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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 • • • • Lifestyle : diet and exercise Glycemic control Treat hypertension Treat Lipids TARGETS • • • • • • • 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 • • • • • • • 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 • • • • • 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 • • • • 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 • • • • • • 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 • • • • 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 !