4e0325420b8bbe4f12e8cd3f Hakkunamatata 1308830281599 Diabetes

7/27/2019 4e0325420b8bbe4f12e8cd3f Hakkunamatata 1308830281599 Diabetes

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Guide to diabetes


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Definition

Diabetes mellitus is a syndrome

characterised by chronic

hyperglycaemia and disturbance of

carbohydrate, fat and protein

metabolism associated with absolute orrelative deficiency in in insulin

secretion and\or insulin action.


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Insulin allows glucose (sugar) to enterbody cells to convert it into energy.

Insulin is also needed to synthesizeprotein and store fats. In un controlleddiabetes, glucose and lipids (fats)

remain in the blood stream and, withtime damage the bodys vital organsand contribute to heart disease.


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Classification

Diabetes is classified into three main types:

Type 1 previously called insulin-dependent

diabetes mellitus (IDDM)

Type 2 previously called non-insulin-

dependent diabetes mellitus(NIDDM)

Gestational Diabetes Mellitus(GDM)


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Type 1 Diabetes

Occurrence:

Autoimmune disease wherein the immune system

attacks B-cells of pancreas and destroys them. Thepancreas then produce little or no insulin.

Scientists do not know exactly what causes the

bodys immune system to attack the B-cells, butthey believe that both genetic factors and

environmental factors and possibly viruses, are

involved.


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Characteristics:

Often develops in children and young adults, but

the disorder can appear at any age.

Symptoms usually develop over a short period,although B-cell destruction can begin year earlier.

If not diagnosed and treated with insulin, a person

can lapse into a life-threatening diabetic coma,also known as diabetic ketoacidosis.


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Type 2 diabetes

Occurrence:

The most common form of diabetes.

Due to reduce insulin secretion orperipheral resistance to action of insulin.

The result is the same as for Type 1

diabetes, glucose builds up in the blood andthe body cannot make efficient use of itsmain source of fuel.


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Often part of a metabolic syndrome

that includes obesity, elevated blood

pressure, and high levels of blood

lipids.


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Characteristics:

Contributes 90 to 95% of total diabetes and one-

third not been diagnosed.

This form of diabetes usually develops in adults.

About 80% of people with Type 2 diabetes are

overweight.

Increase in incidence of childhood obesity leads toType 2 diabetes becoming more common in young

people


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Symptoms & Management for

Type 1 and Type 2 Diabetes

Symptoms:

Increased thirst and urination.

Constant hunger.

Weight loss.

Blurred vision Extreme fatigue.

Slow healing of wounds or sores.


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Management:

Diet

Exercise

Insulin for Type 1 and OHAs or insulin in

Type 2

Education

Monitoring blood glucose and therapy


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Gestational Diabetes:

Occurrence:

Develops in pregnancy and disappears after

delivery, however with increased risk in

getting later in life

Insulin resistance due to pregnancy.

Genetic predisposition.


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Management:

Diet: provide adequate calories which will

not lead to hyperglycemia or ketonemia.

Exercise: that does not cause fetal distress,

contractions or hypertension.

Insulin: to maintain blood glucose,

fasting


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Diagnosis

The fasting plasma glucose test in the

preferred test for diagnosis Type 1 or Type

2 diabetes. However, a diagnosis of diabetesis made by an one of the three positive tests,

with a second positive on a different day:


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A random Plasma glucose value (taken any

time of day) of 200mg/dl or more, along

with the presence of diabetes symptoms.

A plasma glucose value of 126/mgdL or

more, after a person has fasted for 8 hours


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An oral glucose tolerance test (OGTT)

plasma glucose value of 200 mg/dL or more

in the blood sample, taken 2 hours after aperson has consumed a drink containing 75

grams of glucose dissolved in water. This

test, taken in a laboratory or the doctorsoffice, measures plasma glucose at timed

intervals over a 3-hour period.


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Gestational Diabetes

Diagnosed based on plasma glucose values

measured during the OGTT. Glucose levels

are normally lower during pregnancy, so thethreshold values for diagnosis of diabetes in

pregnancy are lower. If women has two

plasma glucose values equal to or more thanany of the following values after a 100gm

OGTT, she has gestational diabetes:


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1-hour level of 180 mg/dL

2-hour level of 155 mg/dL or 3-hour level

of 140 mg/dL

Fasting plasma glucose level of 95mg/dL


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People with impaired glucose metabolism, a

state between normal and diabetes are at

risk for developing diabetes, heart attacks,and strokes. There are two forms of

impaired glucose metabolism.


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Impaired Fasting Glucose (IFG):

Fasting plasma glucose level of 110 to 125

mg/dL, a level higher than normal but less

than the level indicating a diagnosis ofdiabetes.


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Impared Glucose Tolerance (IGT)Means that blood glucose during the oral

glucose tolerance test is higher than normal

but not high enough for a diagnosis ofdiabetes. IGT is diagnosed when the

glucose level is 141 to 199 mg/dL, 2 hours

after a person is given a drink containing 75grams of glucose.


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OGTT

OGTT is performed using a 75 or 100 gm oral

glucose load in the morning after a noncaloric 8-

hour fast. Water is allowed, but not coffee orsmoking.

Test should be performed on an individual without

underlying illness and/or interfering drugs. OGTT

is not appropriate for a patient who is

malnourished, on a restricted carbohydrate diet, or

with acute and chronic illness.


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Patient should be ambulatory and not to bed rest,

hospitalized , or immobilized. During the test,

patient should be resting comfortably. Patient should consume an unrestricted diet

containing at least 150g carbohydrate daily for

three days before test.

Just a confirmatory test, not to be done regularly.


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Glycated Hemoglobin (HbA1c) Test

Indicates blood glucose control over a

period of approximately 3 months.

Normal range varies depending on the

method the lab uses: usually 4-7%,

correlating to average blood glucose of 60-

150 mg/dl (3.3-8.3 mmol/l)


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Should be prescribed by health care

provider every three months for Type 1

diabetes and at 3-6 months intervals forType 2, to help determine overall control.

Patient does not need to be fasting to have

this blood test performed


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Ketone Test

Ketone is by product of fat metabolism;

presence of ketone indicates that the body is

not metabolizing food properly because oflack of available insulin or carbohydrate;

may indicate impeding or established

diabetic ketoacidosis (DKA), a conditionthat requires immediate medical attention.


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Method: Dipstick

When to test:

When blood glucose level is consistently

>300 mg/dl (16.7 mmol/l). During period of acute illness (illness is a

stress that can cause and hyperglycemia).

When symptoms of hyperglycemiaaccompanied by nausea, vomiting andabdominal pain are present.


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Treatment strategy


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Goals Of Treatment

Control high blood glucose (hyperglycemia)

Avoid low blood glucose (hypoglycemia).

Treatment of associated conditions, such as highblood pressure, cholesterol disorder and obesity.

Prevent or retard the progression of complications

of diabetes such as blindness, kidney failure, heartdisease, stroke and amputation of legs.


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Treatment Plan

1. Management of Blood Glucose:

Target Blood Glucose values:

(as recommended by the American Diabetes Association)

Pre-meal blood glucose 80-120 mg/dl

Bedtime blood glucose 100-140 mg/dl

*HbA1c Less than 7%


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However, not every person is a candidate for such

tight blood glucose control. This should not be

attempted in: Frail, elderly person who have already developed

the complications of diabetes such as blindness

and end-stage kidney failure.

Elderly patients having frequent low blood

glucose episodes.


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Management of cholesterol:

Target Cholesterol Levels

(as recommended by the American diabetes association)

LDL Cholesterol Less than 100 mg/dl

HDL Cholesterol Greater than 45 mg/dlTriglycerides Less than 200 mg/dl


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Management of High Blood Pressure Target blood pressure in diabetic patients

should be less than systolic 130/ diastolic 85

mm Hg, as recommended by the Americandiabetes Association.

The treatment strategy also involves correct

nutrition, moderate exercise and propermedication.


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Nutrition

Nutrition is an important element in

diabetes management.

Diet content should be 10-2-% protein, 60%

carbohydrates and 20% fats.


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Dos of diabetic diets

Consistency in diet and meal timings

according to medicines.

Multivitamin containing an antioxidant such

as vitamin ,beta-carotene, vitamins C and E.

Minimum of 1200 kcal/day for women and

1500 kcal/day for men.


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Sodium level (salt intake) should be

maintained between 2.4 and 3.0 gm/day for

people without hypertension and >2.4gm/day for people with mild to moderate

hypertension.

Fibre of approximately 20- 35 gm/day froma variety of food sources should be

consumed


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Donts of diabetic diets

Avoid alcohol especially if diabetes is not in

control.

Avoid in-between meals. Adhere to the time

and size of the meal decided.

Avoid fasts and fasting alters body

metabolism, adversely affecting the diabeticstate.


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Exercise

Exercise can improve the health and

outlook of life. Regular and controlled

exercise not only helps to increase glucoseutilization but also helps to maintain

desirable health.


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Dos in exercise

Check the patients for blood pressure, blood fat

levels, HbA1c, health of heart, circulatory and

nervous systems, kidney function, eyes and feet. Choose exercises that fit the patients health.

Exercise should be preceded and followed by 5-10

minutes of slow, continuous, aerobic activities.


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Remember the feet.Advice them to wear thecomfortable shoes for the sport.

Watch the low blood sugar, insulin or oraldiabetes medicine may lead to low bloodsugar levels.

Advice the patients to keep a snack handyto avoid low blood sugar levels during theexercise.


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Donts in exercise

Advise not to snack unnecessarily before

exercise.

Uncomfortable shoes should not be worn

while exercising.

Avoid exercising in extreme cold or heat.

Exceeding target heart rate of 60 to 80% of

estimated maximum heart rate.


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Oral Hypoglycemic Agents

OHAs are primarily used in type 2 diabetes

adjunct to nutrition therapy and exercise.

Oral agents are broadly classified as

follows:


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First generation sulfonylureasGeneric name Dosage

range per day

Duration of

action

Side effect of class

Chlorpropomide 100-500 mg 6-2 hrs Prolonged

hypoglycemia,

cholestaticjaundice,

Hypersensitivity;

alcohol flush

Tolbutamide 500-3000 mg 6-2 hrs Hypoglycemia,

hypersensitivityTolazamide 100-1000 mg 12-24 hrs Hypoglycemia,

hypersensitivity

Aceohexamide 500-1500 mg 12-24 hrs Hypoglycemia,

hypersensitivity


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Second generation sulfonylureas

Generic name Dosage

range per

day

Duration

of

action

Side effects

Of class

Glipiside 2.5-40 mg 12-24 hrs Hypoglycemia,

hypersensitivity

Glibenclamide 5-20 mg 12-24 hrs Hypoglycemia,

hypersensitivity

Glymeperide 1.8 mg 24 hrs Hypoglycemia,

hypersensitivity

Gliclazide 40-240 mg 12-24 hrs Hypoglycemia,

hypersensitivity


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Agents enhancing effects of insulinGeneric name Dosage

Range

Per day

Duratio

n of

action

Side effects of class

Metformin

(Obimet)

500-2500

mg

6-8 hrs Gi upset; diarrhea;

possible resumption

of ovulation in

premenopausal

anovolvutary

patients; acidosis (if

renal, liver, heart

impairment present).


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Agents enhancing effects of insulinGeneric

name

Dosage

Range

per day

Duration

of action


Rosiglitazone 4-8 mg Very long Renal and liver

function studies

should be done to

monitor liver

dysfunction, salt

and water retention,

edema, congestive

heart failure.


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Agents enhancing effects of insulinGeneric name Dosage

range per

day

Duration

of action


Pioglitazone 15-45 mg Very long Renal and liver

function studies

should be done to

monitor liver

dysfunction, salt andwater retention,

edema, congestive

heart failure


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Other Oral agents

Generic name Dosage range

per day

Duration

of action


Repaglinide

(NovoNorm)

1.5-16 mg 2-6 hrs Hypoglycaemia,

arthralgia, leukopenia

Acarbose 25-300 mg < hrs Diarrhoea,abdominal

discomfort, flatulence

Miglitol 25-300 mg


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Incidence of HOA failure

Primary failure:

About one third of of Type 2 patients fail to

respond to sulphonylurea treatment within

one month of initiation of therapy.


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Secondary failure:

Of the patients that initially achieve

satisfactory glycaemic control, about 5 to

10% go on to develop secondary failureeach year, so that after 10 years only about

half of the patients continue to have

satisfactory response.


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Secondary failure: (continued)

From the data of the UKPD study, it

appears by the sixth year,approximately

50% of the patients randomized tosulphonylurea needed supplemental insulin

to maintain adequate glycemic control.


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Diagnosis OHA failure:

It is a condition in which an individual does not

respond adequately/ satisfactorily with OHAs.

Clinically, following parameters can be of greatrelevance in diagnosing OHA failure:

1. Inadequate improvement in the classical signs

and symptoms of diabetes viz., polydypsia,

polyuria, polyphagia and fatigue.


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2.Weight loss accompanied by rising blood

glucose and recurring infections.

3.Inadequate/deteriorating blood glucosecontrol. The objective to the pursued on this

front is:

Fasting blood glucose


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4.High and increasing number of tablets with

inadequate control; especially exceeding

two to two and a half tablets in case ofcommonly used OHA.


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Dose at which review is essential

Oral hypoglycemic Agent Mg per day No of tablets

Glibenclamide (Glyburide) 10 2

Gipzide 10 2

Glyclazide 120 1.5


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Dose at which review is essential

Poor performance with the above doses

indicates the necessity to review the

entire therapy and the therapeutic

alternative to be considered at this

point of time is initiation of insulin

therapy

2 ibili i


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,are 2 possibilities:

Stop HOA treatment and start insulin

therapy (substitution) or

Continue OHA treatment and add

insulin therapy (supplement)


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Oral antidiabetics are contraindicated in

Type 1 diabetes and in Type 2 diabetes

undergoing surgery, serve infections, liverand kidney disease, and gestational

diabetes.


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Insulin

Insulin are always used in patients with

Type 1 diabetes and may be required in

patients with Type 2 diabetes or gestationaldiabetes.

Insulin can be broadly classified on the

basis of species, action profile and strength.


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Sources of insulin: human, porcineand Bovine

Species Structural difference Immunogenecit

y

Human Identical to physiologicalinsulin

Least

Porcine Differs in one amino acid

from Human insulin

Negligible

Bovine Differs in three amino

acids from Human insulin

More


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Action profile of insulin:

Type Onset Peak duration

Rapid-acting

Human

Actrapid

hrs 1-3 hrs 8 hrs

Indication

1. For dose titration, quick glycemic control2. Emergencies like diabetic ketoacidosis (DKA),

hyperosmolar non-ketotic state (HONK)

3. Stressful conditions like surgery, labour,myocardial infraction


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Type Onset Peak Duration

Intermediate

Acting lenteHuman

Monotard

2.5 hrs 7-15 hrs 24 hrs

Indication

1. OHA Failure

2. Pregnant diabetes

3. Chronic infections in Type 2 diabetes e.g Tuberculosis


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Intermediate

Acting NPHHuman

Insultard

1.5 hrs 4-2 hrs 24 hrs

Indication

1. OHA Failure




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Pre-mixed (30/70

regular/NPH)Human Mixtard

hrs 2-8 hrs 24 hrs

Indication

1. OHA Failure



4. Any other indications where a mixture of rapid and

intermediate acting insulin is desired in the ratio of 30:70


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Pre-mixed 50/50

regular/NPHHuman Mixtard 50

hrs 2-8 hrs 24 hrs

Indication

1. Patients with modern lifestyles on two large daily meals

2. Patients with high post prandial blood glucose levels


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Amounts of insulin

Insulin regimen should be individualized

depending on lifestyle, activity level and eating

pattern. Continuous treatment and monitoring are the main

stay.

Efforts should be taken to keep blood glucose as

close to the target range (72 mg/dl before a meal,

180 or less two hours after a meal).


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Insulin Initiation

Substitutions

Stop OHA tablets.

Start with Intermediate insulin 0.2 units /kg

body weight before breakfast or at bed time

(upto a maximum of 20 units).

Increases by 2-6 units every 3-4 days if

necessary.


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Note:

If post prandial blood glucose levels are too

high add Rapid action insulin. Alternatively,

Pre-mixed insulin could be used. If the doseexceeds 30-40 units, divide the dose into

daily injections 2/3rd before breakfast and

1/3rd

before dinner.


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Supplement

Continue with OHA tablet with out any

change in dose.

Start with 0.1 to 0.2 units of

intermediate insulin per Kg body

weight before breakfast or bed time.


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Supplement: (continued)

Increase dose by 2-4 units every 3-4

days if necessary

If more than 30-36 I.U. is required for

adequate control ( i.e FGB


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Suggested Guidelines For Fine

Tuning Split Mix Regimens

Response to insulin treatment may be

different in different patients may require

adjustment to the insulin regimen. The tablegiven below depicts a simple way to adjust

the dose.


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Adjustment to morning injections

Before Lunch Before Dinner

If persistent

hyperglycaemia (orglycosuria) occur

Increase fast acting

(soluble) insulin inthe morning

injection by 2IU

Increase

intermediate actinginsulin in the

morning injection

by 2 IU

If hypoglycaemiaoccurs with out

explanation

Decrease fastacting (soluble)

insulin next

morning by 2 IU

Decreaseintermediate acting

insulin next

morning by 2 IU


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Adjustment to evening injection

Before Lunch Before Dinner

If persistent

hyperglycaemia(or glycosuria)

occur

Increase fast acting

(soluble) insulin inthe evening injection

by 2IU

Increase intermediate

acting insulin in theevening injection by

2 IU (after excluding

nocturnal

hypoglycaemia

If hypoglycaemia

occurs without

explanation

Decrease fast acting

(soluble) insulin

evening injection by

2 IU

Decrease

intermediate acting

insulin in the evening

injection by 2 IU


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Mixing Insulin

NPH and short-acting insulin formulations

when mixed may be used immediately or

stored up to 2 weeks. Mixing of regular and lente is not

recommended unless injected immediately

after preparation; binding action of regularand lente begins immediately and effect of

regular may be blunted.


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Insulin Administration

Choose a syringe compatible with the insulin

strength (i.e.40 I.U. insulin)

For cloudy insulin (suspension) invert the vial afew times until the suspension has been mixed

well.

Draw air into syringe corresponding to the

prescribed dose of insulin and slowly inject airinto vial held vertically at eye level, then draw up

insulin


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Insulin Administration: continued

Inject excess amount of insulin back into the vial

held vertically at eye level and pull out the needle.

Lift up the skin at the injection site in a broad foldand insert needle at an angle of 45 into the sub-

cutaneous tissue, inject insulin slowly.

In order not to injure the tissue beneath the skin

rotate the injection site in the chosen area.


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Delivery Devises

Needle and Syringe

A common way of administering insulin is

with a needle and syringe.

Syringes come in a range of capacities (1ml,

0.5ml, or0.3ml) and different strengths.

Most suitable size can be selected to deliver

the insulin dosage as per the requirement.


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Needles also come in different gauges and

lengths, and have very fine points and

special coatings to make them relativelypain-free although some people find them

daunting and not very convenient.


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Insulin Pens (NovoPen 3)

Easiest and the most convenient way of

administrating insulin.

Accurate even at extremely low dosage.

NovoPen 3 reduces the insulin

administration to mere two step procedure:

Dial the dose and inject.


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Advantages:

Combination of insulin pens and Penfillscompletely eliminates the need to handle

syringes and vials. No need to mix and measure and therefore

improves dosage accuracy.

NovoPen 3 is compact enough to fit easilyinto a purse or pocket and convenient tocarry anywhere.


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Launch of single penfills has further

enhanced convenience to buy and has also

offered economy to the patient by avoidinghuge investment at one single time.


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Disposable Pens (NovoLet):

Premixed, prefilled and ready to use

disposable insulin delivery devices.

Patients just have to dial dose, inject anddispose the pen after use of 300 units of

insulin.

NovoLets useful in initiating insulin therapyin


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OHA inadequacy and failure

Pre and post operative conditions

Gestational diabetes mellitus

NovoLets are available in all the varieties of

insulin viz.

Mixtard 30 NovoLet, Mixtard 50 NovoLet,

Actrapid NovoLet, Insulatard NovoLet


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Storage of Insulin

Refrigerate unopened insulin (will be good until

the expiration date on the vial).

The vial of insulin is used within 30 days ofopening, may be stored at room temperature (>2

degree Celsius and


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Needs to be stored between 2 degree

Celsius to 8 degree Celsius without

dampness and direct exposure tosunlight.

In transportation it is to be dispatched

with coolants and thermocol boxes.


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Neutral insulin should be a clear solution

whereas premixed and intermediate

insulin are suspensions.

Magnus Novo Nordisk offer complete

range of insulin with C4 (Complete care

cool chain) guarantee.


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Diabetes Treatment Chart

Define individual Aims of therapyVery symptomatic

Severe

hypoglyceamia

Ketosis Pregnancy

Diet and Exercise

Glycemic goals

Glycemic goals

achived

Monotherapy

Repaglinide

Sulphonylurea

Biguanide Alpha-

glucosidase inhibitor

Thiazolidinedione

Insulin


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Traditional Medicines

Due to chronic nature of the disease, patients

try various therapies available in the market,

which are clinically not proven. The basisof the usage of these medicines is no side-

effects but then efficacy is always a

question mark. Some of the traditionalmedicines used in the treatment are:


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Better substances like Neem leaves, Bittergourd,

Methi etc.

Ayurvedic drugs viz. Vijasar, Bittergourd, JamoonSeeds and Nisha Amlakki are used commonly.

However their clinical results have not been either

conclusive or not published.

Spirulina (fresh water algae) that grows in watertanks is used, but not significant effect seen on

blood sugar.


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Precautions

It is essential to provide the efficacy and

safety of traditional medicines in wide

variety of patents and to look for long termsafety and efficacy in human beings.

Any system of medicine that claims that it

has cure or relief for Diabetes has to undergo the clinical safety tests before it is

accepted.


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Scientific proof and clinical study

should authenticate any such claims in

magazines and newspapers.

Drugs that may alter the


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g y

glycemic control of sulfonylureas

A. Enhance hypoglycemic effect (decrease

blood glucose)

Alcohol (acute use) Methyldopa

Allopurinol Monoamine Oxidase

(MAO) inhibitors

Androgens Phenobarbital

Anticoagulants Phenylbutazone

Chloramphenicol Probenecid


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Clofibrate Salicylates

Fenfluramine Sulfinpyrazone

Flucanazole Sulfonamides

Gemfibrozil Ticuclic antidepressants

Histamine H2 antagonists Urinary acidifiers

Decrease hypoglycemic


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effect(increase blood glucose)

Beta-blockers Rifampin

Cholestyramine Urinary alkalinizers

Diazoxide Diuretics


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Drugs that interact with insulin

Enhance hypoglycemic effect (decrease blood

glucose)

Angiotensin-convertingenzyme (ACE)inhibitors

MAO inhibitors

Alcohol Mebendazole

Anabolic steroids Octreotide

Beta-blockers(delay recovery

from hypoglycemia)

Pentamidine

Calcium Phenylbutazone


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Chloroquine Pyridoxine

Clofibrate Salicylates

Fenfluramine Sulfinpyrazone

Guanethidine Sulfonamides

Lithium carbonate Tetracyclines

Decrease hypoglycemic effect


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(increase blood glucose)

Acetazolamide Empinephrine

AIDS antivirals Estrogens

Asparaginase Enthacrynic acid

Calcitonin Isoniacid

Contraceptives, oral Lithium carbonate

Conticosteroids Morphine sulfate


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Cyclophosphamide Niacin

Dextrothyroxine Phenothiazine

Diazoxide Nicotine

Diatiazem Thiazide diuretics

Dobutamine Thyroid hormone


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Low Blood Sugar (Hypoglycemia)

A common problem in diabetic patients

whether on oral antidiabetics Or insulin.

Hypoglycemia can be longer & serious withsome oral antidiabetics because of their

longer duration of action and unpredictable

pharmacokinetics.


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Symptoms of Hypoglycemia:

Sweating

Palpitations

Shakiness Blurry vision

Headache

Frequent hunger

Feeling of passing out

Decreasedconcentrating ability

Inappropriate behavior

Loss of conciousness


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Treatment of Hypoglycemia:

Check blood glucose to exclude other reasons.

If glucose meter not readily available, thenpresume hypoglycemia and institute testamentimmediately.

Provide glucose tablets, fruit juices,candy,etc.

If the patient becomes unconscious, a Glucagon

injection (GlucaGen Hypokit) Should beadministered.

Recheck blood glucose after 30 minutes.


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Hypoglycemia can be recurrent on

administration of long acting insulin or

drugs such as Glyburide, Glipizideespecially if patients also have kidney

disease.

Patients are generally monitored in thehospital for 24 48 hours for any recurrent

hypoglycemia.


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Diabetic ketoacidosis

Symptoms:

Anorexia, nausea, vomiting

Thirst, Polyuria

Weakness

Abdominal pain

Visual disturbance

Weight loss


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Signs:

Elevated blood glucose (>250mg/dl)

Ketonuria/Ketonemia

Plasma bicarbonate


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Treatment:

Replacement of fluid loss to correct dehydration &hyperosmolarity

Replacement of electrolysis with potassium

containing saline

Correction of hyperglycemia by insulin and fluidreplacement

Ketosis and acidosis are simultaneously correctedby above measures

Identification and correction of precipitatorycauses.


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Complications: Long Term

Diabetes is the silent killer as it affects

almost all the organs of the body and

usually leads to a host of complications ifnot controlled aggressively.


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Kidney Disease

Symptoms:

Hypertension, edema, proteinuria and renal

insufficiency


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Diagnosis:

Urinary microalbumin excretion testing

Spot urine sample testing


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Treatment:

Tight control of blood glucose in most diabeticpatients.

Dietary protein restrictions.

Excessive urinary microalbumin excretion shouldbe treated with an ACE-inhibitor agent (providedthere are no contraindications) even if their blood

pressure is not elevated. This helps to controlintraglomerular hypertension.

High blood pressure should be aggressivelytreated in diabetic patients and target blood

pressure should be less than 130/85mg Hg.


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Monitoring:

Urinary albumin excretion test on a yearly

basis


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Eye Disease

Symptoms:

Diminished visual activity; frequent change

in power of lens, painful eye


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Diagnosis:

Check visual acuity with Snellens chart,

seperately for each eye

Dilate pupils Examine fundi by ophthalmoscope

Microaneurysms, retinal hemorrhages,hard

exudates from eye.


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Treatment:

Aggressive control of blood glucose and

blood pressure in most diabetic patients.

Laser photocoagulation surgery for diabeticmacular edema or proliferative retinopathy.

Vitrectomy surgery for vitreous hemorrhage

or severe progressive neovascularization.

M


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Monitoring:

Yearly eye examination of the diabetic

patient by an ophthalmologist

F P bl


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Foot Problem

Symptoms:

Tingling, pins & needle sensation, burning

sensation, numbness or pain.

Di i


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Diagnosis:

Carefully inspect the feet (whole foot, nails)

Check peripheral pulses

Examine for neuropathy i.e touch andvibration

T


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Treatment:

Best treatment is regular care of the feet.

Tight blood glucose control is crucial.

The mode of treatment depends upon

the degree of lesions,

neuropathic & vascular assessment

and X-ray.

Treatment can range from bed rest, antibioticsaccording to culture and sensitivity, plaster, specialshoes to ampulation.

M i


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Mentoring:

A podiatrist should be visited for regular

foot checking.

E il D f i


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Erectile Dysfunction

Erectile dysfunction is the most common

male sexual dysfunction in diabetes.

Treatment options for diabetic

til d f ti


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erectile dysfunction

General measures

Improving diabetic control

Reduce alcohol intake

Withdraw causative drugs

Nonhormonal therapy

Alpha-2-adgrenergic blocking agents (yohimbine

hydrochloride) Type-specific phosphodiesterase inhibitors

(sildenafil citrate)

N i i Th


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Noninvasive Therapy:

Vacuum erection devices

Intracavernosal injection of vasoactive

agents (mixture of papaverine,phentolamine, prostaglandin E1)

Invasive therapy:

Penile prosthesis (malleable versusinflatable device)

Microvascular arterial bypass surgery

H t Di


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Heart Disease

Symptoms:

Augina symptoms: chest, arm, and/or jaw

pain (discomfort), Shortness of breath, coldclammy sweat

Myocardial infraction (ML)- silentML

more common.

Di i


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Diagnosis:

Examine blood pressure

Electrocardiogram monitoring particularly

ambulatory ECG monitoring for silent ischemia

Stress testing for coronary heart disease

Echocardiography (with Doppler)

Testing of cholesterol

T t t


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Treatment

Antiplatelet / anticoagulants:

Start Aspirin 80 to 325mg/d if not

contraindicated Manage warfarin tointernational normalised ratio 2 to 3.5 for

post ML-patients not able to take aspirin


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ACE inhibitors in post-ML patients:

Start early post-ML in stable high risk

patients (anterior ML, previous ML, Killip

class II Continue indefinitely for all with LV

dysfunction

Use as needed to manage blood pressure orsymptoms in all other patients

B t bl k


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Beta-blockers:

Start in high risk post-ML patients

(arrhythymia, LV dysfunction, inducible

ischemia) at 5 to 28 days with continuationfor six months minimum

Use as needed to manage angina, rhythym,

or blood pressure in all other patients

Pregnancy and Diabetes


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Insulin treated diabetes

Planned Pregnancy

Good glycemic control be obtained before

conception. In some situations intensivestabilization pre-pregnancy may benecessary

Good glycemic control before and

throughout pregnancy reduces the risk ofcomplications for the mother and foetus.


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For pre-pregnancy stabilization use at least

a twice daily mixtures of short and

intermediate acting insulin. Reinforce education on diet and insulin self

adjustment.

Preconception goal for glycemic


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control

Premeal glucose 70 to 100 mg/100 ml (3.8

to 5.5 mmol/l)

1 to 2 hour post meal glucose at or below150 mg/100ml(< 8.3 mmol/ol)

Serial H BA1c levels to be maintained at the

normal or near normal value.

Other Assesments


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Other Assesments

Asses for any diabetic complications

(hypertension, ischemic heart disease,

nephropathy, neuropathy, retinopathy andsevere gastroenteropathy).

Obsteric assessment

Thyroid function test as per local practice

Optimal Target Index for Glycemic

C t l D i P ith di b t


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Control During Pregnancy with diabete

Blood Glucose Goals in Diabetic Pregnancy

Fasting 60-90 mg/100 ml (3.3-5.0 mmol/l)

Premeal 60-105 mg/100 ml(3.3-5.0 mmol/l)

1 hour postprandial 100-120 mg/100ml(5.5-6.7 mmol/l)

2 a.m 6 a.m Hours 60-120 mg/100 ml(3.3-6.7 mmol/l)


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Oral hypoglycemic treated diabetes

Oral hypoglycemic drugs should be

discontinued and human insulin therapy

instituted. Planning for pregnancy; preconceptions

goals for glycemic control; other

assessment; and Optimal Target Index forglycemic control during pregnancy with

diabetes.

Gestational diabetes


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Gestational diabetes

Gestational diabetes mellitus develops in

approximately 2-5% of pregnant women.

GDM are at increased risk for thedevelopment of Type 2 diabetes later in life

and their infants are at risk for macrosomia.

Screening, diagnosis and

treatement


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treatement

All pregnant women should be screened for

glucose intolerance between 24th and 28th

week

Diagnosed GDM


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Diet; monitor glycemia, foetus

Fasting blood glucose < 105

mg/100ml (5.8 mmol/l) and 2-hour postprandial >120 mg/100

ml (>6.7 mmol/l)

Continue diet and monitor

glycemia and foetus

Initiate Human Insulin

treatment; monitor

glycemia and foetus


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Diabetes is frequently associated with

infections as seen in clinical practice, but

not clearly proved. Defects in both cellmediated immunity and polymorphonuclear

functions have seen experimentally shown,

but their exact role in human beings is yet to

be clearly shown.


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A decreased perfusion due to abnormality in

microvascular circulation and neuropathy

may worsen the prognosis as infection setsin.

The entire immune system is altered to

defense against microbial invasion, certaindefects may be more directly associated

with certain infections in diabetes.

Skin infections


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Skin infections

Due to compromised host defense and high

blood sugars, microbes withy low virulence

easily cause infections of the damaged skin. Staphylococcus aurous infection causing

boils, carbuncles and abscesses are the most

common skin infections.

Diagnosis:


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Diagnosis:

Confirmation is by biopsy of the affected

area

Treatment:

Board-spectrum antibiotics, antifungul

agents

Tuberculosis


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Tuberculosis

Tuberculosis is common with diabetes in

India.

Diagnosis: Chest X-ray

Sputum and urine examination

Hematology

Symptoms:


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Symptoms:

Weight loss

Fever with chills

Weakness

Excessive urination

Treatment:


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Treatment:

Antitubercular therapy of INH, Rifampicin,

Ethambutol and Pyrazinamide.

Rifampicin and INH interact with OHAsand therefore choose insulin to initiate

antidiabetic treatment.

Surgery


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Surgery

During surgery utmost care is required from

the family physician in co-ordination with

anesthetist to achieve proper glycemiccontrol and avoid complications. The

management differs as per the current

treatment and status of diabetes. Broadly

surgery management in diabetics is

undertaken in following three phases:

Pre-operative Management


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Pre-operative Management

In patients managed on diet, assess for metabolic

control with proper diet. If uncontrolled, admit

patient 1-2 days before operation and initiate

Human Actrapid.

In patients managed on oral anti-diabetics, shift to

shorter acting sulphonylurea. Biguanide should be

stopped one week before and the patient should beshifted to insulin for stabilisation


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In patients on insulin, shift from

intermediate acting insulin to short acting

insulin (Human Actrapid) Frequent monitoring is required.

If optimal control is not achieved with

subcutaneous Human Actrapid, consideredintervevous infusion.

Peri-operative (during surgery)

Management


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Management

In patients only managed on diet institute insulin ifhyperglycemia develops & persists postoperatively.

In patients managed on oral medication, avoidbreakfast and no medication on day of treatment.Treats as non diabetic if blood glucose is


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In patients managed on insulin,set up i.V,

infusion (10% Dextrose 500ml + I.U.

Human Actrapid+10 mmol KCL) andregimen adjust as per patients requirement.

Monitor patient frequently (1-2 times every

hour) during operation.

Post-operative (after surgery)

Management


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Management

In diet treated diabetics, return to pre-

operative dietary management incase of

minor surgery. In major surgery, treat withHuman Actrpid (8-12 units) t.d.s before

each meal. Further titrate the dose as per the

requirement.


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In patients managed on oral medication

recommence sulphonylureas with first meal

in case of minor surgery. In major surgery,treat with Human Actrapid (8-12 units)

t.d.s. before each meal. Further titrate the

dose as per the requirement.


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In patients managed on insulin, continue theinfusion at the same rate until oral feedingcommences. If infusion is prolonged (24 hrs),

check electrolytes daily (Na/K). Initiate Human Actrapid (equivalent to pre-

operative dose) with oral feeding

After 2-3 days, restabilise on suitable regimen for

the patients. Measure Ketone bodies and blood glucose

frequently


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Being sick can make the blood glucose level

go up very high.

It can also cause serious conditions that canput up the patient in a coma.

What Happens When the Patient

is Sick


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is Sick

Patient when sick is under stress leading to releaseof hormones, which raises blood glucose levels,and interferes with the glucose-lowering effects of

insulin. Easy to lose control of the diabetes leading to

ketoacidosis and diabetic coma particularly inpeople with Type 1 diabetes.

People with Type 2 diabetes, especially olderpeople, can develop a similar condition calledhyperosmolar hyperglycemic nonketotic coma.

Diabetes Medicines


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Diabetes Medicines

Type 1 diabetes, it is advisable to take extra

insulin to bring down the higher blood sugar

levels. Type 2 diabetes, may be able to take pills,

or may need to use insulin for a short time.

Food


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Food

Eating and drinking can be a big problem.

But it is important to stick to the normal

meal plan. Easy to run low on fluids when one is

vomiting or has fever or diarrhea. Extra

fluids will also helps get rid of the extra

sugar (and possibly ketones) in the blood.

Medicines to Watch Out For


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Medicines to Watch Out For

Advice to check the label of over- the-counter

medicines before buying them to see if they have

sugar. Small doses of medicines with sugar are

usually okey.

Many medicines when taken for short-term

illnesses can affect blood sugar levels, even if they

dont contain sugar. For example, aspirin In largedoses can lower blood sugar levels


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Some antibiotics lower blood sugar levels in

people with Type 2 diabetes who take

diabetes pills. Decongestant and some products for

treating colds raise blood sugar levels.

Monitoring Glucose level Regular / frequent monitoring required

Travel


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Before a long trip, medical examination is

necessary to make sure diabetes is in good

control.

Packing Tips


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g p

Whether traveling by car, plane, boat, bike, or foot,

the patient will want keep this carry-on bag with

him at all times. Pack this bag with:

All the insulin and syringes needed for the trip

blood and urine testing supplies (include extra

batteries for the glucose meter)

All Oral medications (an extra supply is a goodidea)


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Other medications or medical supplies, such as

glucagon, antidiarrhea medication, antibiotic

ointment, antiemetic drugs

ID and Diabetes identity card

A well-wrapped, air-tight snack pack of crackers

or cheese, peanut butter, fruit, a juice box, and

some form of sugar (hard candy or glucose tablets)to treat low blood glucose.

Insulin During Travel


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g

Insulin stored in very hot or very cold temperature

may lose strength. Dont store insulin in the glove

compartment or trunk of the car

Insulin used in India are of the strength 40 and 100

I.U.

In foreign countries, insulin may come as I.U.40

or I.u.80. If the patient needs to use these insulin,one must buy new syringes to match the new

insulin to avoid mistake in the insulin dose.

Crossing Time Zones


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g

If one takes insulin shots and will be crossing thetime zones, remember:

Eastward travel means a shorter day, less insulin

may be needed. Westward travel means a longer day, so more

insulin may be needed.

To keep track of shots and meals through

changing time zones, advice the patient to keep hiswatch on his home time zone until the morningafter he arrives.

After Arrival


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f

After a long flight, it is advisable to take it easyfor a few days. Test the blood sugar often.

If one takes insulin, plan the activities so that one

can adjust insulin dose and meals. Ask for a list of ingredients for unfamiliar foods.

Some foods may upset the stomach and hurt thediabetes control.

Always advice to wear comfortable shoes and

4e0325420b8bbe4f12e8cd3f Hakkunamatata 1308830281599 Diabetes

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