T McD Kluyts 1

GUIDELINES FOR THE FOLLOW-UP OF DIABETES

MELLITUS TYPE 2 PATIENTS

byT McD Kluyts

University of Pretoria

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PRE-TEST List the target organs in

DM2

Indicate the main reasons for routine urinalysis

Indicate the principle lifestyle modification measures that should be employed in DM2.

CNS including autonomic system, Eyes, Kidney, C-V system

Proteinuria, Ketonuria, Occult infection

Diet, exercise, weight loss, addiction management.

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CRITERIA FOR THE DIAGNOSIS OF

DIABETES MELLITUS

Fasting plasma glucose 7.0 mmol/l. or

Symptoms of diabetes plus:

casual plasma glucose concentration 11.1 mmol/l.1

or2-h PG 11.1 mmol/l during an OGTT.

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Diabetes Mellitus Type 2

Previously NIDDM, Adult type DM, type 2 DM

DM 2 • Not insulin dependent for survival• Age 30+ at diagnosis• Usually obese• Few classic symptoms• Ketoacidosis rare

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The following measures are directed towards :

Glycaemic control and

Prevention of complications

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SUBJECTIVECompliance

ComplicationsPatients questions

OBJECTIVEExaminations

Sideroom proceduresSpecial investigations

MONTHLY FOLLOW-UP

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SUBJECTIVE

Compliance:

•Check the patients medicines

•Discuss the taking of medicines

•Establish supervision and

•monitor bloodglucose, diet and exercise records

SUBJECTIVE

Complications:Ask about: Vision Feet Infections Pains and Sensations

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SUBJECTIVE

Questions from the Patient:

• Encourage patient to talk and to ask questions

• Re-affirm treatment schedule

• Explore family situation

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OBJECTIVE

Physical examination:• Pulse, bloodpressure, temperature,

respiratory rate.• Eyes: Cataracts and vision• CVS: Heart and peripheral circulation• CNS: Muscle strength, reflexes,

sensation, proprioception• BMI

OBJECTIVEObjective

Sideroom procedures:•Blood glucose•Urine Labstix•Urine microscopy

Special investigations:

•Never routinely, only as and when indicated by examination

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OBJECTIVE

Urine: • glucose and ketones are

important   Blood glucose:

• measure with glucometer Foot examination:

• skin,circulation, shoes Look at home monitoring chart

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Three- to six monthly :

As monthly + lab tests:

• HbA1c – measurement• Urine for proteinuria• Snellen test, visual fields• ECG• Lipid profile• Feet examination

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ANNUALLY

Monthly examination + Lab tests Neurological status Cerebral function Micro-circulation Lipid profile Micro-albuminuria ECG Fundoscopy

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KEY TESTS

TEST OR EXAM FREQUENCY

Glycated Hb 2x per year

Fundoscopy 1x per year

Foot exam Quaterly

Lipid profile 1-2 yearly

S-createnine Yearly

Microalbuminuria Yearly

Blood pressure Each visit

BMI Each visit

ECG 2x per year

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PATIENT EDUCATION

This is the cornerstone of effective diabetes care.

Sufficient time and resources should be made available in order to do this effectively.

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RECORD DEGREE OF CONTROL

Patients with poor or brittle control, should be seen at least once a month.

Well controlled diabetics can be seen at longer intervals eg 2-4 monthly.

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Criteria for intervention

CRITERIA OPTIMAL ACCEPTABLE ACTION NEEDED

BLOOD GLUCOSE

FASTING 4-6 6-8 >8

POST-PRANDIAL

4-8 8-10 >10

GLYCATED Hb %

<7 7-8 >8

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WEIGHT

As obesity virtually always accompanies type 2 diabetes, it should be targeted in its own right.

A weight loss of 5-10% should be the initial aim. It has been shown to improve insulin resistance and all its associated parameters

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Weight

Body Mass Index (BMI) = Mass in kg/Length in meter2

Optimal Acceptable

Action needed

BMI <25 20 - 26 >27

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WEIGHTEvidence demonstrates

that:• structured, intensive

lifestyle programs

involving participant education,

• reduced dietary fat and energy intake,

• regular physical activity• and frequent participant

contact are necessary to produce long-term weight loss of >5% of starting weight.

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GLUCOSE TREATMENT

RECOMMENDATIONS FOR DM2 Always provide or refer for dietary and

lifestyle advice at diagnosis If random glucose values > 15 mmol/L ~

consider starting oral agents together with lifestyle modification from the start

If overweight (BMI > 25) ~ consider metformin unless contra-indicated

If postprandial glucose values constitute the major abnormality or sulphonylureas contra-indicated (e.g. renal failure) ~ acarbose or meglitinides may be considered

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GLUCOSE TREATMENT (Continued)

If insulin resistance is the major abnormality , metformin should be considered as first line or add on therapy. If metformin is contra-indicated or poorly tolerated (e.g. raised serum creatinine or major cardio-pulmonary risks),then thiazolidinediones may be used.

Always start with monotherapy and titrate dosage to maximum over 1-3 months

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GLUCOSE TREATMENT (Continued)

If goals still not reached, add second agent (lowest dose, titrate when necessary).

If goals still not attained despite good

compliance and absence of major stressors such as infection, consider insulin therapy

In such cases, insulin therapy may be initiated as intermediate or long-acting insulin at bedtime (titrate against pre-breakfast reading), with or without oral agents. If possible, self glucose monitoring should be done in all patients on insulin.

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GLUCOSE TREATMENT (Continued)

Initial insulin dose is 0.2-0.3 U/kg

If more than 30 U per day are required or clinical judgment indicates, use twice daily biphasic insulin (2/3 intermediate, 1/3 short acting). Consider referral.

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BLOOD PRESSURE GOALS

SYSTOLIC <130

DIASTOLIC <80

With Proteinuria

SYSTOLIC <120

DIASTOLIC <70

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BLOOD PRESSURE TREATMENT

Angiotensin converting enzyme (ACE) inhibitor based

Low dose diuretics, eg hydrochlorothiazide (HCTZ) 12.5mg or Indapamide 1.25 -2.5 mg/day may be appropriate first line agents

Most patients will require at least 2

agents

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BLOOD PRESSURE (continued)

ACE inhibitors or angiotensin II receptor antagonists are indicated in the presence of micro- or macroalbuminuria

In patients over age 55 yrs with or without hypertension, but with another cardiovascular risk factor, an ACE inhibitor should be considered to reduce the risk of cardiovascular events.

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LIPID GOALS

TotalCholesterol <5.0

LDL <3.0

HDL >1.2

Triglycerides <1.5

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LIPID TREATMENT

LDL-cholesterol above 3 mmol/l ~ consider a statin as therapy

Triglycerides above 1.5 mmol/l ~ check for secondary causes, consider using a fibrate

LDL-cholesterol and triglycerides elevated ~ statin and fibrate if persistant

Fibrates contra-indicted with impaired renal function ~ refer.

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ASPIRIN RECOMMENDATIONS

As a primary prevention strategy in high-risk men and women with type 1 or type 2 diabetes including diabetic subjects with the following:

• a family history of coronary heart disease, • cigarette smoking, • hypertension, • obesity, • albuminuria (micro or macro), • age >30 years or • dyslipidaemia.

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ASPIRIN RECOMMENDATIONS(continued)

Use aspirin therapy as a secondary prevention strategy in individuals who have evidence of large vessel disease, eg • a history of myocardial infarction, • vascular bypass procedure,• stroke or transient ischaemic attack,• peripheral vascular disease,• claudication and/or • angina.

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ASPIRIN RECOMMENDATIONS(continued)

Use 150-300 mg aspirin per day (enteric coated if possible)

People with aspirin allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease are not candidates for aspirin therapy.

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ASPIRIN RECOMMENDATIONS (continued)

Aspirin therapy should not be recommended for patients under the age of 21 years because of the increased risk of Reye’s syndrome

associated with aspirin use in this population

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Exercise Record

The exercise parameters are as follow:• To reach a pulse rate of max – 20%

for age and sex and maintain for 20 minutes at least

• 3 times per week at least• Walking or running or cycling or

swimming or any combination thereof

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Weight and diet record

This should include weekly weight measurements

Dietary notes where indicated to explain weight changes

Doctor/dietician’s comments

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Glucose control record

The ideal would be twice daily blood-glucose recording: morning and evening. This might be impossible for unsubsidised patients

to attain, and daily urine testing will have to suffice as a minimum requirement.

Blood glucose should be done fasting in the mornings, and 2 hours postprandial at night.

Urine glucose should be measured fasting in the morning 1 hour after emptying the overnight bladder, and/or 15 minutes after emptying the 2 hour postprandial bladder in the evening.

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SCENARIO 1

A 24 year old male student presents to you with a history of Diabetes Mellitus 2 for 2 years, complicated by systolic hypertension. He tells the story that he suddenly became ill while attending a rugby training camp 2 years ago. He has never before been ill in his life except for a chronic seasonal rhinitis for which he has been taking numerous treatment regimes in the past.

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SCENARIO 1 (Continued)

At the moment he is taking Glucophage and Diamicron one each twice daily

On examination he is well built, weighs 110kg and is 1,8m tall

His BP is 128/84

His father’s sister is a diabetic

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SCENARIO 1 (Continued)

He is still participating in sport, but had to retire from provincial level participation since the start of his illness

He is complaining of tiring easily His random blood glucose today is

8.6mmol/l He is not keeping record of his exercise

efforts or his diet

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SOLVING THE PROBLEM

Main problem Additional factors

Help seeking Education

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SCENARIO 2

A 38 year old lady with Diabetes Mellitus 2 on insulin replacement therapy visits you for a renewal of her medication

She has been on Humoloc Mix 25 but when she went to the chemist last month for a repeat, she was told that it was no longer “on code”

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SCENARIO 2 (Cont)

She was not given any instruction on how to use it

She is using 46 Units nocte On examination her blood pressure is

160/90; blood glucose = 18,6; she has 1+ oedema of the legs; her BMI = 31,5

She is also taking Coversyl 4mg daily with Natrilix 2,5mg daily for her blood pressure

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SOLVING THE PROBLEM

Main problem Additional factors

Help seeking Education

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ACKNOWLEDGEMENT

Parts adapted from SEMDSA guidelines 2002 (Prof Paul Rheeder)

ADA clinical practice recommendations 2002. Diabetes Care 2002; 25(1) supl 1

WEBSITE:

http://www.novonordisk.com

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Thanks !