive thrist ,urination,hunger???do you get up

at night to void urine???• Family history of diabetes???• Any medication taken???• Dry mouth???• Delayed wound healing???

• How often do you monitor your urine or blood glucose level?what is your glycosylated hb test result???

• How frequently(IF EVER) do you experince hypoglycemic episodes???

• Ask for neuropathy ,nephropathy,retinopathy???

Hyperglycemia

• Diagnostic clues:• Acidosis with blood ph..7.3• Dry warm skin• Kussmauls respiration• Fruity sweet breath odor• Rapid weak pulse• Altered level of consciousness

• Hyperglycemia Conscious patient-should not receive any dental treatment untill physician is consulted

• Unconscious patient-• Step1:termination of dental therapy• Step2:activation of dental office emergency

team• Step3:patient kept in supine position with legs

elevated

• Step3:removal of dental material from mouth• step4:A-B-C….air breathing circulation• Check airway…breathing pulse…must initate basic

life support.adequate oxygenation is given,untill underlying matabolic cause is removed patient remains unconscious

• Step5:iv infusion of dextrose and normal saline..insulin must be administered carefully and blood test performed to monitor effect

• step6:adminstration of oxygen

• transportation of patient to hospital

• A B C D P• hypoglycemia-conscious patient• Step1:recognition of hypoglycemia…dr should know how long ago

he ate or took insulin• Step2:termination of treatment• E soft can• Step4:administration of oral carbohydrates..sugar orange juice

candy• step5:RECOVERY

Drugs and insulin

treatment

• Various treatment option:• Diet plus life style modification• Diet plus oha• Diet plus insulin• Diet plus oha plus insulin• The recommended allocation of calories are• Carbohydrates(50%)protein(10-15%)fats(30-

35%)

• DRUGS FOR TYPE2:• Biguanides….ex:METFORMIN..increased insulin

sensitivity• THIAZOLIDINEDIONES…..ex:rosiglitazone,pioglitazone .

stimulate insuline secretion..inc insulin sensitivity,lower ldl,inc glucose uptake by tissues

• sulfonylurea:GLIPIZIDE,GLUBURIDE,TOLBUTAMIDE..stimulate insulin secretion

• meglitinides:repaglinide….stimulate insulin secretion• Glucosidase inhibitors:acarbose….decreases hydrolysis

and absorption of complex carbohydrate

INSULIN PREPARATION

• Rapid acting…lipro,aspart• Regular cting…humulinR novolinR• Intermediate-acting:nph• Long-acting-insulin glargine

• Vascular system:artherosclerosis,microangiopathy• kidnay: diabetic gluromeurlonephritis• Nervous system:neuropathy• Eyes:retinopathy,glaucoma• skin..diabetic xanthoma,mycosis,pruritus• Pregnancy..large babies,still births,congenital

defects• Diabetic foot ulcer• Diabetic ketoacidosis,hypoglycemic coma