Diabetes update. Content Diagnostic criteria Nutritional management Oral Hypoglycaemic agents...
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Transcript of Diabetes update. Content Diagnostic criteria Nutritional management Oral Hypoglycaemic agents...
Diabetes update
Content
• Diagnostic criteria
• Nutritional management
• Oral Hypoglycaemic agents
• Insulin in Type 2 diabetes
• Hypoglycaemia
• Foot care
Diagnosis• Symptoms + 1 abnormal blood
glucose valueor
• 2 abnormal blood glucose values
(not using a home blood glucose monitoring kit)
Symptoms
• Polyuria• Polydipsia/nocturia• Tiredness• Weight loss (Type 1)• Blurred vision• Ketones in urine (Type 1)• Dehydration
Diagnostic blood glucose values
• FBG >= 7 mmol/l
• RBG >= 11.1mmol/l
• IFG >6mmol/l and <7 mmol/l
• OGTT
• IGT 2 hour BG >7.8 mmol/l and <11.1mmol/l
Nutritional management
Dietary recommendations for diabetes
• Eat starchy foods regularly
• Eat more fruit and vegetables
• Reduce animal or saturated fat
• Cut down on sugar
• Reduce salt
Balancing food choices
Eat starchy foods regularly
• Bread• Potatoes• Rice• Pasta• Cereals• Chapatis
Eat more fruit and vegetables
• Fresh• Frozen• Tinned• Dried• Juice
Reduce animal or saturated fat intake
• Use low fat milk
• Use low fat spread
instead of butter
• Use oil high in
unsaturated fat, eg
olive oil, rapeseed oil
Use less fat in cooking
• Grill
• Dry-roast
• Microwave
• Steam
Choose the right sort of fat
SATURATED
• Full fat dairy produce (eg cheese, butter, full cream milk)
• Pies
• Biscuits
• Savoury snacks
• Lard
• Hard vegetable fat
MONO- UNSATURATED
• Olive oil
• Rapeseed oil
• Groundnut oil
POLY- UNSATURATED
• Sunflower oil (products)
• Oily fish
Cut down on sugary foods
• Not a sugar free diet
• Cut out sweets• Cut out sugary
drinks
Choose low sugar products
• Use diet or low calorie, sugar free drinks
Intense sweeteners
• Tablet• Liquid• Granulated
Avoid diabetic products
• Cost
• Laxative effects
• Focus on ‘sugar free’
• Still raise blood glucose levels
• Still contain same calories
Reduce salt intake• Cut down on
added salt• Use alternative
seasonings• Look out for
reduced/low sodium foods, eg bread
• Avoid salt substitutes
Eat regular meals based on carbohydrate:
Breakfast
Lunch or snack meal
Main meal
Drink alcohol in moderation1 unit of alcohol =
1/2 pint beer or lager or
cider
1 standard glass of
wine
1 pub measure of
sherry, vermouth, aperitif or
liqueur
1 pub measure of
spirit, eg gin, vodka or whisky
Oral agents
Oral agents
• Sulphonylureas
• Biguanides
• Thiazolidinediones (the glitazones)
• Post-prandial glucose regulators
• Acarbose
Sulphonylureas
• Augment insulin secretion from beta cells, so must be some activity remaining.
• Hypoglycaemia may occur • Glipizide and gliclazide most
commonly used
• Can be used in combination
Sulphonylureas…..side effects
• Can cause weight gain, metformin 1st choice in obese
• Care in renal or hepatic failure
• Contraindicated in breast feeding and change to insulin if pregnant or other severe illnesses.
Sulphonylureas…..more side effects
• Hypoglycaemia• weight gain• GI disturbances• Liver disturbances, cholestatic
jaundice, hepatitis• Hypersensitivity reactions
including photosensitivity• Blood Disorders.
Biguanides (well….metformin!)
• Inhibits gluconeogenesis
• Increases peripheral utilisation of glucose
• (Reduces appetite??)
• Dose
Metformin……..
• Drug of choice in obese Type 2 patients
• Not associated with weight gain
• Is effective as monotherapy as well as in combination with an SU, TZD, nateglinide or insulin
• Used alone it can reduce FBG by 22 - 26%
• Used alone it can reduce HbA1c by 12 - 17%
• UKPDS demonstrated a reduction in macrovascular complications and mortality with the use of metformin in obese Type 2 DM
Slide No. 4 • •
UKPDS 34: relative risk reduction withmetformin vs conventional treatment
Rela
tive
ris
k re
duct
ion
for
metfo
rmin
tre
atm
ent
(%
)
Metformin……..contraindications
• Renal failure (local consensus at serum creatinine >150mol/L)
• Acute renal failure may lead to lactic
acidosis
• Hepatic impairment
• Alcohol abuse
• Significant cardiac disease
• Pregnancy and lactation
• Age not proven to be an independent risk factor for metformin use.
Metformin………the side-effects
• Dose requires titration to minimise GI side-effects
• 20 - 30% of patients experience abdominal discomfort, nausea, anorexia or a metallic taste
• Significant proportion of these patients go on to tolerate metformin well
• Evidence of malabsorption of vitamin B12
although very rarely clinically manifested.
Thiazolidinediones (TZDs, the glitazones)
Mode of action
• These act by activating PPARγ (a nuclear receptor responsible for activating insulin-sensitive genes) and hence reducing insulin resistance and increasing the uptake of glucose by the tissues.
• Rosiglitazone (Avandia)
Prandial Glucose Regulators(the meglitinides)
The Meglitinides……...
• Repaglinide (Novonorm™) and Nateglinide (Starlix™)
• Both stimulate insulin release but are chemically distinct and have different mechanisms of action
• Both compounds have very short actions which deal effectively with postprandial glycaemic peaks, and are omitted if a meal is missed
Mode of action…….
Repaglinide…….
Stimulates the same secretory mechanism as SUs, but does not promote insulin release in the absence of glucose.
Licensed for monotherapy and combination
Nateglinide……
Works by restoring early phase insulin release within the cells, and has a synergistic action with metformin.
Licensed for combination with metformin only.
Acarbose
– alpha glucosidase inhibitor
– delay digestion and absorption of starch and sucrose
– use on own or as adjunct
– cause GI upset, flatulence common
– cannot cause hypoglycaemia
Insulin Management
Those requiring insulin
• Type 1 patients• Type 2 – deteriorating control• Prevention of progression of
complications• Poor tolerance of OHAs• Acute situations• Pregnancy
Employment issues
• Group II licence• Services• Police• Fire service• Diving/deep sea work• High work/scaffolding• Planes/boats/trains
Hypoglycaemia
Hypoglycaemia
• Blood glucose below 3.0 mmol/L
• Hypoglycaemic unawareness is a major risk
factor
• Shaky, sweaty, tingling in lips, heart pounding,
irritability and confusion
• Hypos and alcohol
• Hypos in Type 2 Diabetes
Treatment of Severe Hypoglycaemia
• Oral glucose - Lucozade, Hypostop followed by more complex CHO - bread
• IV dextrose 50%• IV, IM S/C Glucagon 1 mg
Complications of severe hypoglycaemia
• Transient hemiplegia• Dysphasia• Pulmonary oedema• Cerebral oedema• Permanent brain damage
‘The diabetic foot’
• Neuropathy
• Ischaemia
• Combination of neuropathy and ischaemia
Ischaemia
• Reduced/absent pulses
• Dry shiny atrophic skin
• Intermittent claudication
• Nocturnal cramps
• Rest pain
Neuropathy
• Nerve damage
• Reduced sensation
• Ulceration
• Not noticed by the patient
Signs of neuropathy
• Lack of sensation
• Numbness/parasthaesia
• Painful neuropathy
• Foot deformity
• Bounding pulses
• Venous distension
• Warm pink skin
Ischaemia and Neuropathy
• Co-exist in diabetic foot• Ulceration• Infection• Gangrene• Amputation
Foot ulceration – risk factors
• History of previous ulceration• PVD• Neuropathy• Foot deformity• Nephropathy
Foot ulceration – risk factors
• Smoking• Footwear• Self treatment• Poor sight• Living alone• Immobility• Male sex
Clinical features of ulceration:
Neuroischaemia has features of bothNEUROPATHIC
ISCHAEMIC
PAIN PAINLESS PAINFUL
CALLOUS YES NO
OUTLINE CIRCULAR IRREGULAR
GRANULATION HEALTHY UNHEALTHY
SITES METS/APEX/ID
HEELS/BORDER DORSUM
Patient education
• Daily foot check• Avoid walking barefoot• Moisturise dry skin• No self-treating• Avoid direct heat• Suitable footwear• If in doubt, seek professional help
Prevention
• Perform a simple foot assessment• Check bare feet• Determine risk• Refer urgently to podiatrist or doctor if:
UlcerationInfectionNecrosis