Download Diabetes Management Guidelines

Diabetes Management
Guidelines
Th i r d E d i t i o n
Ministry of Health
Government
of Fiji
1
2012
DIABETES MANAGEMENT GUIDELINES
Third EdiƟon 2012
MINISTRY OF HEALTH
Government of Fiji
2012
Disclaimer
“Theauthorsdonotwarranttheaccuracyoftheinformationcontainedintheseguidelinesanddonot
takeresponsibilityforanydeaths,loss,damageorinjurycausedbyusingtheinformationcontained
herein.
Whileeveryefforthasbeenmadetoensurethattheinformationcontainedintheseguidelinesiscorrect
andinaccordancewithcurrentevidenceͲbasedclinicalpractice,thedynamicnatureofmedicine
requiresthatusersexerciseinallcasesindependentprofessionaljudgmentwhenusingthese
guidelines.”
ii
GUIDELINESFORMANAGEMENTOFDIABETES
ThirdEdition2012
ThesecondEditionwasrevisedandupdatedbyasubͲcommitteeoftheNationalMedicinesand
TherapeuticsCommittee.
TheDiabetesClinicalServicesNetworkupdatedthis(thethird)editionoftheDiabetesManagement
Guidelineswithcontributionandcommentsfrom:
DrShrishAcharya,ConsultantPhysician;HODMedicine;Chairperson,Medical&DiabetesCSNs
andallmembersoftheDiabetesandMedicalCSNs
DrJemesaTudravu,ConsultantSurgeon;MedicalSuperintendentCWMHospital;ChairpersonofSurgical
CSNandallmembersoftheSurgicalCSN
DrJosephKado,ConsultantPaediatrician;ChairpersonPaediatricCSNandallmembersofthePaediatric
CSN
DrJamesFong,ConsultantObstetrician;ChairpersonObstetricsCSNandallmembersoftheObstetric
andGynaecologyCSN
DrLuisaCikamatana,ConsultantOphthalmologist;MedicalSuperintendentLautokaHospital;
ChairpersonOphthalmologyCSNandallmembersoftheOphthalmologyCSN
MsAnaisiDelai,NationalAdviserNutrition&Dietetics;ChairpersonoftheNutritionandDieteticsCSN
andallmembersoftheNutritionandDieteticsCSN
TheChairpersonandmembersoftheMentalHealthCSN
TheChairpersonandmembersofthePhysiotherapyCSN
TheChairpersonandmembersofthePharmacyCSN
TheChairpersonandmembersoftheLaboratoryCSN
DrIsimeliTukana,NationalAdviserNCDsandmembersoftheNCD/WellnessUnit,MOH.
DrM.Cornelius,TechnicalFacilitator,Diabetes,FijiHealthSectorSupportProgram.
SpecialthankstoDrGyaneshwarRao,ConsultantPhysicianCWMHforhiscontinuoussupportduring
thisprocess.
ContributionsandcommentswerewelcomedandgratefullyreceivedfromDivisionalandSubͲ
DivisionalOfficers.SecretariatsupportwasprovidedbyNationalProjectOfficer,NonͲCommunicable
Diseases,MinistryofHealthandFijiHealthSectorSupportProgram.
iii
PREFACE
TherewasaneedtoupdatetheDiabetesManagementGuidelinesinthelightofrecentdevelopments
andthepreviousguidelinesbeingseven(7)yearsold.TheprevalenceofDiabeteshasbeenonthe
increaseinadultsinFiji(from10%in1980to16%in2002),hencetheaddedreasontomakethe
guidelinesmorecurrent,standardized,detailedanduserͲfriendlyandavailabletoallhealthpractitioners
atallhealthfacilitiesincludingtheprivatesector.
TherevisedGuidelineshavebeenendorsedbytheDiabetesClinicalServicesNetworkswhichcomprises
ofrepresentativesfromalltheotherelevenclinicalservicesnetworks.
TheplanistodistributetheguidelinestoallhealthfacilitiesandalsouseitasatooltocreatecaseͲ
discussionespeciallyfordifficulttomanagepatients.ItwillalsohelpdeͲcentralizebasicDiabetes
managementtoruralandremoteareasandreducereferralstobasehospitalstodifficulttomanage,
seriousandcomplicatedcasesonly.Theguidelinesareexpectedtocreateanetworkamongstallclinical
practitionersforbettermanagementandenhancedcommunication.
ThesubͲcommitteehastakenprideinpresentingtheguidelinesinaverysimpleandcomprehensible
mannertakingintoaccountthedrugsthatarereadilyavailableinFiji.Allrecommendeddrugtherapies
areevidence–basedorhaveuniversallyacceptedstandards.
Theseguidelinesareproducedforallpracticinghealthprofessionalfortheiruseinmanagingpeople
withdiabetesintheireverydayprovisionofcare.
Thegoalistohelppeoplewithdiabetescontroltheirconditions,avoidordelaycomplicationswhile
enjoyingabetterqualityoflife,beingabletocontributepositivelytothecommunity/nationandprevent
themdyingprematurely.
IherebyacknowledgeAusAIDsupportfortheproductionoftheseguidelinesthroughtheFijiHealth
SectorSupportProgram.
………………………………………
DrMeciuselaTuicakau
DeputySecretaryHospitalServices
Chairperson,NationalMedicinesandTherapeuticsCommittee
MinistryofHealth
iv
DIABETESMANAGEMENTGUIDELINES
TableofContents
No
Topic
Page
1
2
NationalNCDProgram
1
2
2
3
3
4
5
6
7
8
9
10
11
Introduction
2.1Recognition
2.2Diagnosis
Managementofdiabetesinadults
3.1Reviewofhistory,physicalexaminationandrelevantinvestigations
3.2CategoriesandReferralrecommendations
3.3NonͲpharmacologicalintervention(SNAP)
3.4 ManagementofhyperglycemiaͲPharmacologicalintervention
3.5Generalapproachtomanagementofdiabetes
3.6Specialsituationsinthemanagementofdiabetes
Treatmentofassociatedmetabolicconditions
4.1Hypertension
4.2Hyperlipidemia
4.3AntiͲplatelettherapy
Managementofacutecomplicationsofdiabetes
5.1Hypoglycemia
5.2DiabeticKetoacidosis(DKA)
5.3HyperosmolarHyperglycemicstate
Managementoflatecomplicationsofdiabetes
6.1Retinopathy
6.2Nephropathy
6.3Neuropathy
6.4Diabeticfootdisease
Targetsforcontrolindiabetes
Diabetesinchildren
Diabetesinpregnancy
References
Annexes
4
4
5
5
8
13
15
17
17
17
17
18
18
19
21
22
22
24
26
27
29
30
35
42
43
v
1.NATIONALNCDPROGRAMME
NationalNonͲCommunicableDiseases(NCD)PreventionandControlStrategicPlan2010Ͳ2014
The MOH National NCD Strategic Plan proposes intervention “from womb to tomb with a
doubleedgedsword”andmakingNCDseveryone’sbusiness.
TheGoal: Fijiwithahealthylifestylepopulation
Aim:
ImproveFiji’sNationalNCDstatusby5%in2014
Objectives:
x ReducetheprevalenceofcommonNCDriskfactorsby5%in2014
x Reducetheprevalenceofintermediateriskfactorsby5%in2014
x ReducetheprevalenceofmajorNCDsinFijiby5%in2014
x Improveearlydetectionand3M(Mouth,Muscle,Medication)managementofNCDs
in80%ofprimaryhealthcarefacilitiesinFijiby2014
x Improve3MmanagementofNCDadmissionsin80%ofSubͲdivisionalandDivisional
hospitalsinFijiby2014
GoalsoftheNationalDiabetesPlan
TheNationalcommitmenttoDiabetesistoreduceprevalenceby5%by2014andimprovethedelivery
ofDiabetesservices.Tobeabletodeliverthis,thehealthsystemneedsto:
x PromotetheHealthandWelfareofpeoplewithDiabetesandprovidesupportfortheirfamilies.
x PromoteabetterunderstandingandawarenessofDiabetesinthegeneralcommunity.
x Develop and implement innovative and cost effective ambulatory care services that
complementtheworkofotherhealthcareprofessionals.
x Developandmaintainhighstandardsofcarethrougharangeofqualityimprovementactivities.
x Conducthighqualityclinicalandeducationalresearch.
x Provideuptodateandinnovativetrainingofhealthprofessionals.
x Maintainacomprehensivedatabasetosupportalltheactivitiesofthehealthfacilitiesincluding
screening high risk persons and supporting planning and research on Diabetes care in our
community.
Theaimofthediabetesmanagementguidelinesisto:
x
x
x
x
Recognizeearly,diagnoseandmanageDiabeteseffectively.
Helpdeferordelaytheonsetofcomplications.
Managecomplicationseffectivelywiththeavailableresources.
Haveaneffectivereferralsystemforoptimuminterventionateverylevel.
(SeeAnnex3:Keyinterventionsandchecklistoftasks)
1
2.INTRODUCTION
Diabetes mellitus is defined as a metabolic disorder of multiple aetiology, characterized by chronic
hyperglycaemiawithdisturbanceofcarbohydrate,proteinandfatmetabolismresultingfromdefectsin
insulin secretion, insulin action, or both. However while insulin defects mentioned are critical
abnormalities,severalotherfactorscontributetothehyperglycaemicstate.
Themajortypesofprimarydiabetesmellitusare:
x Type1diabetes
x Type2diabetes
x Gestationaldiabetes
2.1RECOGNITION
Type1diabetesischaracterizedbyprogressivebetacelldestruction,severeinsulindeficiency,andthe
urgentneedforinsulinreplacementtherapybecauseoftheriskofketoacidosisanddeath.Patientsare
usuallylessthan30yearsbutitcanpresentinolderpatients.Theonsetofsymptomsismorerapidand
ketonesareusuallypresent.
At presentation, the patient with suspected Type 1 diabetes should be immediately assessed to
determineappropriatemanagement.Itisadvisabletoreferallsuchcasestothenearesthospitalforthe
initialmanagement.
Type 2 diabetes is common and is the predominant form of diabetes. It often goes undiagnosed for
manyyearsbecausethehyperglycaemiadevelopsgraduallyandatearlystagesofthediseaseprocessit
isoftennotsevereenoughforthepatienttonoticeanyoftheclassicsymptomsofdiabetesandindeed
mayhaveevidenceofcomplicationsatdiagnosis.
Thereareanumberoffactorsknowntobeassociatedwithahigherriskofdevelopingtype2diabetes
andanypersonwithanyofthesefactorsshouldbescreenedforthediagnosisofdiabetes.
PopulationatRiskincludes:
x
x
x
x
x
x
>30yearolds
HighRiskEthnicity
Previous history of Gestational Diabetes
Mellitus(GDM)
FamilyhistoryofDiabetesMellitus
PhysicalInactivity
MacroͲvascularDisease
HypertensionorDyslipidaemia
x
x Obesity
A person, not known to have diabetes, presenting with the following symptoms (which are typical
symptomsofdiabetes)needstohavebloodsugartestsdonetoestablishthediagnosisofdiabetes:
x
x
x
x
x
x
weightloss
polyuria
polydipsia
lethargy
pruritusvulvae
Balanitis
Conditions listed below may suggest underlying diabetes which requires confirmation with the
appropriatebloodsugarstudies:
Footsepsis,multipleabscesses,delayedwoundhealing,neuropathy,visualimpairment
2
Gestationaldiabetesisdiabetesdevelopingforthefirsttimeinpregnancy.Itspathophysiologyissimilar
toType2diabetes.Theinterpretationofbloodglucoselevelsfordiagnosisismorestringentcompared
tothatofothertypesofdiabetes.Itmaydisappearafterdeliverybutsignalsahighriskofdeveloping
diabetesinlaterlife.Henceaclosemonitoringofsuchclientsisessential.
2.2DIAGNOSISOFDIABETESMELLITUS
Afirmdiagnosisofdiabetesisbasedonbloodsugarlevels.Urinetestingisnotreliable.Capillaryblood
glucosetestingifusedshouldbeconfirmedbyvenousbloodtesting.Anovernightfastingbloodsugar
levelisoftenpreferredthoughrandombloodsugarscanbeused.Twopositiveresultsontwodifferent
daysarerecommended.Asinglepositiveresultissignificantifthereisunequivocalhyperglycaemiawith
metabolicdecompensationorisaccompaniedwithsymptomsofdiabetes.
Thediagnosisofdiabetesisbasedonthefollowingbloodresults:
VenousBloodSugar
FastingBloodSugar(FBS)
RandomBloodSugar(RBS)
Normal
<6.1mmols/l
<6.5mmol/l
ImpairedFastingGlucose
Between6.1to7.0mmol/l
ImpairedGlucoseTolerance
Between6.5to11.0mmol/l
DiabetesMellitus
>7.0mmol/l
Thevaluesabovedonotapplytopregnantmothers.
>11.0mmol/l
The HbA1c result of 6.5% or more is now considered to be useful in the initial diagnosis of diabetes,
howeveritsgreatestvalueinFijiatpresentisformonitoringthecontrolofbloodsugarlevels.
Blood glucose levels above the normal but below that, which is diagnostic of diabetes, are not to be
neglected as they constitute two very important entities called Impaired Fasting Glucose (IFG) and
Impaired Glucose tolerance (IGT), the management of which requires active lifestyle changes (SNAP
Intervention–seeunder3.2)topreventthedevelopmentofdiabeteslaterinlife.Theseindividualsmust
becloselymonitoredwithfurtherbloodglucosetestresultsin6months’time.
3
3.THEMANAGEMENTOFDIABETESINADULTS
Diabetes in adults is mainly Type 2 but Type 1 diabetes can also occur. In a person known to have
diabetesoronewhohasbeennewlydiagnosed,themanagementaspectshouldnotonlyfocusonthe
controlofbloodsugarsalonebutbeviewedasapackage.Theoveralldiabeticmanagementrequiresa
multifactorial approach to prevent the development of cardiovascular and microvascular disease. A
practicalapproachtothemanagementoftype2diabetesinadultsisconsideredbelow.
3.1CLINICALASSESSMENT
All diabetic patients require a thorough clinical assessment on initial visit, which includes a review of
history, physical examination and relevant investigations as outlined below. Any further assessment
thereafterwillbelessintensivebutwilldependontheclinicalstatusofthepatientatthatstage.
ReviewofHistory
Physicalexamination
Relevantinvestigations
Order&reviewinvestigationsasindicated
Full Blood Count: A low Hb may
indicate an underlying chronic kidney
disease
General health & interͲ Height&Weight(BMIcalculated Bloodbiochemistry:urea,electrolytes,
currentillness
creatinine, lipid profile, FBS or RBS,
HbA1c
Familyhistoryofdiabetes Pallor
UrineformicroͲalbuminuria(iftestnot
Socialhistory
Vitals: Pulse and blood pressure possible,doproteinuria)
(BP),respiration&temperature(if indicated). BP measurement
shouldincludeanyposturaldrop.
Current medications and Heartandlungexamination
historyofdrugallergy
Examinationoftheextremitiesfor
oedema, peripheral pulsation and
neuropathy
Visualacuityandfundoscopy
Capillarybloodglucose
KetonesͲifwarranted.
SeverityofSymptoms
Alertnessandhydration
4
3.2CATEGORIESANDREFERRALRECOMMENDATIONS
0
1
Category
Definition
PeopleatRiskofDiabetes
Newlydiagnosed
RecommendedAction
ManagedatHealthCentresandNursingStations
Refertothehealth centre/subdivisionalhospital
2
3
Establishedandwellcontrolled
Establishedandpoorlycontrolled*
ManagedathealthCentres/subdivisionallevel
RefertotheHubCentre/SubdivisionalHospital
4
Establishedwithcomplications
RefertotheHubCentre/divisionalHospital
5
Establishedwithcomplicationsandother RefertoDivisionalHospital
conditions/complicatedissues
*Seetablefortargetsforcontrolonpage30
Oninitialassessment,patientsshouldbescreenedforcomplications.Ifnocomplicationsexist,perform6monthly
screening.Ifcomplicationsexistthenrefertoappropriatechaptersintheguidelineformanagement.
3.3NONͲPHARMACOLOGICALINTERVENTION(LIFESTYLEMANAGEMENT)
Modificationofadverselifestylefactorsisanintegralpartinthemanagementofalltypesofdiabetesand
in the prevention of diabetes. The important factors requiring attention include smoking, nutrition,
alcoholandphysicalinactivity(SNAP).
Smoking: In patients with diabetes smoking is an independent risk factor for cardiovascular disease.
There is no safe level of smoking. Passive smoking is also detrimental. All patients who smoke and are
sufferingfromdiabetesmustbeencouragedtostopsmokingorprovidedassistancetoquitsmoking.
ImportantadvicetopeoplewantingtoQuitSmoking:
x
Tellyourfamily,friendsandcoͲworkersthatyouarequitting
Askfriendswhosmokenottosmokearoundyouorofferyouacigarette
Followthe4D’s:
o Delay
o Deepbreathing
o Drinkwater
o Dosomethingelse
Avoidalcoholandgrogwhichcanleadtosmoking
x
x
x
x
Nutrition (Diet and weight control): Type 2 diabetes is associated with obesity. Weight
management is an integral part of diabetes care. Studies have shown that weight reduction
improveshyperglycaemia.Itcanalsoassistinreducingthedoseorinstoppingtheantidiabetic
medicationsandinthecontrolofhyperlipidaemiaandbloodpressure.Therearemanywaysfor
achieving weight reduction. It can be through the individual’s diet and physical activities and
thesecanbetargetedeasily.Ahealthyrecommendeddietistobepursued.Thedietshouldbe
richinfibre,wholegrains,andlegumes;containlessthan7%saturatedfatandnotransfats.The
dietshouldalsobelimitedincaloriesandincludefoodswithlowglycaemicindex.
x
x
TheBodyMassIndexiscalculatedusingthefollowingformula:
BodyMassIndex(BMI)= weight(kg)
Heightxheight(inmeters)
¾
5
Forrisklevels–refertoAnnex1
The
following
advice
is
for
managing
diabetes
through
healthy eating:
A healthy diet will help people with diabetes control blood glucose levels and reduce the risk of
complications.Allstarchyandsugary(carbohydrate)foodsarebrokendowninthestomachto
sugar(glucose)andabsorbedintotheblood.
People with diabetes
should avoid eating too much carbohydrate foods which increase blood glucose
levels.
RelevantrecommendationsfromtheFoodandHealthGuidelinesforFiji(Appendix2)are:
x Eatavarietyoffoodsfromthe3FoodGroupsineachmeal.GoLocal!
•Chooseandpreparefoodanddrinkswithlesssalt,sugar,fatandoil.
•Stopsmoking.Ifyoutakekava&/oralcohol–Drinkresponsiblyandavoidbingedrinking.
•Eatmorelocalfruitsandvegetables.
•Bephysicallyactivetomaintainahealthyweight
Inadditiontotheabove:
x Eatingregularmeals
x AimtoeatlowGlycemicIndex(GI)foodssuchaswholemealproductsandleafyvegetables
x Trytoincludeatleast2portionsoffishperweek,ifpossible.
The diet recommended for diabetic people is the same as a healthy diet recommended for the general
population.Theproportionoffoodfromeachfoodgroupeatenoverawholedayneedstobemadeupof:
x Abouthalffromthehealthandprotectivegroup(fruitsandvegetables);
x Aboutonethirdfromtheenergygroup(starchyfoods);and
x TheremainderfromthebodyͲbuildinggroup(protein)suchasmeat,fishanddhal.
Peoplewithdiabetesalsoneedtoavoidtakingsugarandsugaryfoods.
x
Alcohol–alldiabeticpatientsmustbeawareofhighcaloricvalueofalcoholandtheeffectofexcess
consumption on body weight. If consumed, alcohol intake should be no more than two standard
drinksdaily.Thereisariskofseverehypoglycaemiaifexcessalcoholisconsumed.
The following advice is for diabetic patients who take alcohol:
Peoplewithdiabetesareadvisedtoavoidorlimitalcoholintakebecause:
•Alcoholicdrinkscontainsugarandwillcausethebloodglucoseleveltorisequickly
•Extraenergy(calories)canincreasebodyweight
•Itcaninteractwithdiabetesmedications
•Itcanmasksymptomsofhypoglycaemia
•Othermedicalconditionsmaybeworsened
Itisgoodtoadheretotherecommendedguidelinesforalcohol.
Guidelines:
Men1Ͳ2standarddrinksperday
Women1standarddrinkperday
Onestandarddrinkcontains10gofalcohol.Examplesofstandarddrinksare:
h 285millilitres(ml)fullͲstrengthbeer,or
h 375mllightbeer(averagecan)
h 100mlwine(smallglass)
h 30mlspirit(barmeasure)
AVOIDBINGEDRINKING(KEEPTO2orLESSSTANDARDDRINKSPERDAY)
6
x
Physicalinactivity:Regularphysicalactivityisimportantindiabeticpatients.Itisimportanttoget
thepatient’sviewonphysicalactivities,thecurrentactivitiespursued,theactivitiespossibleand
how to accommodate relevant activities in daily routine. Patients are to be advised to keep
themselves active in their own ways daily and if possible to pursue at least 30 minutes of
moderate intensity physical activity such as brisk walking, cycling and gardening. Patients who
havenotbeenphysicallyactivepreviouslyshouldbeadvisedtostartslowandgoslow.Thoseon
antiͲdiabetic medications, especially insulin therapy, should be advised to take some
carbohydrate intake prior to moderate intensity physical activity to avoid the risk of
hypoglycaemicattacks.
Thefollowingadviceisfordiabeticpatientswho arephysically active:
x Adoptthetypeofphysicalactivitythatyoucando
x Drinkwaterbefore,duringandafterexercise
x Donotexerciseimmediatelyaftertakinginsulin
x Bealertforsignsoflowsugarandtakeappropriatemeasuresiflowsugarconditionarises
x Beactive1Ͳ2hoursafteryouhaveeaten
x WearcomfortableandwellͲfittingshoes
x Seekadvicefromyournearesthealthworkerwheneverneeded.
Patientswithendorgandamage(complications)willneedspecializeddiet&physicalactivityplans.
x
Stress
During stress, there is an increased demand for energy mainly from the body’s stored fat and
glucose.Peopleunderstresstendtoneglectlookingafterthemselves.Theymayforgettotake
theirmedicationsorfailtomonitortheirfoodchoicesorintake.Somepeoplecopewithstressby
takingalcoholordecreasetheirphysicalactivities.
Peoplewithdiabetesshouldbecounseledto:
x
x
x
x
x
Handlestressmorepositively
Replacebadornegativethoughtswithgoodorpositiveones.
Controlthebody’sreactionstostressthrough
o Relaxationtechniques:likebreathingexercises,meditation,yoga,
o Exercisingordancing
o Listeningtocalmingmusic
Talktosomeoneandshareworries.Ithelpstoseethingsinadifferentlight.Theymaynotbereallyas
badaswethink.
Startahobby,learnnewthings!
Practicethe12S’s(refertoAnnex2forthelist)
Throughrelaxation,theydecreasethebody’sneedforenergy,consequentlydecreasingbloodglucoselevels.
7
3.4MANAGEMENTOFHYPERGLYCAEMIA Theoverallaimofglycaemicmanagementistominimizelongtermcomplicationswhileavoidingsevere
hypoglycaemicevents.Resultsofvariousrandomizedtrialsindiabeticpatientshaveshownthatcontrol
ofhyperglycaemiadelaystheonsetandslowstheprogressionofmicrovascularcomplications.However
itseffectonmacrovasculardiseaseremainsuncertain.
The first step in the control of hyperglycemia is setting an appropriate glycaemic target in each
individual.Inyoungerpatientswithnocomplicationsofdiabetesanearnormalglycaemictargetcanbe
aimedfor,whileinolderpatientswithcardiovasculardiseaseandmultiplevascularriskfactors,ahigher
glycaemictargetshouldbethegoal.Intensiveglucosecontrolinthelatterposesadverseeffectsfrom
themultipledrugsusedandtheriskofhypoglycaemia.ThiscanbedocumentedinthepersonalDiabetes
RecordBookissuedtodiabeticpatientsattendingSOPDclinics.
Activelifestyleintervention(SNAP)shouldbepursuedpriortointroducingdrugtherapyassomeType2
diabeticpatientsmayachievesatisfactoryglycaemictargetwithouttheuseofdrugs.
WhentostartPharmacologicalInterventionforhyperglycemia
x
Uncomplicatednewlydiagnoseddiabeticpatientswhoareunabletocontrolbloodsugarswith
lifestyleinterventionwithin6weeks.
Newlydiagnosedpatientswithdiabeticcomplications.
x
Thecommonlyusedglucoseloweringdrugsinthemanagementofdiabetesarediscussedbelow:
3.4.1.Biguanides
Metformin is the only drug of the biguanide group available on the Fiji Essential Medicine Formulary
(EMF). It lowers blood glucose by suppressing hepatic glucose production and increasing tissue
sensitivity to insulin. It should be considered as the first line treatment for all patients suffering from
diabetesandisthepreferreddruginobesetype2diabeticpatients.
It is cleared from the body predominantly by renal excretion. It accumulates in renal impairment and
should be used with caution in patients with serum creatinine of more than 200 umol/L or eGFR of
<45ml/min.PatientsreceivinglongͲtermmetforminshouldhaveregular(atleast6Ͳmonthly)monitoring
oftheirrenalfunction.Itsroleinpregnancyandbreastfeedingmothersisdiscussedundergestational
diabetes.
It can cause lactic acidosis in situations such as ischemic heart disease, congestive heart failure and
renal impairment. It should be stopped for 48 hours before surgery or administration of contrast
radiographyandonlyresumedonceurineoutputandrenalfunctionhavereturnedtoacceptablelevel
asstatedavove.Thereisnoriskofhypoglycaemiawhenusedalone.
Itsmajoradverseeffectsare:anorexia,nausea,abdominaldiscomfortanddiarrhoea.
Metforminisgivenorally2Ͳ3timesadayandtakenwithoraftermealstoavoidgastricintolerance.The
dosevariesfrom500mgdailytoamaximumof3g/dayindivideddoses.Mostphysicianslimitthedose
to2gramsdailybecause,athigherdoses,gastrointestinalsideeffectsaremorecommon.Itisadvisable
to begin with a smaller dose to start with and increase the dose gradually to facilitate compliance;
otherwisethedevelopmentofgastrointestinalsideeffectswillstopthepatientfromtakingthedrug.
8
3.4.2.Sulphonylureas
Two of these compounds, glibenclamide and glipizide, are available on the Fiji EMF. They act on the
pancreatic betaͲcells and induce insulin secretion. Glibenclamide is predominantly cleared by the
kidneysanditisrecommendedinyoungerpatients.Incontrast,glipizideisclearedbytheliverandthe
kidneys and it is the recommended drug in older patients and in patients with renal impairment.
Sulfonylureas are used in lean type 2 diabetic patients. They can be combined with metformin if the
diabetescontrolisinadequate.
Thesedrugsarenotrecommendedinpregnancyandforlactatingmothers.
Hypoglycaemiaisthemajoradverseeffectespeciallywhenthereissignificantrenalimpairment.Thisis
lesslikelywithshorter–actingdrugs(i.e.glipizide)butmuchmorelikelywithlongerͲactingcompounds
(i.e.glibenclamide).Glipizidecanbegivenasasingledoseupto15mg/dayorallywithmealsandintwo
divideddosesabove15mguptoamaximumof40mg/day.Thedosageofglibenclamidevariesfrom
2.5mgto20mgdailyorallywithmealsandintwodivideddosesabove10mguptoamaximumof20
mg/day.
Gliclazideisanoralhypoglycaemicdrugandisclassifiedundersulphonylureagroupofdrugs.Itisused
whendiabetesisnotcontrolledwithlifestylemodificationsorwheninsulintherapyisnotrequired.Itis
metabolizedbytheliverandiscontraindicatedinseverehepaticandrenaldysfunction.Itisavailableas
immediatereleasetablet,80mgstrength,orasaModifiedRelease(MR)formulations,30mgand60mg
strength. The initial dose is 40Ͳ80 mg daily and is adjusted according to response up to 160 mg as a
singledose;higherdosesaredividedandgivenastwicedaily.Themaximumdoseis320mgdaily.The
MRpreparationdosagevariesfrom30Ͳ120mgoncedailyatbreakfast.
Glimepirideisasulphonylureaantidiabeticmedication.Itmaybeusedaloneorwithotherantidiabetic
medications.Theusualdoseis1Ͳ2mgwithbreakfast,itisgivenoncedaily.Furtherdosageadjustments
aremadeeverytwoweeksasrequired.Themaximumdoseperdayis8mg.
GliclazideandGlimepiridearenotavailableonFijiEMFbutcanbeobtainedfromtheretailpharmacies.
3.4.3.OtherOralAntiDiabeticDrugs
Thiozolidinediones Ͳ Two commonly used drugs are Pioglitazone and Rosiglitazone, the former is
preferredbecauseofbettersideeffectprofile.Thecommonsideeffectofthesedrugsincludeoedema,
weight gain and precipitation of heart failure, hence these drugs are contraindicated in heart failure.
Risk of fracture should be considered in the long term in females treated with pioglitazone. They
increasetissuesensitivitytoinsulin.Pioglitazonecanbeusedasmonotherapybutcanbecombinedwith
dualortripletherapyincombinationwithmetformin,sulphonlyureaorinsulin.Thedoseofpioglitazone
is15Ͳ30mgasasingledose.
AlphaglucosidaseInhibitors–theseareoralglucoseloweringagentsthatinhibitalphaglucosidase
enzymesinthebrushborderofthesmallintestine.Theseenzymesconvertcomplexcarbohydrateinthe
intestinetosimplesugarsforabsorption.ThedrugavailableinthisgroupisAcarbose.Itcanbeusedas
monotherapyorcombinedwithotheroralantidiabeticmedicationsincludinginsulin.Thecommonside
effects include abdominal discomfort because of fermentation of undigested carbohydrate by colonic
bacteria.Hypoglycaemiadoesnotoccur.Itisnotrecommendedinchronicintestinaldisease,intestinal
obstructionandcirrhosis.Smallerdosesarerecommendedinrenalandhepaticdysfunction.Acarbose
9
comesas25mg,50mgand100mgtablets.Startthedosewith25mgthreetimesadayto100mgtds
asrequired.Itshouldbetakenwiththefirstbiteofameal.
ThereareotherantidiabeticmedicationswhicharenotavailableinFiji.TheseincludePeptylpeptidaseͲ
4Inhibitors,MeglitinidesandGlucagonlikePeptideͲ1Agonists(GLPͲ1).
3.4.4.Insulins
There are three insulin preparations available on the Fiji EMF and are discussed below. The usage of
thesepreparationsisdiscussedlater.
Insulin is given using conventional disposable insulin syringes. Insulin pens and preͲfilled syringes are
expensiveoptionsandareavailableonlyintheprivatesector.
Thepreferredsitesofinjectionaretheabdominalwall,thedeltoidsandthethighs.Itisrecommended
thatthesesitesberotatedregularly.
Types
CharacteristicsofavailableInsulins
OnsetofEffects
MaximumEffect
(InHours)
(InHours)
0.5
2–5
ShortͲactingsolubleinsulin
(ActrapidHM,HumulinR)
IntermediateͲacting isophane insulin 1–2.5
(ProtaphaneHM,HumulinNPH)
Biphasicisophaneinsulin
0.5Ͳ1
(Mixtard70/30)
Duration
(InHours)
6–8
4–12
16–24
2Ͳ12
16–24
ThereareothertypesandbrandsofInsulinavailableoutsideofFijiEMFsuchasthelongactingpreparations
detemirandglargine.
InsulinPens
Theseareinsulindeliverydevicesavailableinmanydifferentbrandsandmodels,mainlyforpersonal
use.Theygenerallyfallintotwo(2)groups:reusablepensanddisposablepens.
ReusableinsulinpensareloadedwithaninsulinͲfilledcartridgebeforeuseandreplacedbyanother
cartridgewhenempty.Setoffive(5)replaceablecartridgesareusuallyavailablewitheachcartridge
containingeither150or300unitsofsoluble,intermediateormixedinsulin.Needlesareavailable
separately.
Disposableinsulinpenscomefilledwithinsulinandarediscardedwhenempty.Needlesareavailable
separatelyanddisposablepensmaybeavailableinsetsoffive(5).
Thereareadvantagesanddisadvantagesofusingtheinsulinpens:
Someadvantagesarethattheyarediscreet,userfriendly,insulinispreͲfilled,peniseasilyportableand
convenientforinjectionsawayfromhome.
Somedisadvantagesarethatthepensmaybemoreexpensive,notalltypesofinsulinmaybeavailable
andtheydonotallowmixingofinsulin.
Formoreinformationrefertowww.bd.com/us/diabetes/page.aspx?cat=7001&id=7254&
www.insulinpens.com/
10
Insulinpensarenowavailableingreatmanystyles.
InsulinPumps(alsoknownascontinuoussubcutaneousinsulininfusiontherapy)
Thesearesmallcomputerizedinsulindeliverydeviceswhichcanbewornonthebeltorkeptinthe
pocketsofpatients.ThepumpsallowforacontinuousflowofrapidͲactinginsulinintothebodythrough
acatheterinsertedundertheskinoftheabdomen.Theinsulinpumpisdesignedtodeliveracontinuous
amountofinsulin,24Ͳhoursadayaccordingtoaprogrammedplanuniquetoeachpumpwearer.The
amountofinsulindeliveredcanbechangedbytheuser.Theinsulinpumpisanalternativetomultiple
dailyinjectionsforintensiveinsulintherapy(whichincludesfrequentbloodglucosemonitoringaswell).
Thepumpsalsohavethecapabilityofrecordingthehistoryofinsulindeliveryandthiscouldbe
downloadedontoacomputerforanalysis.
Inrecenttimesinsulinpumptechnologyisbeingcombinedwithcontinuousbloodglucosemonitoring
system.Whenthefeedbackloopiscomplete(insulindeliverybasedonfeedbackofthebloodglucose
level)thesystemmayfunctionasartificialpancreas.
Formoreinformationreferto:diabetes.webmd.com/insulinͲpump;
en.wikipedia.org/wiki/insulin_pump;www.medtronicͲdiabetes.com.au
Note:VerysmallnumbersofpatientsinFijiareusingtheinsulinpensandevenfewermaybeusingthe
pump.However,visitorstothecountrymaybeusingthesedevicesandmayseekyouradviceorhelp.
Insulintreatmentintype2diabetes
(i)Decidingwhentostart
x Failureoforalhypoglycaemicagents–insulintherapyshouldnotbedelayed.Earlytreatment
delayscomplicationsandpreservesbetacellfunction.
x Patientsundergoingmajorsurgery,
x Criticallyillpatients,
x Pregnancy
(ii)Administeringinsulinwithoralhypoglycaemicdrugs
x As outpatient treatment, initiate with Isophane or mixed insulin 10 units subcutaneously at
bedtimeandadjustdoseaccordingtobloodsugarlevels.
x Ifthe bloodsugarisnotcontrolledthenuseIsophaneormixedinsulin10unitssubcutaneously
twicedailywithsubsequentadjustmentofthedoseaccordingtobloodglucoselevels.
11
x
Oral hypoglycaemic agents should not be stopped with the commencement of insulin therapy
thoughadjustmentscanbemadeasrequired.
(iii)Insulinregimens
(a) MultipleͲdose(“QID”)regimen
Thisregimenismoresuitedforstabilizationofbloodsugarforinpatients.
x Solubleinsulinstartingwith5unitssubcutaneously30minutesbeforeeachmeal
AND
x Isophane8unitssubcutaneouslytwiceaday.
Insulindosesshouldbeadjustedbasedonthebloodsugarlevels.
(b) Twicedailyregimen
Thisregimencanbeusedforcontrolofbloodsugarforbothinpatientsandoutpatients.
• Mixtard insulin70/30, starting with 10 units in the morning and 5 units in the evening
subcutaneously30minutesbeforemeals.Adjustinsulindosetocontrolbloodsugars.
Ifmixedinsulinpreparationisunavailablethenuse:
Isophaneinsulin10unitsinthemorningand5unitsintheeveningsubcutaneously30minutesbeforemeal.
Dosesareadjustedtocontrolthebloodsugarlevels.
Inprinciple,twoͲthirdsoftheinsulindoseshouldbeadministeredinthemorningandonethirdinthe
evening.However,insulindosesshouldbeadjustedbasedonthebloodsugarlevelsandincrementsof
5unitsperdosearerecommended.
Ifbloodsugarlevelremainsuncontrolledthencontactthemedicalregistraratyourdivisionalhospital.
*Forbothinsulinregimen,extrasolubleinsulin5unitssubcutaneouslycanbegivenifbloodsugarsare
notcontrolled.
12
3.5GENERALAPPROACHTOTHEMANAGEMENTOFDIABETES
ThegeneralapproachtothemanagementofdiabetesisoutlinedbelowinFigure1.
Allpatientswithtype1diabetesbesideslifestylemodifications(SNAP)requireinsulintherapy.Adultscan
be managed as an outpatient. (Note: children diagnosed with Type 1 diabetes should be referred to a
specialistpaediatricunitforfullassessmentandthemanagementisdiscussedinsectionunderDiabetes
inChildren).
For all patients with type 2 diabetes, NonͲPharmacological (SNAP) intervention is
essential.Thisapproachcanproducegoodglucosecontrol.Drugtherapyshouldonlybe
consideredifbloodsugarlevelsremainuncontrolledafter6weeksoflifestylemodifications.
The decision to commence glucose lowering medications is based on the degree of
hyperglycaemiaandthepresenceorabsenceofsymptoms.
In general, the use of oral glucose medications should be considered if despite SNAP
interventionthefastingglucoselevelsareabove7mmol/Land/orHbA1cis>7.0%.The
figurebelowshowsthetargetstobeachievedthatensuesgooddiabeticcontrol.
Aimfor:
Fasting
4Ͳ 6mmol/l
Bloodglucosecontroltargets Random
5Ͳ 9mmol/l
forpersonswithType2
7%
Diabetes
HbA1c
NOTE:Asdiscussedabovetheglycaemictargetforolderpatientswithcardiovasculardisease
andmultiplevascularriskfactorswarrantslevelshigherthanthatmentionedabove(8Ͳ10mmol/l)
Metforminisnowgenerallyconsideredtobefirstlinetreatmentunlesscontraindicated.A
sulphonylureagroupofagentlikeglipizideorglibenclamideisaddedlaterifthebloodsugar
levels are still not adequately controlled. Treatment with other oral glucose lowering
medications(glitazones,alphaglucosidaseinhibitors)and/orinsulinneedstobedetermined
onanindividualbasis.
Glucosecontrolprogressivelydeterioratesovertimerequiringanincreaseindrugtherapy
tomaintainglycaemiccontrol.About50%ofpatientswillrequireinsulintherapyinaddition
tooralmedicationswithin5to10yearsofdiagnosisofType2diabetes(secondaryfailure).
In these patients combining oral glucose lowering medications with insulin minimizes the
amountofinsulinrequired.
13
TREATMENTFLOWCHARTFORCONTROLOFHYPERGLYCAEMIA
DIABETESMELLITUS
Established
NonͲPharmacologicalIntervention(SNAP)
Type1diabetesType2diabetes
CommenceinsulinGlycaemiccontrolPoorglycaemic
Adjustdosetoachievesatisfactorycontroland
adequatecontrolasymptomaticsymptomatic
PursueSNAPStartmetforminandadjustdose
Addsulphonylureaifuncontrolled
Ifstilluncontrolled,glitazoneorinsulinbeadded
Ifinsulintherapyiscommenced,startroughlywith0.3unit/kgofbodyweight.
Note:continueoralantidiabeticdrugs.
Withinsulinthefollowingregimenscanbeused,itispreferabletostartwiththeregimen
andmakeadjustmentslater
Ͳsingledoseofisophanenocte(intermediateinsulin)or
Ͳisophaneinsulintwiceadayor
Ͳmixtardinsulin(30/70)twiceadayor
Ͳsolubleinsulintdsandisophanenocte
Figure1
14
3.6SPECIALSITUATIONSINTHEMANAGEMENTOFDIABETES
3.6.1PHYSICALACTIVITY
x
x
x
Physicalactivitycarriesadditionalrisksindiabeticpatientsoninsulintherapy.
Hypoglycaemiaisamajorconcerninthissituation.
Formildtomoderatephysicalactivity(e.g.fastwalkingonaflatsurface,mopping
thefloor)for30minutes,extracarbohydratesshouldbetakenbeforehand.
For “short bursts” or longer strenuous physical activity (e.g. scrubbing the floor,
movingheavyfurniture),itisadvisabletoreducedosageofshortͲactinginsulin.
3.6.2FASTING
Manypatientswithdiabetesfastforreligiousorotherreasons.
ForType1diabeticpatients:theirusualdailyinsulindosecanbedividedintotwodosesgivenbefore
eachofthetwomainmealsoftheday.
ForType2diabeticpatients:Thetimingofthedoseoftheoralhypoglycemicagentisimportant.
Forthosepatientsonmetformin,dosescanberearrangedtocoincidewiththetwomainmealsofthe
day.
ForthosepatientsonsulfonylureasespeciallyGlibenclamide:foroncedailydosage,givemedicationwith
thefirstmainmealandforthoseontwicedailydosage,givethemedicationwiththetwomainmeals.
3.6.3ILLNESS
Metaboliccontrolmaydeterioraterapidlyduringillnessofanykind.
As part of their education program all patients should have a contingency plan on
whichtheycanworkonifanillnessupsetstheirdiabetescontrol.
Thereshouldbeclosemonitoringofbloodsugarlevels.
Insulin doses should be adjusted according to blood sugar levels and changed to
shortͲactinginsulinforbettercontrol.Insulinmustnotbestopped.Ifthereisaneedto
reducethedose,itshouldnotbemorethan30%.
Oralhypoglycaemicdrugsshouldnotbestoppedunlessthepatientcannoteat.
Maintenanceoffluidintakeisimportant.
Ifthepatientisunabletotakeinsolidfood,substitutewithfruitjuices,regularsoftdrinks,
orotherfluidscontainingglucose.
Patientswhohaverepeatedvomitingshouldcontactmedicalhelpearlyasbothintakeof
fluidsandcarbohydratesneedtobemaintained.
Thepatientshouldhavethoroughknowledgeofwhen,howandwheretocontactaspecialisthealthcare
facility.
3.6.4TRAVELING
Patients on insulin can travel overseas as long there is proper adjustment of their food
andinsulindosestoadapttothechanginglocaltimes.
Journeysshouldbecarefullyplanned.Enoughinsulinforthewholetripwithsomespares
shouldbecarried.InsulinshouldbekeptcoolinsideawellͲinsulatedbag.Itisadvisable
15
tocarryamedicalreportfromthedoctorwithtreatmentdetailstofacilitatecustoms
clearance. The report will assist in dealing with any medical problems that may arise
duringtraveling.
Easilyabsorbedsugaryfoods(e.g.lollies,fruitjuice)shouldbeavailablewhiletravelingas
wellasfoodthattakesalittlelonger(e.g.crackers)toabsorb.Thesecanbetakenifthereis
anindicationofimpendinghypoglycaemia.
16
4.0TreatmentofAssociatedMetabolicConditions
4.1Hypertension
Thisisamajorriskfactorforbothcardiovasculardiseasesandrenalcomplications.
Blood pressure control is more important than the choice of antiͲhypertensive drugs.
However, angiotensin converting enzyme inhibitors (ACEIs) are the firstͲline drugs in
controlling hypertension. Other antiͲhypertensive drugs such as betaͲblockers (e.g.
atenolol), slow release calcium channel blockers (e.g. nifedipine), and loop diuretics
(e.g.furosemide)canalsobeused.InFiji,methyldopaisavailableandcanbeusedifthe
above drugs are not available. A combination of the above drugs might be needed to
achievedesiredbloodpressurecontrol.
WhenACEIsareusedtocontrolhypertension,itisimportanttomonitortherenalfunction
two weeks later. A slight increase in serum creatinine is generally expected and is
usually less than 30% of baseline values. If there is more than 30% rise in serum
creatininefromthebaselinevalues,itisrecommendedthatACEIsshouldbestoppedand
replaced by another antiͲhypertensive drug after consultation with the specialist at the
divisional hospital. This rise in serum creatinine might indicate underlying renal artery
stenosis.
Treathypertensionasfollows:
i. If renal function is normal (regardless of blood pressure) but microalbuminuria is
present,startenalapril5Ͳ40mgdaily.ThetargetofBPcontrolislessthan130/80mm
Hg.
ii.Inthepresenceofrenalimpairmentand/orsignificantproteinuria(>1g/dayor++++ondipstick),
theBPshouldbelowerthan120/80mmHg.
Caution is required with ACEIs therapy because of the risk of development of
hyperkalemia.Whenpossible,itisadvisabletomonitorelectrolytesatleastonceeverysix
monthsorearlierifrequired.AcommonsideeffectofACEIsiscough.Analternativeisto
useACEreceptorblocker(notavailableintheFijiMedicineFormulary).
4.2Hyperlipidemia
Thisisacommonoccurrenceindiabeticpatients.
Elevated triglycerides and LDL (lowͲdensity lipoprotein) cholesterol with reduced HDL (high density
lipoprotein) cholesterol is a common pattern and may warrant treatment. Getting the best possible
controlofbloodglucoseisanimportantfirststrategy.Iflipidabnormalitiespersistdespitethis,theymay
needtobetreatedintheirownright.Therecommendeddrugsarestatins(e.g.simvastatin,atorvastatin,
pravastatin,lovastatin).Thecommonsideeffectsoflipidloweringdrugsaremuscleandliverproblems.
ItisadvisabletodoLFTsbeforestartingstatinsandamonthaftercommencementofstatins.
Lipidloweringdrugtherapywithsimvastatin40mgoratorvastain10mgisrecommendedforprimary
prevention in patients with type 2 diabetes aged > 40 yrs regardless of baseline cholesterol. Patients
under40yearsandotherimportantriskfactorsshouldalsobeconsideredforantiͲlipidtreatment.
4.3Antiplatelettherapy
Unless*contraindicatedAspirinisrecommendedforadultswithdiabetesandahistoryofcardiovascular
diseases(CVD).IntheabsenceofCVD,itis“reasonable”toconsiderAspirininthosepatientswhoareat
anincreasedriskbasedonage(males>50yearsandfemales>60years)andatleastoneadditionalCVD
riskfactorsuchassmoking,dyslipidemia,hypertension,familyhistoryofdiseaseandalbuminuria.
*CommoncontraindicationstoAspirintherapyare:
Historyofpepticulcerdisease
GIbleed
Lowplateletstates
intracranialbleed
Bleedingdisorder
17
5.0ManagementofacutecomplicationsofDiabetes
5.1HYPOGLYCAEMIA
Hypoglycaemiaisaconditiondefinedasafallinthebloodsugarleveloverashortperiodoftimecausing
symptoms.Diabeticpatientsaremorepronetohypoglycaemicsymptoms,mainlybecauseoftheuseof
oralhypoglycaemicagents,insulinandtheriskofsepsis.However,thethresholdvariesfrompersonto
person.Adiabeticpatientwhoissubjecttolowbloodsugarlevelsmostofthetimemaynotexperience
anysymptomsforseveralhoursevenwithbloodsugarlevelsaslowas1.0mmol/l.Ontheotherhanda
diabeticpatientwithpersistentlyelevatedbloodsugarlevelmayexperiencehypoglycaemicsymptomsif
thebloodsugarlevelfallsquicklybutisstillabovethenormalrange.
Hypoglycaemiapresentsas:
sweating, tremor, tachycardia and pallor from adrenal and sympathetic
activity triggered by the low blood glucose and/or hunger, and can proceed to
mentalconfusion,comaandseizures.
Patients suffering from preͲexisting autonomic neuropathy may not have any warning symptoms that
manifestswithneurologicalsymptomsstraightway.
Thefactorsthatprecipitatehypoglycaemiainclude:
x highinsulindose
x highdosesofsulphonylureas
x presenceofrenalfailure
x liverfailure
x septicaemia
x missedordelayedmeals
x hormonaldisturbances,and
x vigorousphysicalactivity.
Patientsshouldbetreatedurgently.
Ifthepatientisconsciousandabletoswallow,giveasugaryfoodordrinkfollowedby
foodsthattakelongertobeabsorbede.g.crackers.
Ifthepatientisunabletoswalloworbecomesunconsciousathome,givesugarpasteor
honey into the mouth and transfer immediately to the nearest health care facility for
intravenous glucose therapy. At the health care facility, if the patientisunconsciousor
unabletoswallow:
x Give 50 ml of 50% dextrose intravenously followed by continuous
intravenousinfusionof5%dextroseforupto24hours.
Hypoglycaemia in the elderly, particularly as a consequence of accumulation of
sulphonylureaintheplasma,maybedifficulttoreverseandmayreoccurforseveraldays
afterstoppingthedrug.
It is important to educate all diabetic patients on the symptoms of hypoglycaemia, the
factors that may precipitate it, the preventive measures and the treatment that can be
undertakenincasesofmildattacks.Inseverecasesitisimportanttoadvicetherelatives
to seek immediate help from the nearest health facility to avoid any irreversible brain
damage.
18
5.2DIABETICKETOACIDOSIS(DKA)
5.2.1Generalconsiderations
Diabeticketoacidosis(DKA)ischaracterizedbythetriadofketosis,hyperglycemiaand
academia.ThepresenceofketonebodiesisaconsistentfindinginDKA.DKAoccurs
predominantlyinType1diabeticpatientsbutcanoccurinType2diabetes.Itmightbethefirst
presentationinanunknowntype1personwithdiabetes.
Thediagnosticfeaturesinclude:
x
x
x
x
x
x
vomiting,
abdominalpain,
Kussmaul’sbreathing,
dehydration,
ketoticbreath,
mental confusion progressing to
coma.
Itisnecessarytotesturineformoderatetolargeketonebodies.Venousratherthanarterial
bloodpHandbicarbonatearenowpreferred.
ThecommonprecipitatingfactorsofDKAinclude:
x
x
x
historyofomissionofinsulin;
drugs,e.g.corticosteroids;sepsis;
acute coronary event; recent trauma; and
pregnancy
5.2.2Management
Management should be undertaken urgently in the nearest health care facility. The most important
therapeutic intervention in DKA is an appropriate fluid replacement. Insulin therapy can be started
subsequently. Discuss with the medical team at the divisional hospitals. Ensure that patient has 2
Intravenousaccesses.
Transferpatienttoanappropriatehealthfacilityoncehis/herconditionhasbeenstabilized.
a.Fluids:Administerintravenousinfusionofnormalsalineasfollows:
•
•
•
•
Firstliterfor30minutes
Secondliterforonehour
Thirdliterfor2hours
Fourthliterfor4hours
Furtherinfusionshouldbeadministeredaccordingtoclinicalassessmentofthepatient.
Once the blood sugar level reaches 14mmol/l, change intravenous fluid to 5% dextrose (Note 10%
dextrosefluidpreferred).If5%dextroseisnotavailable,usedextrosesaline.
It is important to continue normal saline to correct circulatory volume along with dextrose infusion if
necessary.Cautionisrequiredintheelderly,pregnant,andthosewithrenaland/orcardiacdysfunction.
19
b.Insulin
AfixedrateIVinsulininfusion0.1unitperkilogrambodyweight(estimatedifnecessary)is
recommended.
Test:
x Bloodsugareverytwohours
x Urineketonesevery4hours.
x Venousbicarbonateevery4hours
x Serumpotassiumandsodiumevery4hours.
Thefixedratemayneedtobeadjustedif:
x theketoneconcentrationisnotfallingfastenough
x Thevenousbicarbonatelevelisnotrisingby3mmol/Lperhr.
x Thecapillarybloodglucoseleveldoesnotdecreaseby3mmol/Lperhr
Insulindosescanbehalvedwhenbloodglucoselevelreaches14mmol/L.Thereafter,insulincanbe
changedtomultiple–doseinsulinregimensubcutaneouslyfollowedbytwiceͲdailydosing.
Ifvenousexcesscannotbeestablished,give:
x ShortactinginsulinIM8units/hour
x Donotgivesubcutaneously,asinshockstatetheabsorptionispoor
c.ElectrolytesandAcidBasedDisturbance
(i).Potassium
(i) Insulin takes glucose and potassium into the cells and their respective serum concentrations
fall.Potassiumshouldbeadministereddependingontheserumlevelsasfollows:
o ifremainsabove5.5mmol/L–donotgivepotassium
o iflevelbetween3.5–5.5mmol/l
ƒ Initiateintravenouspotassiumatarateofnomorethan10–20mmol/hour
(addedtoIVinfusionfluidbag)onceinsulinandfluidshavebeenstartedand
renalfunctionandurinaryoutputhavebeenassessedassatisfactory.
o Iflevelisbelow3.5mmol/L
ƒ Reviewpotassiumrequirement.
ƒ Aseparatepotassiuminfusionlineshouldbestarted
Potassiuminfusionshouldnotexceed20mmolperhour.
(ii).Bicarbonate
Measure venous rather than arterial bicarbonate and PH. Sodium bicarbonate should not be given
routinely.It isonlygiven when the bloodpHislessthan7.0.In suchcases,infuse50mmolofsodium
bicarbonateoveronehour.
d.Treatmentofunderlyingcause
Treattheunderlyingcauseespeciallyinfections.
e.Othermeasures
x
x
x
Anindwellingcathetershouldbeinsertedtomonitorurineoutput.
Oxygentherapyifrequired
Insertionofnasogastrictubeifparalyticileusdevelops.
20
f.PatientEducation
x reͲeducateaboutavoidanceofthecomplication
x therecognitionofearlywarningsignsandsymptoms.
5.3HYPEROSMOLAR,HYPERGLYCAEMICSTATE
Thisisarelativelyuncommoneventusuallyoccurringasadramaticpresentingfeatureor
asacomplicationoftype2diabetes.
Itpresentswithahistoryofthirst,polyuriaandprogressiveimpairmentofconsciousness
commonlyinapatientwhois60yearsorolder.ItdiffersfromDKAinthatpatientswith
hyperosmolar,hyperglycaemicstatedonotdevelopketoacidosis.
Investigationsrevealveryhighbloodglucose,usuallyhigherthan30mmol/L,theserum
sodiumisoftenelevatedandthecalculatedserumosmolality>320mOsm/l.6
Management
ThetreatmentissimilartothatinDKA(seeabove).
Intravenous isotonic saline, low dose intravenous insulin (4Ͳ6 u/hour by infusion) and
carefulattentiontoserumpotassiumconcentrationsarethecentralstrategies.Careful
monitoringisrequiredasinDKA.
Onrecovery,thepatientmaynotneedlongͲterminsulintherapy.Afteraninitialperiodof
stabilization with insulin, most patients with type 2 diabetes who present in a
hyperosmolar, hyperglycaemic state can be controlled with oral hypoglycaemic drugs
combinedwithdiet.
21
6.0ManagementofLatecomplicationsofdiabetes
Diabetesmellitusisassociatedwithavarietyoflatecomplicationsthatareeithervascularornonvascular.
The vascular complications are broadly classified as microvascular or macrovascular. The microvascular
complicationsareRetinopathy,NephropathyandNeuropathyandmacrovascularCoronaryHeartdisease,
CerebrovascularDiseaseandPeripheralVascularDisease.
(Forcommunityeducationpurposes,theacronym‘SNAKE’isusedtoidentifythelatecomplicationsintheskin,
nerves,arteries,kidneysandeyes).
Majorriskfactorsforthedevelopmentofcomplicationsinclude:
Youngerageatonset
Familyhistoryofcomplications
Longerdurationofdiabetes
Hypertension
Poorglycaemiccontrol
Smoking
Dyslipidaemia
6.1RETINOPATHY
ALL PERSONS WITH DIABETES MELLITUS NEED REGULAR EYE CHECK UP FOR EARLY
DETECTIONOFDIABETICRETINOPATHYTOPREVENTBLINDNESS.
Diabetic retinopathy is a major cause of visual impairment and blindness in Fiji.
Howeverwithgoodmanagementvisualimpairmentduetodiabetescanbeavoided
for the vast majority of patients. Retinopathic lesions are divided mainly into two
categories:backgroundandproliferativeretinopathy.Henceallpatientswithdiabetesneed
regulareyecheckup.Importantpointstonoteare:
x DiabeticRetinopathyisasymptomaticinitsearlystage
x Screeningistheonlywaytoidentifypeoplewithdiabeticretinopathy
x Timelytreatmentcanpreventvisionlossfromdiabeticretinopathy
Therearetwomaincategoriesofdiabeticretinopathy:
x NonͲproliferativediabeticretinopathyͲpreviouslycalledbackgroundDR.Atthisstagetheblood
vesselsleakandwithprogressiontheymaygetoccluded.
x Proliferativediabeticretinopathy(whennewbloodvesselsgrow).
Somepatientsdevelopmaculaoedemaandthiscanbepresentineithercategories.
Bothproliferativeretinopathyandmaculaoedemaifuntreatedcanleadtovisualimpairment.
Thereisalsoanincreasedriskofcataractindiabeticpatients.
6.1.1 Riskfactorsfordiabeticretinaldisease(clinicalmodifiers)
poorglycaemiccontrol
raisedtriglycerides&serumcholesterol
raisedbloodpressure
Pregnancy
durationofdiabetes
MicroͲalbuminuria&proteinuria
Patientswithmultipleriskfactorshaveahighriskofdevelopingdiabeticeyedisease.
6.1.2Symptomsofdiabeticretinopathy
Diabeticretinopathyoftenhasnoearlywarningsignsandvisionmayremainunaffecteduntilthe
diseasebecomessevere.Also,diabeticretinopathyprogressesrapidlywithoutmuchwarning.
22
Thereforeitisimperativethatregulareyeexaminationsarecarriedouttomonitorprogressionofthe
disease,toidentifyandtreatvisionthreateningDR.
6.1.3 Screening
TherearetrainedscreenersatDivisionalHospitalEyeClinicsandonoutreach.Theytakefundus
photographs,graderetinopathyandonlyrefertoophthalmologistscasesthatneedfurtherassessment.
ThegradingisdoneaccordingtothePacificIslandDRGuidelines.
Therecommendedscreeningtoolinorderofpreferenceisafundusorretinalcamera,followedbyan
indirectophthalmoscopeandlastlyadirectophthalmoscope.Forthelattertwo,thepupilshavetobe
dilated.
A.PeoplewithType1diabetes:
Initiatescreening5yearsafterdiagnosisofdiabetesismade,oratpuberty,whicheveristheearlier.
B.PeoplewithType2diabetes:
Initialscreeningisdoneoncediagnosed.OngoingscreeningisdoneatleasteveryyearifnoDRis
detected.
C.Pregnantwomenwhohavediabetesiealreadydiabeticandbecomespregnant:
Screeningisdoneearlyinthefirsttrimesterofthepregnancy,regardlessofprevioushistoryof
screening.Ifthere’snoretinopathyandnoclinicalmodifierspresent,annualscreeningcancontinueas
usual.Ifminimalretinopathyispresent,frequentscreeningthroughoutthepregnancyisindicated,and
hastobeseenbyanophthalmologist.GiventhatdiabetesmellitusishighlyprevalentinFiji,pregnant
womenwithraisedbloodsugarshouldbescreenedaswellatbooking.
D.Followup
OnͲgoingscreeningiscarriedoutbetween1to2yearsifnoDRisdetected.Refertoophthalmologist
onceanyDRisdetected.Thefrequencyoftheassessmentsisincreaseddependingontheseverityofthe
retinopathyandtheriskfactorsforprogressiontovisionͲthreateningdisease.
Whentoscreen?
Type1DM
Type2DM
DM+Pregnant
Whentoscreen?
Initially
5yearsafterDiagnosis
AtDiagnosis
Initially
Beforepregnancy
(Planned)or1st
Trimester
FollowͲ
up
NoDR:Annualto2yrs
AtPuberty
DR:Accordingtograde
NoDR:Annual
DR:Accordingto
grade
FollowͲ
up
Dependingon
grade
***Pregnant
withraised
Bloodsugar
AtBooking
Advice
***Exceptions
6.1.4EyeAssessment
x Check visual acuity with Visual Acuity (Snellen’s) chart – unaided or aided (with
present glasses). Check with pinholeifvisualacuity6/12orworse.
x Checkpupilreactioninbotheyes[directandconsensual]
x Checkdepthofanteriorchamberwithlightdirectedfromthelaterallimbus
x Checkredreflexwithophthalmoscope;ifpresent,dofundusphotography.
23
IFFUNDUSCAMERANOTAVAILABLEORPOORREDREFLEX
x Dilatepupilswithtropicamideeyedrop.Addphenyephrineeyedropifavailable.
x Checkforcataractorvitreousbleed/opacity
x AssessRetinausinganindirectophthalmoscopeoradirectophthalmoscope.
What everyone can do !
Yes
Ask
>1year
GetEye
Askif
when?
examined
Eyes
examined
Defaulted
GetEye
for
clinic
examined
Diabetes
Geteye
Check
eye
No
examined
Compliant
appointment
problem
date
6.1.5 Managementofdiabeticretinopathy
LasertreatmentisavailableinalldivisionsinFiji.ThistreatmentcanslowdowntheprogressionofDR
andcanstabilizevision.CasesrequiringlasertreatmentaretobereferredtotheEyeClinicinthe3
DivisionalHospitalsifthisserviceisnotavailableinyournearestsubdivisionalhospitalonoutreach.
6.2NEPHROPATHY
Diabetic nephropathy usually takes 10Ͳ15 years to develop after the onset of
hyperglycemiaanditencompassesallthelesionsoccurringinthekidneysofpatients
with diabetes mellitus. Microalbuminuria is the earliest manifestation of diabetic
nephropathy and is a marker of progressive deterioration of renal function.
Microalbuminuria is defined as urinary albumin loss to between 30 and 300 mg per
day. In practice a more practical assessment is based on albumin/creatinine ratio
(ACR), >2.5mg/mmol in men and >3.5 mgs/mmol in women is often used to define
microalbuminuria.
Proteinuriaispresentwithraisedurinaryalbuminexcretionof>300mg/day.AnACR
>30mg/mmolinaspoturineisconsistentwithadiagnosisofdiabeticnephropathy.
Glomerularfiltrationrate(GFR).ThisisoftencalculatedbyusingCockcroftandGault
formulaasshownbelowandusefulinassessingkidneyfunction.
CreatinineClearance:
CrClinmales=(140Ͳageinyears)Xweight(kg)x1.23
Serumcreatinine(Pmol/l)
CrClinfemales=(140Ͳageinyears)Xweight(kg)x1.03
Serumcreatinine(Pmol/l)
24
6.2.1StratificationofChronicKidneyDisease(CKD):
Stage
I
II
III
IV
V
RenalFunction
NormalGFR
Mildimpairment
Moderaterenal
impairment
Severerenal
impairment
Endstagerenaldisease
GFR(ml/min/1)
ш90
60Ͳ90
30Ͳ59
15Ͳ29
<15
6.2.2Assessment
ƒ
ƒ
ƒ
ƒ
Test urine for microalbuminuria if facilities available. If present repeat in 6
weekstoconfirmthatitispersisting
Testurineforproteinuriaifmicroalbuminuriafacilitiesnotavailable
Arrangeforbloodureaandcreatinineifproteinuriapresent
Yearly assessment of renal function is important in the absence of
microalbuminuria,
6.2.3Management
(i) ManagementofMicroalbuminurium
Theliteraturerecommendstreatmentwithangiotensionconvertingenzymeinhibitors
(ACEIs)oncemicroalbuminuriaisdetected.InFiji,therecommendeddrugis:
Enalapril2.5Ͳ5mgdaily.
(ii) ManagementofEstablishedDiabeticNephropathy
Ingeneral,treatmentofestablisheddiabeticnephropathyincludesthefollowing:
x controlofproteinintake
- isnotrecommendedinearlystagesofchronickidneydisease(stages1Ͳ3)
- isforstages4Ͳ5
x useofACEInhibitorsandACEreceptorblockerstoreduceproteinuria
- The use of above drugs can cause microalbuminuria to regress to no albuminuria in
diabetes. All attempts should be made to reduce proteinuria immaterial of baseline
proteinexcretion
x controlofbloodpressure
Ͳ blood pressure lowering is associated with a reduced rate of chronic kidney disease
progression
Ͳ refertothesectionunderbloodpressurecontrolindiabetes
x controlofhyperglycaemia
- meticulouscontrolofhyperglycaemiashouldbemaintained
x controlofhyperlipidaemia
- lipid disorders may contribute to the development and progression of diabetic kidney
disease
- refertothesectionunderlipidcontrolindiabetes
x controlofothervascularriskfactors,i.ecessationofsmoking.
For end stage renal disease, renal replacement therapy in the form of dialysis or renal
25
transplantneedstobeconsidered.Refertoconsultantphysicianforadvice.
Goodbloodpressurecontrolaswellasgoodglucosecontrolisessentialinalldiabetic
patientstoreduceprogressionofcomplications.
6.2.4Referral
ƒ
RefertophysicianifeGFR<30ml/min
6.3NEUROPATHY
Severaldifferenttypesofneuropathycandevelopindiabeticpatients.Thecommonly
seenonesareperipheralsensoryͲmotorandautonomicneuropathy.
6.3.1PeripheralsensoryͲmotorneuropathy
SymptomsofperipheralsensoryͲmotorneuropathyinclude:
ƒ numbness,
ƒ paresthesia,
ƒ pain,and
ƒ weakness.
Ifpainisprominent,severaltreatmentshavebeenshowntobeeffectiveandimprovingthequalityoflife.
Tricyclicantidepressantsandanticonvulsantsshouldbeconsidered.
Amitriptyline50Ͳ150mgorallyatbedtime
OR
Carbamazepineupto600mgorallydailyintwodivideddoses.
Carbamazepineshouldbeintroducedgraduallystartingat100mgtwicedailyandthedose
to be increased gradually until the maximum dose that can control the pain can be
achieved.Gabapentin,anotheranticonvulsantnotavailableonFMFisalsoeffective.Itcan
becombinedwithopiateanalgesiainpatientsnotcontrolledonmonotherapy.
Goodglycaemiccontrolisessentialforcontrolofsymptoms.
6.3.2Autonomicneuropathy
Autonomicneuropathycanpresentas:
posturalhypotension,
dysphagia,
intermittentdiarrhoea
impotence,
bladderatony.
Posturalhypotensionrequiresspecialistassessmentbutthepatientmayrespondto:
Fludrocortisone0.1to0.3mgsorallydaily.
26
6.4DIABETICFOOTDISEASE
Diabetic foot problems are a common complication of diabetes and include neuropathy, peripheral
vasculardiseaseandfootulceration.Peripheralneuropathywithorwithoutvasculardamageputsfeetat
riskfromulcerationandinfectionwhichmayleadtogangreneandtheneedforamputation.Diabeticfoot
infectionsinvolvetheskinandsofttissueaswellasunderlyingmuscleandbone,andshouldalwaysbe
regarded as serious. Amputation rates are higher for patients with diabetes than patients for without
diabetes.Diabeticfootscreeningiseffectiveinidentifyingthelevelofriskofdevelopingfootulcerationin
patientswithdiabetes. Knowingthelevelofriskisimportantin providingcorrectadvicetopatientson
foot care. An annual screening from the diagnosis of diabetes is appropriate. However more frequent
screeningmaybewarrantediftheriskofdevelopingfootulcerationremainshigh.
6.4.1FootAssessment
History
x Inquireaboutanyprevious
footproblems,symptomsof
pain,tingling,numbness.
x Anyhistoryofintermittent
claudicationandrestpain
PhysicalExamination
x Examinethefeetforanyhighriskcharacteristicssuchas
cornandcallus,toedeformitiessuchasclawtoes,hammer
toes,bonyprominences,anyinfectioninbetweenthetoes,
andpoorperfusion;
x Testsensationusinga10grammonofilamentor128Hz
tuningfork;
x Testanklereflexes;
x Palpatepedalpulsesandpoplitealpulse;
x MeasureAnkleͲBrachialIndex;
x Assessfootwearandgeneralfootcare.
6.4.2RiskFactorsforDiabeticFootProblems
Themajorriskfactorsfordiabetesfootproblemsare:
x Peripheral Neuropathy – peripheral neuropathy and in particular sensory loss is a significant risk
factorforthedevelopmentofdiabeticfootproblems;
x PeripheralArterialDisease – poor arterial blood supply is also a significant risk factor for diabetic
footulceration;
x PoorGlycaemicControl
– poor blood glucose level control increases the risk of neuropathy,
vasculardiseaseandinfection;
x FootDeformities –Footdeformityisariskfactorforulceration.Hammertoe,clawtoes
andbonydeformitiessubjectthefoottohighpressureandtraumathatcanleadtoulceration;
6.4.3RiskClassification
Assessingtheriskofdevelopingfootulcersandsubsequentcomplicationsdeterminesthefrequencyof
clinicreview.
27
RiskClassificationfortheDiabeticFoot
(adaptedfromInternationalConsensusontheDiabeticFoot.1999;Frykbergetal,2006)
RiskStatus
ClinicalFindings
Clinicalreview
RiskI
LowRisk
Risk2
MediumRisk
Risk3
HighRisk
Risk4
AcuteFoot
Problems
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Noincreasedriskoffootproblems
Nosignsofperipheralneuropathy
Noperipheralvasculardisease
Nofootdeformity
Peripheralvasculardiseaseand/or
peripheralneuropathy
Impairedsensation
Footdeformities
Peripheralneuropathy
Peripheralvasculardisease
Historyofpreviousfootulcersor
amputation
Acutefootproblems,e.g.ulceration
Ischemia
Infection
AcuteCharcotfoot
Annualreview
Everythree[3]tosix[6]months
Everyone[1]uptosix[6]months
Refertospecialist.Needsreview
everyone[1]toseven[7]days
dependentonneed
6.4.4ManagementofDiabeticFoot
i. Education
Alldiabeticpatientsmustbeadvisedto“KEEPYOURFEETHEALTHY”by:
x Controllingbloodglucoselevelwellatalltimes;
x Checkingtheirfeeteveryday;
x Avoidingwalkingaroundbarefeet;
x Washingfeeteveryday;
x Keepingskinsoftandsmoothwithoilorlotion;
x Avoidingcontactwithhotorcoldsurfaces;
x Wearingproperfittingfootware;
x Cuttingtoenailsasrecommended;
x Stoppingcigarettesmokingimmediately.
ii. GlycaemicControl
Tight glycaemic control (HbA1c below 6.5%) is important to reduce the risk of vascular disease,
neuropathyandinfection.
iii. AggressiveTreatmentofInfection
Recognizeandtreatinfectionearlyandaggressivelywithproperantibiotics.50%ofdiabeticpatients
willnotshowclassicsignsofinfection.Diabeticinfectionsareoftencaused byamixtureoforganisms
(aerobesandanaerobes).
28
x
x
Formildtomoderateinfections,giveMetronidazole400mgorally8hourly
PLUS
Flucloxacillin500mgorally6Ͳhourly.
Forsevereinfections,refertothesurgicaldepartmentofthedivisionalhospitals.
iv. WoundCare
Early and regular debridement of dead and devitalized tissues will provide an effective wound bed for
healing. Sharp debridement by a skilled practitioner is very useful. A moist wound environment will
encouragehealing.Awouldbedthatistoomoistortoodrywilldelaywoundhealing.
v. MultidisciplinaryApproach
Thebenefitofmultidisciplinaryapproachiswellestablished.ThecontributionsfromSurgeons,Physicians,
FootClinicNurses,Podiatrists,Physiotherapistandhealtheducatorsmustbesoughttoenhancethecare
fordiabeticfeet.
7.0Targetsforcontrolindiabetes
Itisimportanttohaveasetoftargetsfordiabetescontrol.Thesetargetsareusuallysetby
internationaldiabetesagenciesbasedonmajorresearchfindings.Seetablebelow.Thesetargetsneed
tobediscussedbetweenthepatientandthedoctorbeforeinitiatingtreatmentandduringeachfollow–
upvisit.(Thiscanbedocumentedinthepersonaldiabetesrecordbookforthepatients).
TargetsforcontrolinDiabetes.
Indicator
Fasting Blood glucose
(mmol/L)FBS
Random Blood Sugar
(mmol/l)RBS
Good
4.0Ͳ 6.0
Fair
6.1Ͳ7.0
4.0Ͳ 8.0
8.1Ͳ10.0
Poor
>7.0
10.0
*HbA1c(%)
Totalcholesterol(mmol/L)
<6.5
<4.0
6.5Ͳ 7.5
4.1Ͳ 4.9
>7.5
5.0
HDLͲcholesterol(mmol/L)
>1.0
1.0Ͳ 0.9
<0.9
LDLͲcholesterol(mmol/L)
Triglycerides(mmol/L)
<3.0
<1.5
3.0Ͳ 4.0
1.6Ͳ 2.0
>4.0
>2.0
<130/80
M:<25
F:<24
>130/80Ͳ <140/90
M:<27
F:<26
140/90
M:>27
F:>26
Bloodpressure(mmHg)
**Bodymassindex(kg/m2)
2
IdealBMI:20Ͳ25kg/m *HbA1cͲamountofcirculatingglycosylatedhaemoglobin,ameasureoftheoverallcontroloverpreceding3
months.
**BMIrangesrecommendedforPacificIslandersaresomewhathigherat20.5Ͳ27.0.
(Source:Schultz,D.1999.BMICutͲoffforPacificIslanders.NationalFoodandNutritionCentre,Suva.)
29
8.0DiabetesinChildren
Introduction
WorldwidetheincidenceofType1diabetesinchildrenrangesfrom0.1–37.4per100000.InFiji,
this is uncommon with an estimated prevalence of <1 per 100 000 below 15 years. However,
thereisanincreasingtrendofobesityinchildrengloballyandhenceincreasingincidenceofType
2diabetesinchildren.
Aim
To provide the best clinical practice guideline on Diabetes in children for use by any doctor or
nurseatthesubͲdivisionalhospital,healthcentreandnursingstationlevel.
ParametersoftheGuideline
Thisguidelinecoverschildrenaged<15yearsdiagnosedwithtype1(Part1)andtype2diabetes
mellitus(Part2).
8.1TYPE1DiabetesMellitus:
The recognition of Type 1 is highlighted, in page 2 of this guideline. Below are some of the
importantfeaturesofdiabeticketoacidosiswhichachildoradolescentmightpresentwith.
I.
Clinicalpresentation:
Ia)
Emergencypresentations
Theusualemergencypresentationofdiabetic ketoacidosisinachildoradolescentincludesthe
followingclinicalfeatures:
x Severedehydration
x Shock (rapid pulse rate, poor peripheral circulation, mottling and peripheral
cyanosis)
x Hypotension(alatesignandrareinchildrenwithDiabeticKetoacidosis)
x Frequentvomiting
x Continuingpolyuriadespitethepresenceofdehydration
x Weightlossduetofluidlossandlossofmuscleandfat
x Flushedcheeksduetotheketoacidosis
x Acetonedetectedonthebreath
x Hyperventilation of diabetic ketoacidosis (Kussmaul respiration) is
characterized by a high respiratory rate and large tidal volume of each
breath,whichgivesitasighingquality
x Disorderedsensorium(disoriented,semiͲcomatosedorrarelycomatosed)
Ib)
NonͲEmergencyPresentationofdiabetesincludes:
x Recent onset of enuresis in a previously toiletͲtrained child, which may be
misdiagnosed as a urinary tract infection or the result of excessive fluid
ingestion
x Vaginalcandidiasis,especiallyinprepubertalgirls
x Vomiting,whichmaybemisdiagnosedasgastroenteritis
x Chronicweightlossorfailuretogainweightinagrowingchild
x Irritabilityanddecreasingschoolperformance
x Recurrentskininfections
30
II
MedicalManagement
The majority of children with type 1 diabetes present at diagnosis with DKA.
ManagementofDKAiscoveredinthePICUguidelines.ManagementwillincludeABCplus
consultyourdivisionalpaediatricianforfurthercarebeforereferral.
ChildrenwithDKAmustbereferredtoDivisionalHospitalforspecialisedcare.
Belowisanalgorithmonmanagement,adoptedfromthePICUguideline.
31
Algorithmforthemanagementofdiabeticketoacidosis
Source:adaptedfromDungeretal.KargerPubl.1999
ClinicalSigns
Immediateassessment
Biochemicalfeatures&investigation
Assessdehydration
Ketonesinurine ClinicalHistory
Deepsighingrespiration(Kussmaul)
Elevatedbloodglucose
Smellofketones Acidaemia
Polyuria
Lethargy/drowsy+/Ͳvomiting
Bloodgasesurea,electrolytesothers
investigationsasindicated
Polydipsia
Diagnosisconfirmed
Wtloss(Weigh)
DiabeticKetoacidosis
Shocked(reducedperipheralpulses) Dehydration>5%
Reducedconsciouslevel/coma
Notinshock
Acidotic(hyperventilation) Vomiting
Resuscitation
IVTherapy
Airway+NGtube
Calculatesfluidrequirement
)
Breathing(100%O
2
Circulation(0.9%saline10Ͳ20
Correctover48hrs
ml/kgover1Ͳ2h&repeatuntil
circulationisrestored)butdo
notexceed30ml/kg
Continuousinsulininfusion
Clinicalobservations
Hourlybloodglucose
Hourlyfluidsinput&output
Acidosisnotimproved
ReͲevaluate
IVfluidcalculations
Insulindeliverysystem&dose
Bloodglucose17mmol/l
Or
Bloodglucosefalls>5mmol/l/h
IVFTherapy
Therapy
StartwithSCinsulin.Continue
oralfluids
Noimprovement
Neurologicaldeterioration
Warningsigns:
headache,slowingheartrate,
irritability,decreasedconsciouslevel
Incontinence,specificneurological
signs
Changeto0.45%saline+5%glucose Excludehypoglycemia
Improvement
Clinicallywell,toleratingoralfluids
Management
Givemannitol0.5/kg
TransitiontoSCinsulin
RestrictIVfluidsby1/3
StartSCinsulinthenstopIVinsulinafter30minutes
Callseniorstaff(DivHosp
Consultant
32
Minimaldehydration
Toleratingoralfluids
IIa.Diagnosis&Assessment:
The diagnosis and assessment is similar to those in adults, and is documented in page 2 of this
guideline.
IIb.InsulinTherapy:
Consultations with the Divisional Hospital need to be sought as previously mentioned in the
managementofDKA.Thisisalsoadvisableincasesofinsulindoseadjustments,inordertoavoid
sideͲeffectsandcomplications.
1.Nutrition
Nutrition is a fundamental component in Type 1 Diabetes management in children. This is not
different from adult nutrition as highlighted on pages 5 & 6 of DMG. However, in children
adequateenergyandnutritionalintakefornormalgrowthanddevelopmentisalsoapriority.
2.MonitoringofGlycaemicControl
Thisincludes:ͲHomeglucosemonitoring
Ͳ MonitoringHbA1C&
Ͳ MonitoringKetones
3.PhysicalActivity
As part of the fight against nonͲcommunicable diseases, physical activity is very much a key
component. This is well documented on page 7 of this guideline. However, special precautions
needtobetakenespeciallytoavoidcomplicationswhicharehighlightedonpage18.
4.PsychosocialIssues
Psychosocial stresses are common and have adverse effect on diabetes control due to nonͲ
adherencewithtreatmentregimes.Theyarecommonlyexperiencedwhereeducationallevelof
parents are low, nonͲcohesion in the family, autonomy is impeded or promoted at an
inappropriate time. Adolescent years are particular risk periods. Arrange frequent family
conferenceandinvolvecounsellors,othersupportnetworksandpsychiatristwhereappropriate.
5.SpecialSituations:Hypoglycaemia:
Hypoglycaemia is a common occurrence in Diabetes, and needs to be well addressed. Refer to
page18oftheseguidelinesforfurtherinformation.
6.DiabetesComplications&Screening
Diabetic Retinopathy, nephropathy, neuropathy and other associated complications and
conditions are well documented in children as well as adults. Refer to pages 22 to 27 of these
guidelinesformoredetails.
7.ClinicFollowUp
Minimalofthreemonthlyreviewsperyearatthedivisionallevelisrequired,andmorefrequent
reviews may be needed if diabetes control is poor. At least one subͲdivisional review per year,
eitherasanoutreachclinicoratthesubdivisionalclinic.Reviewwillincludemonitoringofhome
glucose,HbA1candurinaryketones.
33
8.School
Allchildrendiagnosedwithdiabetesshouldparticipateinnormalschoolactivities.Alettershould
besenttotheheadteacherorprincipalhighlightingthefollowing:
ͲEmergencymanagementofhypoglycaemia,
ͲMedicalemergencycontact,carerscontactand
Ͳ need for certain privileges such as allowing food consumption during
examsandsports.
8.2Type2DiabetesMellitus:
Diagnosis&TreatmentofType2Diabetesinchildren(pleaserefertoAdultdiabetesprotocol):
Beginningonpage3oftheseguidelines.
I
Diagnosis–asintype1diabetes
II Who To Screen: Is highlighted on page 2, however other risks to note in children
includethosebelow:
x Obesity
x StrongfamilyhistoryofTypeIIDiabetes
x Highriskethnicgroup
x Presenceofclinicalsignssuchasacanthosisnigricans
x Diagnosisofpolycysticovariansyndrome
(RefertoAdultdiabetesprotocolforfurtherinformationonscreening)
34
9.0Diabetesinpregnancy
Theterm“gestationaldiabetes”hasbeenusedtodefinewomenwithonsetorfirstrecognitionof
abnormalglucosetoleranceduringpregnancy.MorerecentconsensusfromtheInternational
AssociationofDiabetesandPregnancyGrouphaverecommendedachangewherediabetesdiagnosed
duringpregnancyisclassifiedasovertorgestationalbasedonspecificbiochemicalparameters.Ourlocal
datasupportstheuseofthischangeinFijiinthatmanyofoursocalledGDMcasescanberedefinedas
OvertDiabetes.
Theriskofadversepregnancyoutcomesincreasescontinuouslyasmaternalfastingplasmaglucoselevel
increasesfromtheч75mg/dL[4.2mmol/L],andastheonehourandtwohouroralGTTvaluesincrease;
thereisnoclearthresholdthatdefinespatientsatincreasedrisk.Adverseoutcomesinclude:
Preeclampsia,Hydramnios,Foetalmacrosomia,Foetalorganomegaly(hepatomegaly,cardiomegaly),
birthtrauma,operativedelivery,perinatalmortality,neonatalrespiratoryproblemsandmetabolic
complications(hypoglycemia,hyperbilirubinemia,hypocalcemia,erythremia)
TodatediabetesscreeninginpregnancyinFijiisdoneselectively.Currentevidencebasedonalocal
studyandinternationalevidenceindicatesthatuniversalscreeningneedstobeintroducedinamanner
thatissuitedtolocallyavailableresources.TheObstetricsandGynaecologyCSNsuggestssuchscreening
forallbasedonhistoricalriskmarkersandbiochemicalscreeningasfollows:
HighRiskGroupForDiabetesinPregnancyandGDM
x MaternalAgeш35years
x FamilyHistoryofDiabetes(parents/siblings)
x Pastpersonalhistoryofabnormalglucosetolerance
x Previousverylargebaby>4.5kgbirthweight
x PolycysticOvarianSyndrome
x Persistentglycosuria
x MorbidlyObese(BMI>40)
x Previousunexplainedperinatallossorbirthofamalformedchild
x CurrentuseofGlucocorticoids
ModerateRiskGroupForDiabetesinPregnancy
x Obeseclients(BMI>30)orsignificantweightgaininearlyadulthoodandbetweenpregnancies
Previouslargebaby>4.0kgbirthweight
x Pasthistoryofrecurrentmiscarriageш3miscarriages
x Glycosuriainfirstantenatalclinic
x PreͲexistingHypertension
ScreeningandDiagnosticCriteriaforGDM
InitialRiskAssessment
OvertDiabetesshouldbeimmediatelymanagedasDiabetesinPregnancy.
35
ScreeningforGDMFlowChart
HighRisk
RISKMARKERASSESSMENTOFALLPREGNANTWOMENATBOOKING
NonHighRisk
•1 or more
High risk factor(s) or
No High Risk Factors
• 2 or more Moderates risk Markers
Performfull75gGTTatbooking
AbnormalNormalAbnormal
DoFBS/RBSatbooking
Normal
Nomoderaterisk
factors
Atleast1Moderate
ManageasDiabetesRepeat75gGTTatManageasperinthetablebelowRepeat50gGCTNofurthertest
Inpregnancy26Ͳ28weeks
at26Ͳ28weeks
x
The50gGCTscreeningtestcanbereplacedbyafull75gGTTifthisispreferredbythe
patientandiseasiertoorganizelocally.
NOTE:AtANYstageofpregnancy,ifthereisclinicalsuspicionthatdiabetesmaybepresent,
prompttestingwith75gGTTshouldbeorganised.
36
CLASSIFICATIONOFALLDIABETESSCREENINGTESTand75gGLUCOSETOLERANCETEST(GTT)
AbnormalSignificance
GCT(Screeningtest)VenousBGLш7.8mmol/L*RequiresGTT
VenousBGLш11.1mmol/LTreatasOvertDiabetes
FBS(Screeningtest)VenousBGLш5.2and<7mmol/LRequiresGTT
VenousBGLш7mmol/LTreatasOvertDiabetes
RBS(Screeningtest)VenousBGLш7.0and<11mmol/lRequiresGTT
VenousBGLш11.1mmol/LTreatatOvertDiabetes
GTT(Diagnostictest)FBGLш5.1mmol/LorGDM
IhrBGLш10.0mmol/lOR
2hrBGLш8.5mmol/l
(1ormoreabnormalreadings)**
Asdiscussedabove,adiagnosisofovertdiabetesismadeinwomenwhomeetanyofthefollowing
criteriaattheirinitialprenatalvisit:
*Fastingplasmaglucoseofш126mg/dL[7.0mmol/L],or
*HbA1cш6.5%usingastandardizedassay,or
*Randomplasmaglucoseofш200mg/dL[11.1mmol/]thatissubsequentlyconfirmedbyelevated
fastingplasmaglucoseorHbA1c,asnotedabove.
Currentrecommendationsarethatthediagnosisofgestationaldiabetesismadeattheinitialprenatal
visitifthefastingplasmaglucoseisш92mg/dL[5.1mmol/L],but<126mg/dL[7.0mmol/L].However,
thishaswardworkimplications,thustheaboveisrecommendedfornow.Theresourceimplicationsof
theserecommendationswillneedtobereviewedbeforefullyadoptingthisrecommendation.
Currentrecommendationsindicatethatifovertdiabetesorgestationaldiabeteshasnotbeendiagnosed
withinitialtestingatthefirstprenatalvisit,a75gramtwohouroralGTTshouldbeadministeredat24
to28weeksofgestationtoallpatients.WhilstthiswouldbeidealtheCSNconcernswithresource
restrictionshaveresultedinrecommendationsforGCTscreeningat24to28weeksforthesubͲgroup
withnormalFBSbutmoderateriskfactors.
AllabnormalscreeningtestsusingCapillaryBloodSamples(CBGorCapillaryBloodGlucoseTesting)
mustberepeatedwithavenousbloodsamplebeforefurthercourseofactionisdefined.Hencethe
needtoensurethatvenousbloodglucosetestingfacilitiesareavailableateverySDHandmajorhealth
centres.
37
CAUTION:About1%ofwomenwithGestationalDiabetesinaclinicsettingareatriskofdeveloping
Type1Diabetes.
Type1DiabetesshouldbesuspectedinwomenwhohaveminimalornoriskfactorsforGDM,present
withhighBGL(e.g.>20mmol/L),+significantketonuria.Thesewomenshouldbefollowedupforat
least2yearspostpartum.Notethat,theirpostpartumGTTmaybenormaloronlyshowIGTinthefirst
yearpostpartum.
Womenwithknownimpairedglucosetolerance(IGT)
Womenwithknownimpairedglucosetolerance(IGT)preͲpregnancyshouldgenerallybetreatedas
GDMoncepregnantanddonotneedtoundergoafurtherGTTinpregnancy.
ScreeningTest:50gGlucoseChallengeTest(GCT)
*Dietarypreparation(e.g.3daydiet/fasting)arenotrequired
*Shouldbedoneinthemorning
*Clienttobeseatedforthedurationofthetest
*The50gglucoseloadshouldbeconsumedwithin5minutes
*BloodglucoseMetersareNOTtobeused
*Venousbloodshouldbetaken1hourafterglucoseload,timedaccurately,andthespecimensent
tothelabassoonaspossible
NOTE18%falsenegativerateatthesecutͲoffs
DiagnosticTest:75gGlucoseToleranceTest(GTT)
*3daypreparation–highcarbohydratediet
*Fastfor8Ͳ12hourspriortotest,usuallyfrom10PM(onlyWATERmaybeconsumed–notea,
coffee,etc.)
*Nosmokingonthemorningofthetest(from12MNuntiltestcompleted)
*Shouldstartinthemorningbefore9.30AM(glucosetoleranceworsenslaterintheday)
*Clienttobeseatedforthedurationofthetest
*Abaselinevenousbloodglucoseleveldetermined
*The75gglucoseloadshouldbeconsumedwithin5minutes
*BloodglucoseMetersshouldNOTbeused
*Venousbloodshouldbetakenat1hourand2hoursaftertheglucoseload,timedaccurately,and
thespecimenssenttothelabassoonaspossible.
GlycosuriapresentbutGCTorGTTwerenormal
IfnormalGCTorGTTandsubsequentlyglycosuriaorPolyhydramniosdevelops,orifthereareanyother
clinicalconcernsthatGDMmaybepresent,reͲtestwith75gGTT
x IfGTThasbeenrepeated,andBGLsareclearlybelowcutͲofflevels,andthereisglycosuriaͲ
repeatGTTin4Ͳ6weeks.
ElevatedRandomBGLbutGCTorGTTwerenormal
IfnormalGCTorGTTandsubsequentlyanelevatedbloodglucose(>7.0mmol/l)develops,orifthere
areanyotherclinicalconcernsthatGDMmaybepresent,reͲtestwith75gGTT
x IfGTThasbeenrepeated,andtheBGLsareclosetocutͲofflevels,nofurtheractionshouldbe
neededevenifthereisglycosuria
x IfGTThasbeenrepeated,andtheBGLareclosetocutͲofflevels,andthereisaselevatedblood
glucose(>7.0mmol/l)–repeatGTTin4Ͳ6weeks
38
VomitingduringtheGCT/GTT
x IfthereisvomitingwithGCTorGTT,thetestshouldberepeatedthenextweekaftergivingthe
clientMaxolononthemorningofthetest
x Ifthewomanvomitsduringtherepeattest,organiseforhertocometoAntenatalClinicfor
somepostprandialbloodtestlevelsandassessment
Ramadan
x Ideally,womenshouldbescreenedforGDMjustbeforeorimmediatelyafterRamadan.
However,ifscreeningisrequiredduringRamadan,GCTshouldbeperformedintheevening.
x IftheGCTisabnormal,adiagnosticGTTshouldbeperformedimmediatelyafterRamadan.In
themeantime,womenshouldbeadvisedtoavoidsimple,carbohydrate(softdrinks,fruitjuice,
etc.)RandombloodglucoselevelsshouldbemeasuredatAntenatalClinicvisits.
5.2MANAGEMENT
AllpatientsdefinedasGestationalDiabetesneedtobereferredtoadivisionalHospitalforinitiation
oftherapy.OngoingtherapycanbeconductedinSubdivisionalHospitalsettingsaslongasthereis
ongoingclosesupervisionbythedivisionalhospitalObstetricsandGynaecologyUnit.
TreatmentFlowChart
Commencebloodglucosemonitoring(fasting
and2hrpp)
Encouragehealthydietandexercise
Continuecurrent
treatment
Is glycaemiccontrolsatisfactory?
Fasting<5.2mmol/L
CommenceInsulintherapy Ͳshot/rapidacting,1Ͳ3timesperday
+/_
Nocteintermediate
ReviewBGLs–timingofreviewneedstobe
determinedonanindividualbasisbutusually
1Ͳ2/weekly
Titrateinsulinasrequiredtomaintaingoal
BGLs
NOTE:Duetosevereinsulinresistance,asmallpercentageofwomenwillrequireinexcessof
350unitsofinsulinaday.Thesewomenarelikelytorequiretheadditionofmorning
intermediateactinginsulintotheirtreatmentregimen.
39
UseofMetformininGestationalDiabetes
InselectedcasesMetformincanbeusedinPregnancyforGDMcaseshoweverthiswillbebasedon
consultationwithdivisionalhospitalconsultants.Metforminisnottobeusedinpeoplewithtype1
Diabetes.
INITIALWORKUPOFALLDIABETESCASESDIAGNOSEDFORTHEFIRSTTIMEINPREGNANCY
1.AssessforcomplicationsofDiabetes
a.BaselineOphthalmicreviewforRetinopathy
b.RenalFunctionTest
c.ChestXͲRay
d.ECG
2.Getabaselinedietaryassessmentandcounselling
3.Counselon:
a.ImpactofDiabetesonPregnancyoutcome,
b.SelfGlucosemonitoring,
c.Logisticsofongoingcare
DIABETESEDUCATIONANDBLOODGLUCOSEMONITORING
InitialeducationshouldcovertheimplicationsofGDMforthemotherandherbaby,bloodglucose
monitoring,overviewondietandrecommendationsregardingexerciseandtheimportanceof
postpartumfollowͲup.WomenwithGDMshouldalsobeprovidedwithpositiveencouragementto
minimizetheiremotionalstress.
OncediagnosedwithGDM,womenneedtomonitortheirBGLfasting(preͲbreakfast)and2hourafter
mealstimedfromthebeginningofthemealsfortherestofthepregnancy.Thereforeclientsshouldbe
instructedtopurchaseabloodglucosemeter.Theyshouldberegisteredwiththedivisionalhospital
diabetesinpregnancyregistryandeffortstoensurecompliancewithreviewschedulesneedtobe
documented.
BGLsinpregnancyareapproximately20%lowerthanoutsidepregnancytherefore,womenshouldbe
giventhefollowingBGLtargetranges.
Fasting:3.5–5.2mmol/l
2hrp.p:5.0–7.0mmol/l(theupperlimitsetbytheADAandACOGis6.7)
HbA1candfructosaminelevelsmayprovideadditionalinformationregardingtheadequacyofthe
glycaemiccontrol.Ingeneral,HbA1cshouldbemeasuredatdiagnosisandmonthlythereafter.It
shouldbenotedthatHbA1c/fructosamineresultsareapproximately20%lowerbymidpregnancy
comparedtooutsidepregnancy.
NOTE:Forclientsonahomeglucosemonitoringscheme,theaccuracyofcapillarybloodglucosetesting
andvenousbloodglucosetestingshouldbereviewedregularlyatleasteverymonth
40
DIETARYASSESSMENTANDADVICE
Nutritionaladviceshouldbeculturallyappropriateandindividualizedtoincorporateeachclient’s
specificneeds.Theadviceshouldcoverbothdiabeticdietrecommendationsandspecificpregnancy
requirements.
Adequatedietaryintakeisimportanttoavoidfoetalgrowthretardation–ketonuriamayhelpdetect
inadequatecarbohydrateintake.Lackofmaterialweightgain(particularlyinnonͲobesewomen)may
alsoindicateexcessiverestrictionoffoodintake.
EXERCISE
Womenshouldbeadvisedthatamoderatedegreeofexerciseisbeneficial,unlessthereareother
medicalorobstetriccontraindications.
INSULIN
AtthisstageitisnotgenerallyacceptedpracticetouseoralantiͲhyperglycaemicagentsinpregnancy.
Thereforeinsulintherapyisindicatedifthebloodglucoselevelsarenotadequatelycontrolledondiet
alone.
Insulintherapyshouldalsobeconsideredifthereisevidenceofreducedoracceleratedfoetalgrowthon
fundalheightorultrasound.
ShortͲactingorrapidactinginsulingivenpreͲmeal(onetothreeinjections/day)shouldbecommenced
if2hrpostprandialBGLsareelevated(>7mmol/l).Ingeneral,individualinsulindosesofbetween5to
10unitsshouldbecommenced,dependingonthedegreeofhyperglycaemia.PreͲbedintermediate
insulinshouldbecommencediffastingBGLsareelevated(>5.5mmol/L).Frequentdoseadjustments
areoftenrequired.ThisinsulinstartingregimeisbasedontheAlfredHospitalDiabetesProtocolandis
theonecurrentlyinuseatCWMHospital.
TIMINGOFDELIVERY
Inwomenwithunfavourablecervices,excellentglycaemiccontrol,novasculardiseaseorpreeclampsia,
normalfoetalgrowth,reassuringantepartumfoetalsurveillance,andnohistoryofstillbirth,induction
canbesafelydelayeduntil40weeks.Iftheaboveconditionsremainandthecervixisfavourablethereis
littlebenefitincontinuingthepregnancybeyond39weeks.Deliveryasearlyas37weeksisindicatedif
thereissuboptimalglucosecontroland/orevidenceofevolvingmaternalorfoetalconcerns.Itis
preferredtodocumentfoetalmaturitybyamniocentesisfornonͲurgentinductionsbefore38weeksor
thosewithunsuregestation.
NOTE:Dailyinsulinrequirementaloneisnotadeterminantoftimingfordelivery.Themain
determinantisoverallqualityofdiabetescontrol.
POSTPARTUMMANAGEMENTOFWOMENWITHGDM
WomenwithGDMareatmarkedincreaseriskoffuturediabetesandshouldbeadvisedregarding
optimumlifestyleandappropriatefollowͲup.Somewomenwillcontinuetohaveabnormalglucose
toleranceintheearlypostpartumperiod.Therefore,womenshouldbeadvisedtoseetheirgeneral
practitioners6weekspostpartumtoundergoarepeatOGTT,andOGTTshouldbeperformedannually
thereafter.
41
11.0References
1.AmericanHeartAssociation&AmericanCollegeofCardiology(jointstatement2006)
2.AustralianDiabetesinPregnancyGuidelinesonDiabetes:UpdatedDecember2002
3.AustralasianPaediatricEndocrineGroupClinicalPracticeGuidelinesforDiabetesinchildren,2005
4.2008Ͳ2013ActionPlanforGlobalStrategyforPreventionandControlofNCDs,WHO
5.InternationalAssociationofDiabetesandPregnancyStudyGroupsConsensusPanel,MetzgerBE,
GabbeSG,etal.Internationalassociationofdiabetesandpregnancystudygroupsrecommendations
onthediagnosisandclassificationofhyperglycaemiainpregnancy.DiabetesCare2010;33:676.
6.ObstetricalmanagementofpregnancycomplicatedbypreͲgestationaldiabetesmellitus;2012Upto
Date
7.JointBritishdiabetessocietyinpatientcaregroup–ManagementofDKAinadults,March2010
8.Proceedingsofthe4thInternationalWorkshopͲConferenceonGestationalDiabetesMellitus.Chicago,
Illinois,USA.14Ͳ16March1997.DiabetesCare1998;21Supp2:B1.
9.ScottishIntercollegiateGuidelinesNetwork.March2010
10.Screeninganddiagnosisofdiabetesmellitusduringpregnancy;2012UptoDate
11.TheAlfredHospitalDiabetesManagementProtocolLatestUpdate:19November2009
12.GlobalGuidelineforType2Diabetes,IDF2012,ClinicalGuidelinesTaskForce
13.ManagementofDiabetesbyScottishIntercollegiateGuidelinesNetwork2010
14‘HealthyEatingGuidelinesinDiabetes’Booklet,MOHFiji2012
15.ApelqvistJ,BakkerK,vanHoutumWH,NabuursͲFranssenMH,SchaperNC.“Internationalconsensus
andpracticalguidelinesonthemanagementandthepreventionofthediabeticfoot”,International
WorkingGroupontheDiabeticFoot,DiabetesMetabResRev.2000SepͲOct;16Suppl1:S84Ͳ92
16.FrykbergR,“PreventingAmputations:TheComprehensiveDiabeticFootExamination”FootNotes,
PresentDiabetesFootnotepublications,retrievedfromwww.presentdiabetes.com;
17.McIntoshC,“DiabeticFootUlcerations:“ReviewofBestPractice”Review,WoundEssentials,
Volume4,2009
18.ThenationalCardiovascularandNCDsurvey1980
19.TheFijiNationalNCDStepsSurvey2002,WHO,MOH,FSMed,MenziesCenterforPopulationHealth
Research,Uni.OfTasmania&AusAID
42
12.0Annexes
Annex1
43
Annex2
Fiji Association of Mental Health's 12 S's to Lessen Stress:
1.
SMILE
2.
STRETCH & EXERCISE
3.
SOOTHING & CALMING MUSIC
4.
SING & DANCE
5.
SHARE WORRIES &TASKS
6.
SPIRITUALITY (PRAYER/MEDITATION)
7.
SIMPLIFY & PRIORITIZE THINGS
8.
SLEEP WELL
9.
SELF-CARE & ESTEEM
10. SOCIALIZE
11. SLOW & DEEP BREATHING
12. SPEND (TIME & MONEY) WISELY
44
Annex 3
KEYINTERVENTIONPOINTSANDASSOCIATEDACTIONREQUIRED
KEYINTERVENTIONPOINTS
ACTION– KEYTASKS
NoDiabetes*
Keepthehealthy,healthy.
Preventthehealthypopulationfromdevelopingriskfactors.
Increasepublicawarenessofriskfactors,thesignificanceofriskfactorsand
riskfactorreductionstrategies.
Reduceriskfactorsinthe‘atrisk’population*
SNAPinterventiontoreduceriskfactors.
Supportgoaldirectedresearchintocausesofandpreventativeinterventions.
ActiveNCDToolKitScreeningforpeopleover30yearsofage.
Provideavenuesforopportunisticscreeningaswell(workplaces,festivals,etc.)
Increasepublicawarenessofsymptoms,riskfactorsandwherepeoplecango
forscreening.
PreͲdiabetes(At–riskpeople)
UndiagnosedDiabetes*
KNOWNDIABETES
x
AtDiagnosis
x
Established
uncomplicated
Diabetes
x
Diabeteswith
complications
Provideservicesfor:
Ͳ Clinicalcareaccordingtoguidelines(DMG,IECs)
Ͳ Educationinself–care&monitoring(PDRB)
Ͳ Informationaboutrecommendationsforclinicalcare(personaltargets
forcontrol)
Provideservicesfor:
Ͳ Routinemonitoringofdiabeticandgeneralhealthstatus
Ͳ Regularscreeningforcomplications
Ͳ Managementofproblemsastheyarise
Ͳ ReinforcementofselfͲcareeducation
Ͳ Affordabletherapiesandsupplies.
Implementprogramsfor:
Ͳ Identificationandreductionofrisksfordiabetescomplications
Ͳ Self–careeducationandpsychoͲsocialsupport
Supportgoaldirectedresearchaimedatcuringdiabetes.
Provideservicesfor:
Ͳ Preventionoftheprogressionofcomplications
Ͳ Self–careeducationandpsychoͲsocialsupport
Ͳ Rehabilitationofpeoplewithdisabilities
Ͳ Palliationforpeoplewithendstagecomplications
Supportgoaldirectedresearchaimedatthereversalofcomplications.
*Untilmodifiableriskfactorsareidentifiableandeffectiveinterventionsavailable,theseinterventionscannotbe
appliedtoType1diabetes.
AdaptedfromtheAustralianNationalDiabetesStrategyandImplementationPlan,1998
45
1
2