Download Management of diabetes

Management of Diabetes
National Guidelines
Dept of Health
SEMDSA
Sep 2005
CLASSIFICATION
• TYPE 1 Bcell destruction
• TYPE 2 Insulin Resistance
• IMPAIRED GLUCOSE REGULATION
{impaired fasting glucose, impaired tolerance}
• GESTATIONAL
• OTHER
DIAGNOSIS DIABETES
• SYMPTOMS PLUS random gluc >11.1 mmol/l
OR fasting glucose > 7.0 mmol/l
{ polyuria, polydipsia, weight loss, pruritis}
OR
• Fasting gluc > 7.0 mmol/l
• 2 hr gluc > 11.1 mmol/l
{on two separate occasions, if asymptomatic }
{ venous plasma samples }
Impaired glucose handling
• Impaired Fasting Glucose
6.1- 6.9 mmol/l
• Impaired Glucose Tolerance
7.8-11.0 mmol/l
Indications for hospital level care
Inpatient referral
• Diabetic keto-acidosis
• Hyperosmolar states
• Hypoglycemia with neuroglycopenia
• Recurrent or persistent poor glycemic
control
• Severe chronic complications of diabetes
• Initiation of intensive insulin regimens
Indications for hospital level care
Hospital OPD referrals
• All type 1 diabetics
• Chronic complications for review
• Persistent hyperglycemia
• All newly diagnosed diabetics
• All diabetic patients for annual review
General Management
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Lifestyle : diet and exercise
Glycemic control
Treat hypertension
Treat Lipids
TARGETS
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Fasting gluc :4-6
Postprandial gluc : 6-8
HbA1c < 7
BP < 130/80
TC < 5
BMI < 25-30
LDL < 2.6
5-10% wt reduction
TG < 1.5
HDL > 1.2
MANAGEMENT
• Diabetes education essential
PLEASE LIAISE WITH YOUR DM NURSE
• Self monitoring
Type 1 : when adjusting doses – 4X/d
maintenance –2X/d
Type 2 : As above?
DRUGS AND INSULIN
• ALGORITHMS PP 11-15 IN HANDBOOK
Insulin Regimens
• Once daily insulin:
Protaphane nocte + OAA’s
0.1 u/kg
• Twice daily insulin: 2/3
1/3
Actraphane B.D
• Basal Bolus: 20 20 20 40 %
Actrapid at mealtimes
Protaphane at 22H00
Total daily dose of insulin
• Type 1 :
0.4-0.6U/kg/d
• Type 2 :
0.2-0.3U/kg/d
Oral Hypoglycemic drugs
• Gliclazide 40 bd to 160mg bd
• Metformin 500 bd to 1g tds
[ obese pts, no major complications and
creat< 150]
Insulin in type 2 diabetes
• Poor control with oral drugs
• Severe infections, major surgery and any
hyperglycemic emergency
• Consider early use for thin patients with
very poor control
• Severe complications, Creat > 150
HYPO’S
• Symptoms : sweating, headache, confusion
etc
• Gluc < 3mmol/l
• Causes : missed meal, exercise, liver disease, renal
impairment, adrenal, dose
• Use sugar plus slow release carbs, 50 ml 50%
dextrose, IVI 5% dextrose, glucagon
• Admit for obs. SU needs longer obs period
• If poor response to therapy, look for other cause of
mental state
HYPERLIPIDEMIA
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Restrict fats to < 30 % /d
As low monosat fat as possible
Chol < 300 mg/d
Wt loss 5-10 %
Exercise 30 min X 5d per week
High fibre, mod alcohol
Control Diabetes
• Statin [ LDL> 2.6 after lifestyle mod, or
established atherosclerotic disease]
• Fibrate for TG elevation after gluc controlled
• Exclude secondary causes : hypothyroidism,
nephrotic syndrome and alcohol
HYPERTENSION
• BP 130/80
• Lifestyle first, except if bp> 180/110, endorgan damage[ then start drugs immed]
• Drugs
HCTZ[ Lasix,if creat>150], AceI[esp
nephropathy], CCB
2ND line : a blocker, b blocker[IHD]
ASPIRIN
• All patients for secondary prevention
• Consider if other risk factors for heart
disease, age > 30
• Age < 21 possibility of Reyes Syndrome
• 75-300 mg
• Check contra indications
DKA
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Gluc > 20
U-dipstix 2+ Ketones
pH < 7.35
SB < 15
Underlying cause? Urine,CXR,ECG
U&E
Fluid
• IVI n/saline
2-3 l over 4 hrs
2l over next 8 hrs
then 1l every 8 hrs
• Colloid if systolic < 100
• ½ n/saline if Na > 155
• Change to dextrose saline when gluc <14
Insulin
• 100 u/100ml n/saline infusion
• +/- 5u/hr
• When gluc < 14, halve rate [2.5u/hr], start
5% dextrose/saline
• Continue until ketones negative
K
• Omit, initially, if s-K > 6
• 20mmol/l
• Re-check K levels 2hrly
Bicarb
• For pH< 7, K>4
• 100mls 8%bicarb with 20mmol KCl over ½
hour
• Rpt pH after 30 min
• Problems with Na load, K shifts,
intracerebral acidosis
Other
• CVP
• Antibiotics
• Convert to regular insulin when ketone free
and eating normally
Hyperosmolar state
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Gluc very high [often >50]
S-osm > 320
Profound dehydration
Mild ketosis, normal pH, older patient
Management
• As for DKA
• Will need more fluid
• CVP monitoring very important
Elective surgery
• Type 1
• Admit patient at least1day prior to surgerybloods, CXR, ECG, correct K
• Schedule for first on slate in morning
• Postpone surgery if >8 [major surg]
>15[minor surg]
• Omit breakfast and morning insulin
• Start GKI infusion at 100ml/hr
• 500 ml 10%Dextrose water + 15U actrapid
+10 mmol KCl
• Check glucose hrly in op, 2 hrly post op
• Aim for gluc 6-11mmol/l
• Check gluc and U & E in recovery room
• If gluc> 11, then mix new bag with 20u actrapid
plus K in 10% d/w
• If gluc<6, then 10u actrapid in new bag
• If K >5.5, then drop KCl from bag
• If K< 4, then add 20mmol KCl to new bag
• Continue infusion till patient eating normally
• If infusion lasts for several days, then use dextrose
saline and ½ insulin dose plus KCL.
• Diet control: if fasting gluc< 7: treat as for
non-diabetic, if gluc>7: use GKI
• Oral drugs: stop metformin 3d prior to
surgery and withold for 3d after,esp if
contrast given. If fasting gluc<7treat as nondiab for minor surgery. The rest: GKI
• Emergency surg: try to delay if ketosis
present for 4-6 hrs[see DKA management
above], then GKI
Sick Days
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Don’t stop usual insulin
Drink plenty of fluids
Gluc 10-14 : add 10% TDD before meal
Gluc 14.1-22: add 20% TDD before meal
Gluc >22 : add 30% TDD before meal
If nauseous, use unsweetened and small
amount of sweetened drinks
• Consult doc urgently if:
Gluc over 22mmol/l
Gluc not coming down
Vomiting/unable to eat for any reason
Ketonuria
Diabetic foot
• Assess vascular, neuropathy and skin/arch
• Risk categories
0 No sensory neuropathy
1 Sensory neuropathy
2 SN plus deformities/features of PVD
3 Previous ulceration or amputation
• Re-vascularization may save the foot from
amputation
• Annexure 5, page 50 for general measures
Retinopathy
Risk groups
• Uncontrolled DM
• Type 1 from early age, puberty
• Long duration of diabetes
• Pregnancy with pre-existing diabetes
• Associated hypertension
Normal retina
Macula
Optic disc
Non-proliferative diabetic
retinopathy
Hard exudates
Severe non-proliferative
retinopathy
Haemorrhage
Cotton wool
spot
Proliferative retinopathy
New vessels
Pre-retinal
haemorrhage
Advanced proliferative
retinopathy
Scar tissue
Early macular oedema
Referrals
Urgent
• All neovascularization
• Decrease in visual acuity- mod-severe
• Preretinal haemorrhage
Soon
• Mod-severe non-prolif retinopathy
• Maculopathy
• Hard exudates within the vascular arcades
Routine
• All new diabetics
Nephropathy
• Incipient nephropathy
microalbuminuria [2/3 in 3 months],HPT
• Overt nephropathy
persistent dipstix proteinuria, HPT
• Renal failure
Raised creat, decreased clearance
microalbuminuria
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30-300 mg/24hr
Spot urinary Alb-creat ratio:3-30mg/mmol
Micral urine dipstix
Spot urinary alb conc : >20mg/l
Management
• Treat lipids
• Glycemic control
Change to insulin if GFR<30 or creat>150
• BP< 125/75
• Ace I: If MAlb, even if BP normal
• Restrict prot to<0.8g/kg/d
• Calcium management
• Dialysis/transplant
Neuropathy
™Diffuse
™Focal
Peripheral polyneuropathy
Proximal Amyotrophy
Autonomic neuropathy
Entrapment
mononeuritis/multiplex
Therapy: tricyclics, tegretol, gabapentin
™THE
™END
™OF
™THE
™STORY
™!