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 Edition 2012
MINISTRY OF HEALTH
Government of Fiji
2012
Disclaimer
Theauthorsdonotwarranttheaccuracyoftheinformationcontainedintheseguidelinesand
donottakeresponsibilityforanydeaths,loss,damageorinjurycausedbyusingthe
informationcontainedherein.
Whileeveryefforthasbeenmadetoensurethattheinformationcontainedinthese
guidelinesiscorrectandinaccordancewithcurrentevidenceͲbasedclinicalpractice,the
dynamicnatureofmedicinerequiresthatusersexerciseinallcasesindependentprofessional
judgmentwhenusingtheseguidelines.
ii
GUIDELINESFORMANAGEMENTOFDIABETES
ThirdEdition2012
ThesecondEditionwasrevisedandupdatedbyasubͲcommitteeoftheNationalMedicinesand
TherapeuticsCommittee.
TheDiabetesClinicalServicesNetworkupdatedthis(thethird)editionoftheDiabetes
ManagementGuidelineswithcontributionsandcommentsfrom:
DrShrishAcharya,ConsultantPhysician;HODMedicine;Chairperson,Medical&DiabetesCSNs
andallmembersoftheDiabetesandMedicalCSNs
DrJemesaTudravu,ConsultantOrthopaedicSurgeon;MedicalSuperintendentCWMHospital;
ChairpersonofSurgicalCSNandallmembersoftheSurgicalCSN
DrJosephKado,ConsultantPaediatrician;ChairpersonPaediatricCSNandallmembersofthe
PaediatricCSN
DrJamesFong,ConsultantObstetrician;ChairpersonObstetricsCSNandallmembersofthe
ObstetricandGynaecologyCSN
DrLuisaCikamatana,ConsultantOphthalmologist;MedicalSuperintendentLautokaHospital;
ChairpersonOphthalmologyCSNandallmembersoftheOphthalmologyCSN
MsAnaisiDelai,NationalAdviserNutrition&Dietetics;ChairpersonoftheNutritionandDietetics
CSNandallmembersoftheNutritionandDieteticsCSN
TheChairpersonandmembersoftheMentalHealthCSN
TheChairpersonandmembersofthePhysiotherapyCSN
TheChairpersonandmembersofthePharmacyCSN
TheChairpersonandmembersoftheLaboratoryCSN
DrIsimeliTukana,NationalAdviserNCDsandmembersoftheNCD/WellnessUnit,MOH.
DrMargaretCornelius,TechnicalFacilitator,Diabetes,FijiHealthSectorSupportProgram.
SpecialthankstoDrGyaneshwarRao,ConsultantPhysicianCWMHforhiscontinuoussupport
duringthisprocess.
ContributionsandcommentswerewelcomedandgratefullyreceivedfromDivisionalandSubͲ
DivisionalMedicalOfficers.
SecretariatsupportwasprovidedbyNationalProjectOfficer,NonͲCommunicableDiseases,
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
1
2
3
4
5
6
7
8
9
10
11
Topic
Page
NationalNCDProgram
1
2
2
3
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
TheMOHNationalNCDStrategicPlanproposesintervention“fromwombtotombwithadouble
edgedsword”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%by2014andimprovethe
deliveryofDiabetesservices.Tobeabletodeliverthis,thehealthsystemneedsto:
x Promote the Health and Welfare of people with Diabetes and provide support for their
families.
x PromoteabetterunderstandingandawarenessofDiabetesinthegeneralcommunity.
x Develop and implement innovative and cost effective ambulatory care services that
complementtheworkofotherhealthcareprofessionals.
x Develop and maintain high standards of care through a range of quality improvement
activities.
x Conducthighqualityclinicalandeducationalresearch.
x Provideuptodateandinnovativetrainingofhealthprofessionals.
x Maintain a comprehensive database to support all the activities of the health facilities
including screening high risk persons and supporting planning and research on Diabetes
careinourcommunity.
Theaimofthediabetesmanagementguidelinesisto:
x Recognizeearly,diagnoseandmanageDiabeteseffectively.
x Helpdeferordelaytheonsetofcomplications.
x Managecomplicationseffectivelywiththeavailableresources.
x Haveaneffectivereferralsystemforoptimuminterventionateverylevel.
(SeeAnnex3:Keyinterventionsandchecklistoftasks)
1
2.INTRODUCTION
Diabetes mellitus is defined as a metabolic disorder of multiple aetiology, characterized by
chronichyperglycaemiawithdisturbanceofcarbohydrate,proteinandfatmetabolismresulting
fromdefectsininsulinsecretion,insulinaction,orboth.Howeverwhileinsulindefectsmentioned
arecriticalabnormalities,severalotherfactorscontributetothehyperglycaemicstate.
Themajortypesofprimarydiabetesmellitusare:
x Type1diabetes
x Type2diabetes
x Gestationaldiabetes
2.1RECOGNITION
Type 1 diabetes is characterized by progressive beta cell destruction, severe insulin deficiency,
and the urgent need for insulin replacement therapy because of the risk of ketoacidosis and
death.Patientsareusuallylessthan30yearsbutitcanpresentinolderpatients.Theonsetof
symptomsismorerapidandketonesareusuallypresent.
Atpresentation,thepatientwithsuspectedType1diabetesshouldbeimmediatelyassessedto
determineappropriatemanagement.Itisadvisabletoreferallsuchcasestothenearesthospital
fortheinitialmanagement.
Type2diabetesiscommonandisthepredominantformofdiabetes.Itoftengoesundiagnosed
formanyyearsbecausethehyperglycaemiadevelopsgraduallyandatearlystagesofthedisease
process it is often not severe enough for the patient to notice any of the classic symptoms of
diabetesandindeedmayhaveevidenceofcomplicationsatdiagnosis.
There are a number of factors known to be associated with a higher risk of developing type 2
diabetes and any person with any of these factors should be screened for the diagnosis of
diabetes.
PopulationatRiskincludes:
x
x
x
x
>30yearolds
HighRiskEthnicity
Previous history of Gestational Diabetes
Mellitus(GDM)
FamilyhistoryofDiabetesMellitus
x
x
x
PhysicalInactivity
MacroͲvascularDisease
HypertensionorDyslipidaemia
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
2
Conditions listed below may suggest underlying diabetes which requires confirmation with the
appropriatebloodsugarstudies:
Footsepsis,multipleabscesses,delayedwoundhealing,neuropathy,visualimpairment
Gestationaldiabetesisdiabetesdevelopingforthefirsttimeinpregnancy.Itspathophysiologyis
similar to Type 2 diabetes. The interpretation of blood glucose levels for diagnosis is more
stringentcomparedtothatofothertypesofdiabetes.Itmaydisappearafterdeliverybutsignals
ahighriskofdevelopingdiabetesinlaterlife.Henceaclosemonitoringofsuchclientsorpatients
isessential.
2.2DIAGNOSISOFDIABETESMELLITUS
Afirmdiagnosisofdiabetesisbasedonbloodsugarlevels.Urinetestingisnotreliable.Capillary
bloodglucosetestingifusedshouldbeconfirmedbyvenousbloodtesting.Anovernightfasting
blood sugar level is often preferred though random blood sugars can be used. Two positive
resultsontwodifferentdaysarerecommended.Asinglepositiveresultissignificantifthereis
unequivocalhyperglycaemiawithmetabolicdecompensationorisaccompaniedwithsymptoms
ofdiabetes.
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,howeveritsgreatestvalueinFijiatpresentisformonitoringthecontrolofbloodsugar
levels.
Bloodglucoselevelsabovethenormalbutbelowthat,whichisdiagnosticofdiabetes,arenotto
beneglectedastheyconstitutetwoveryimportantentitiescalledImpairedFastingGlucose(IFG)
andImpairedGlucosetolerance(IGT),themanagementofwhichrequiresactivelifestylechanges
(SNAPIntervention–seesection3.3)topreventthedevelopmentofdiabeteslaterinlife.These
individualsmustbecloselymonitoredwithfurtherbloodglucosetestresultsin6months’time.
3
3.THEMANAGEMENTOFDIABETESINADULTS
DiabetesinadultsismainlyType2butType1diabetescanalsooccur.Inapersonknowntohave
diabetesoronewhohasbeennewlydiagnosed,themanagementaspectshouldnotonlyfocus
on the control of blood sugars alone but be viewed as a package. The overall diabetic
management requires a multifactorial approach to prevent the development of cardiovascular
andmicrovasculardisease.Apracticalapproachtothemanagementoftype2diabetesinadults
isconsideredbelow.
3.1CLINICALASSESSMENT
Alldiabeticpatientsrequireathoroughclinicalassessmentoninitialvisit,whichincludesareview
of history, physical examination and relevant investigations as outlined below. Any further
assessmentthereafterwillbelessintensivebutwilldependontheclinicalstatusofthepatientat
thatstage.
ReviewofHistory
Physicalexamination
SeverityofSymptoms
Alertnessandhydration
General health and Height and Weight
interͲcurrentillness
calculated)
Family history
diabetes
Socialhistory
Relevantinvestigations
Order & review investigations as
indicated
Full Blood Count: A low Hb may
indicate an underlying chronic
kidneydisease
(BMI Blood biochemistry: urea,
electrolytes,creatinine,lipidprofile,
FBSorRBS,HbA1c
of Pallor
Urine for microͲalbuminuria (if test
Vitals:Pulseandbloodpressure notpossible,doproteinuria)
(BP),
respiration
and temperature (if indicated). BP
measurement should include
anyposturaldrop.
Current medications Heartandlungexamination
and history of drug Examination of the extremities
allergy
for
oedema,
peripheral
pulsationandneuropathy
Visualacuityandfundoscopy
Capillarybloodglucose
KetonesͲifwarranted.
4
3.2CATEGORIESANDREFERRALRECOMMENDATIONS
Category
Definition
0
PeopleatRiskofDiabetes
1
Newlydiagnosed
RecommendedAction
ManagedatHealthCentresandNursingStations
Refertothehealthcentre/subdivisionalhospital
2
3
Establishedandwellcontrolled
Establishedandpoorlycontrolled*
ManagedathealthCentres/subdivisionallevel
RefertotheHubCentre/SubdivisionalHospital
4
Establishedwithcomplications
RefertotheHubCentre/divisionalHospital
5
Established with complications and RefertoDivisionalHospital
otherconditions/complicatedissues
*Seetablefortargetsforcontrolonpage30
Oninitialassessment,patientsshouldbescreenedforcomplications.Ifnocomplicationsexist,perform6monthly
screening.Ifcomplicationsexistthenrefertoappropriatechaptersintheguidelineformanagement.
3.3NONͲPHARMACOLOGICALINTERVENTION(LIFESTYLEMANAGEMENTorSNAP)
Modificationofadverselifestylefactorsisanintegralpartinthemanagementofalltypesofdiabetesandin
the prevention of diabetes. The important factors requiring attention include smoking, nutrition, alcohol
andphysicalinactivity(SNAP).
Smoking:Inpatientswithdiabetessmokingisanindependentriskfactorforcardiovasculardisease.There
isnosafelevelofsmoking.Passivesmokingisalsodetrimental.Allpatientswhosmokeandaresuffering
fromdiabetesmustbeencouragedtostopsmokingorprovidedassistancetoquitsmoking.
ImportantadvicetopeoplewantingtoQuitSmoking:
x
x
x
x
x
x
Tellyourfamily,friendsandcoͲworkersthatyouarequitting
Askfriendswhosmokenottosmokearoundyouorofferyouacigarette
Followthe4D’s:
o Delay
o Deepbreathing
o Drinkwater
o Dosomethingelse
Avoidalcoholandgrogwhichcanleadtosmoking
Nutrition(Dietandweightcontrol):Type2diabetesisassociatedwithobesity.Weightmanagementisan
integralpartofdiabetescare.Studieshaveshownthatweightreductionimproveshyperglycaemia.Itcan
also assist in reducing the dose or in stopping the anti diabetic medications and in the control of
hyperlipidaemia and blood pressure. There are many ways for achieving weight reduction. It can be
through the individual’s diet and physical activities and these can be targeted easily. A healthy
recommendeddietistobepursued.Thedietshouldberichinfibre,wholegrains,andlegumes;contain
lessthan7%saturatedfatandnotransfats.Thedietshouldalsobelimitedincaloriesandincludefoods
withlowglycaemicindex.
TheBodyMassIndexiscalculatedusingthefollowingformula:
BodyMassIndex(BMI)= weight(kg)
Heightxheight(inmeters)
¾
Forrisklevels–refertoAnnex1
5
The following advice is for managing diabetes through healthy eating:
Ahealthydietwillhelppeoplewithdiabetescontrolbloodglucoselevelsandreducetheriskofcomplications.
Allstarchyandsugary(carbohydrate)foodsarebrokendowninthestomachto
sugar(glucose)andabsorbedintotheblood.
Peoplewithdiabetesshouldavoideatingtoomuchcarbohydratefoodswhichincreasebloodglucoselevels.
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.
Alcohol – all diabetic patients must be aware of high caloric value of alcohol and the effect of excess
consumption on body weight. If consumed, alcohol intake should be no more than two standard drinks
daily.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
h
h
h
285millilitres(ml)fullͲstrengthbeer,or
375mllightbeer(averagecan)
100mlwine(smallglass)
30mlspirit(barmeasure)
AVOIDBINGEDRINKING(KEEPTO2orLESSSTANDARDDRINKSPERDAY)
6
Physicalinactivity
Regularphysicalactivityisimportantindiabeticpatients.Itisimportanttogetthepatient’sview
on physical activities, the current activities pursued, the activities possible and how to
accommodate relevant activities in daily routine. Patients are to be advised to keep themselves
activeintheirownwaysdailyandifpossibletopursueatleast30minutesofmoderateintensity
physical activity such as brisk walking, cycling and gardening. Patients who have not been
physically active previously should be advised to start slow and go slow. Those on antiͲdiabetic
medications,especiallyinsulintherapy,shouldbeadvisedtotakesomecarbohydrateintakeprior
tomoderateintensityphysicalactivitytoavoidtheriskofhypoglycaemicattacks.
Thefollowingadviceisfordiabeticpatientswho
arephysically active:
x Adoptthetypeofphysicalactivitythatyoucando
x Drinkwaterbefore,duringandafterexercise
x Donotexerciseimmediatelyaftertakinginsulin
x Bealertforsignsoflowsugarandtakeappropriatemeasuresiflowsugar
conditionarises
x Beactive1Ͳ2hoursafteryouhaveeaten
x WearcomfortableandwellͲfittingshoes
x Seekadvicefromyournearesthealthworkerwheneverneeded.
Patientswithendorgandamage(complications)willneedspecializeddiet&physicalactivityplans.
Stress
During stress, there is an increased demand for energy mainly from the body’s stored fat and
glucose. People under stress tend to neglect looking after themselves. They may forget to take
theirmedicationsorfailtomonitortheirfoodchoicesorintake.Somepeoplecopewithstressby
takingalcoholordecreasetheirphysicalactivities.
Peoplewithdiabetesshouldbecounseledto:
x Handlestressmorepositively
x Replacebadornegativethoughtswithgoodorpositiveones.
x Controlthebody’sreactionstostressthrough
o Relaxationtechniques:likebreathingexercises,meditation,yoga,
o Exercisingordancing
o Listeningtocalmingmusic
x Talk to someone and share worries. It helps to see things in a different light. They
maynotbereallyasbadaswethink.
x Startahobby,learnnewthings!
Practicethe12S’s(refertoAnnex2forthelist)
Throughrelaxation,theydecreasethebody’sneedforenergy,consequentlydecreasingbloodglucoselevels.
7
3.4MANAGEMENTOFHYPERGLYCAEMIA Theoverallaimofglycaemicmanagementistominimizelongtermcomplicationswhileavoiding
severe hypoglycaemic events. Results of various randomized trials in diabetic patients have
shown that control of hyperglycaemia delays the onset and slows the progression of
microvascularcomplications.Howeveritseffectonmacrovasculardiseaseremainsuncertain.
Thefirststepinthecontrolofhyperglycemiaissettinganappropriateglycaemictargetineach
individual.Inyoungerpatientswithnocomplicationsofdiabetesanearnormalglycaemictarget
can be aimed for, while in older patients withcardiovascular diseaseand multiplevascular risk
factors,ahigherglycaemictargetshouldbethegoal.Intensiveglucosecontrolinthelatterposes
adverse effects from the multiple drugs used and the risk of hypoglycaemia. This can be
documented in the personal Diabetes Record Book issued to diabetic patients attending SOPD
clinics.
Activelifestyleintervention(SNAP)shouldbepursuedpriortointroducingdrugtherapyassome
Type2diabeticpatientsmayachievesatisfactoryglycaemictargetwithouttheuseofdrugs.
WhentostartPharmacologicalInterventionforhyperglycemia
x Uncomplicatednewlydiagnoseddiabeticpatientswhoareunabletocontrolbloodsugars
withlifestyleinterventionwithin6weeks.
x Newlydiagnosedpatientswithdiabeticcomplications.
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
patientssufferingfromdiabetesandisthepreferreddruginobesetype2diabeticpatients.
Itisclearedfromthebodypredominantlybyrenalexcretion.Itaccumulatesinrenalimpairment
andshouldbeusedwithcautioninpatientswithserumcreatinineofmorethan200umol/Lor
eGFR of <45ml/min. Patients receiving longͲterm metformin should have regular (at least 6Ͳ
monthly)monitoring oftheirrenalfunction.Itsroleinpregnancyandbreastfeedingmothers is
discussedundergestationaldiabetes.
Itcancauselacticacidosisinsituationssuchasischemicheartdisease,congestiveheartfailure
and renal impairment. It should be stopped for 48 hours before surgery or administration of
contrast radiography and only resumed once urine output and renal function have returned to
acceptablelevelasstatedavove.Thereisnoriskofhypoglycaemiawhenusedalone.
Itsmajoradverseeffectsare:anorexia,nausea,abdominaldiscomfortanddiarrhoea.
Metformin is given orally 2Ͳ3 times a day and taken with or after meals to avoid gastric
intolerance.Thedosevariesfrom500mgdailytoamaximumof3g/dayindivideddoses.Most
8
physicianslimitthedoseto2gramsdailybecause,athigherdoses,gastrointestinalsideeffects
aremorecommon.Itisadvisabletobeginwithasmallerdosetostartwithand increasethe
dose gradually to facilitate compliance; otherwise the development of gastrointestinal side
effectswillstopthepatientfromtakingthedrug.
3.4.2.Sulphonylureas
Twoofthesecompounds,glibenclamideandglipizide,areavailableontheFijiEMF.Theyacton
thepancreaticbetaͲcellsandinduceinsulinsecretion.Glibenclamideispredominantlyclearedby
the kidneys and it is recommended in younger patients. In contrast, glipizide is cleared by the
liverandthekidneysanditistherecommendeddruginolderpatientsandinpatientswithrenal
impairment.Sulfonylureasareusedinleantype2diabeticpatients.Theycanbecombinedwith
metforminifthediabetescontrolisinadequate.
Thesedrugsarenotrecommendedinpregnancyandforlactatingmothers.
Hypoglycaemiaisthemajoradverseeffectespeciallywhenthereissignificantrenalimpairment.
Thisislesslikelywithshorter–actingdrugs(i.e.glipizide)butmuchmorelikelywithlongerͲacting
compounds (i.e. glibenclamide). Glipizide can be given as a single dose up to 15 mg/day orally
withmealsandintwodivideddosesabove15mguptoamaximumof40mg/day.Thedosageof
glibenclamidevariesfrom2.5mgto20mgdailyorallywithmealsandintwodivideddosesabove
10mguptoamaximumof20mg/day.
Gliclazideisanoralhypoglycaemicdrugandisclassifiedundersulphonylureagroupofdrugs.Itis
usedwhendiabetesisnotcontrolledwithlifestylemodificationsorwheninsulintherapyisnot
required. It is metabolized by the liver and is contraindicated in severe hepatic and renal
dysfunction.Itisavailableasimmediatereleasetablet,80mgstrength,orasaModifiedRelease
(MR)formulations,30mgand60mgstrength.Theinitialdoseis40Ͳ80mgdailyandisadjusted
accordingtoresponseupto160mgasasingledose;higherdosesaredividedandgivenastwice
daily. The maximum dose is 320 mg daily. The MR preparation dosage varies from 30Ͳ 120 mg
oncedailyatbreakfast.(Note:30mgofMRproductisequivalentto80mgofconventionaltablet).
Glimepirideisasulphonylureaantidiabeticmedication.Itmaybeusedaloneorwithotheranti
diabetic medications. The usual dose is 1Ͳ2 mg with breakfast, it is given once daily. Further
dosageadjustmentsaremadeeverytwoweeksasrequired.Themaximumdoseperdayis8mg.
GliclazideandGlimepiridearenotavailableonFijiEMFbutcanbeobtainedfromtheretailpharmacies.
3.4.3.OtherOralAntiDiabeticDrugs
ThiozolidinedionesͲTwocommonlyuseddrugsarePioglitazoneandRosiglitazone,theformeris
preferred because of better side effect profile. The common side effect of these drugs include
oedema,weightgainandprecipitationofheartfailure,hencethesedrugsarecontraindicatedin
heart failure. Risk of fracture should be considered in the long term in females treated with
pioglitazone.Theyincreasetissuesensitivitytoinsulin.Pioglitazonecanbeusedasmonotherapy
9
butcanbecombinedwithdualortripletherapyincombinationwithmetformin,sulphonlyureaor
insulin.Thedoseofpioglitazoneis15Ͳ30mgasasingledose.
Alpha glucosidase Inhibitors – these are oral glucose lowering agents that inhibit alpha
glucosidaseenzymesinthebrushborderofthesmallintestine.Theseenzymesconvertcomplex
carbohydrateintheintestinetosimplesugarsforabsorption.Thedrugavailableinthisgroupis
Acarbose.Itcanbeusedasmonotherapyorcombinedwithotheroralantidiabeticmedications
including insulin. The common side effects include abdominal discomfort because of
fermentationofundigestedcarbohydratebycolonicbacteria.Hypoglycaemiadoesnotoccur.Itis
notrecommendedinchronicintestinaldisease,intestinalobstructionandcirrhosis.Smallerdoses
arerecommendedinrenalandhepaticdysfunction.Acarbosecomesas25mg,50mgand100mg
tablets.Startthedosewith25mgthreetimesadayto100mgtdsasrequired.Itshouldbetaken
withthefirstbiteofameal.Themaximumdoseperdayis600mg.
There are other anti diabetic medications which are not available in Fiji. These include Peptyl
peptidaseͲ4Inhibitors,MeglitinidesandGlucagonlikePeptideͲ1Agonists(GLPͲ1).
3.4.4.Insulins
TherearethreeinsulinpreparationsavailableontheFijiEMFandarediscussedbelow.Theusage
ofthesepreparationsisdiscussedlater.
Insulinisgivenusingconventionaldisposableinsulinsyringes.InsulinpensandpreͲfilledsyringes
areexpensiveoptionsandareavailableonlyintheprivatesector.
The preferred sites of injection are the abdominal wall, the deltoids and the thighs. It is
recommendedthatthesesitesberotatedregularly.
Types
CharacteristicsofavailableInsulins
OnsetofEffects
(InHours)
0.5
ShortͲactingsolubleinsulin
(ActrapidHM,HumulinR)
IntermediateͲacting
isophane 1–2.5
insulin (Protaphane HM, Humulin
NPH)
Biphasicisophaneinsulin
0.5Ͳ1
(Mixtard70/30)
MaximumEffect
(InHours)
2– 5
Duration
(InHours)
6–8
4–12
16–24
2Ͳ12
16–24
ThereareothertypesandbrandsofInsulinavailableoutsideofFijiEMFsuchasthelongactingpreparations
detemirandglargine.
InsulinPens
Theseareinsulindeliverydevicesavailableinmanydifferentbrandsandmodels,mainlyforpersonaluse.
Theygenerallyfallintotwo(2)groups:reusablepensanddisposablepens.
ReusableinsulinpensareloadedwithaninsulinͲfilledcartridgebeforeuseandreplacedbyanother
cartridgewhenempty.Setoffive(5)replaceablecartridgesareusuallyavailablewitheachcartridge
containingeither150or300unitsofsoluble,intermediateormixedinsulin.Needlesareavailable
separately.
10
Disposableinsulinpenscomefilledwithinsulinandarediscardedwhenempty.Needlesareavailable
separatelyanddisposablepensmaybeavailableinsetsoffive(5).
Thereareadvantagesanddisadvantagesofusingtheinsulinpens:
Someadvantagesarethattheyarediscreet,userfriendly,insulinispreͲfilled,peniseasilyportableand
convenientforinjectionsawayfromhome.
Somedisadvantagesarethatthepensmaybemoreexpensive,notalltypesofinsulinmaybeavailableand
theydonotallowmixingofinsulin.
Formoreinformationrefertowww.bd.com/us/diabetes/page.aspx?cat=7001&id=7254&
www.insulinpens.com/
Insulinpensarenowavailableingreatmanystyles.
InsulinPumps(alsoknownascontinuoussubcutaneousinsulininfusiontherapy)
Thesearesmallcomputerizedinsulindeliverydeviceswhichcanbewornonthebeltorkeptin
thepocketsofpatients.ThepumpsallowforacontinuousflowofrapidͲactinginsulinintothe
bodythroughacatheterinsertedundertheskinoftheabdomen.Theinsulinpumpisdesignedto
deliveracontinuousamountofinsulin,24Ͳhoursadayaccordingtoaprogrammedplanunique
toeachpumpwearer.Theamountofinsulindeliveredcanbechangedbytheuser.Theinsulin
pumpisanalternativetomultipledailyinjectionsforintensiveinsulintherapy(whichincludes
frequentbloodglucosemonitoringaswell).
Thepumpsalsohavethecapabilityofrecordingthehistoryofinsulindeliveryandthiscouldbe
downloadedontoacomputerforanalysis.
Inrecenttimesinsulinpumptechnologyisbeingcombinedwithcontinuousbloodglucose
monitoringsystem.Whenthefeedbackloopiscomplete(insulindeliverybasedonfeedbackof
thebloodglucoselevel)thesystemmayfunctionasartificialpancreas.
Formoreinformationreferto:diabetes.webmd.com/insulinͲpump;en.wikipedia.org/wiki/insulin_pump;
www.medtronicͲdiabetes.com.au
Note:VerysmallnumbersofpatientsinFijiareusingtheinsulinpensandevenfewermaybeusingthe
pump.However,visitorstothecountrymaybeusingthesedevicesandmayseekyouradviceorhelp.
11
Insulintreatmentintype2diabetes
(i)Decidingwhentostart
x Failure of oral hypoglycaemic agents – insulin therapy should not be delayed. Early
treatmentdelayscomplicationsandpreservesbetacellfunction.
x Patientsundergoingmajorsurgery,
x Criticallyillpatients,
x Pregnancy
(ii)Administeringinsulinwithoralhypoglycaemicdrugs
x Asoutpatienttreatment,initiatewithIsophaneormixedinsulin10unitssubcutaneouslyat
bedtimeandadjustdoseaccordingtobloodsugarlevels.
x If the blood sugar is not controlled then use Isophane or mixed insulin 10 units
subcutaneously twice daily with subsequent adjustment of the dose according to blood
glucoselevels.
x Oral hypoglycaemic agents should not be stopped with the commencement of insulin
therapythoughadjustmentscanbemadeasrequired.
(iii)Insulinregimens
(a) MultipleͲdose(“QID”)regimen
Thisregimenismoresuitedforstabilizationofbloodsugarforinpatients.
x Solubleinsulinstartingwith5unitssubcutaneously30minutesbeforeeachmeal
AND
x Isophane8unitssubcutaneouslytwiceaday.
Insulindosesshouldbeadjustedbasedonthebloodsugarlevels.
(b) Twicedailyregimen
Thisregimencanbeusedforcontrolofbloodsugarforbothinpatientsandoutpatients.
•Mixtardinsulin70/30,startingwith10unitsinthemorningand5unitsintheevening
subcutaneously30minutesbeforemeals.Adjustinsulindosetocontrolbloodsugars.
Ifmixedinsulinpreparationisunavailablethenuse:
Isophaneinsulin10unitsinthemorningand5unitsintheeveningsubcutaneously30minutes
beforemeal.Dosesareadjustedtocontrolthebloodsugarlevels.
Inprinciple,twoͲthirdsoftheinsulindoseshouldbeadministeredinthemorningandonethirdin
the evening. However, insulin doses should be adjusted based on the blood sugar levels and
incrementsof5unitsperdosearerecommended.
If blood sugar level remains uncontrolled then contact the medical registrar at your divisional
hospital.
*Forbothinsulinregimen,extrasolubleinsulin5unitssubcutaneouslycanbegivenifblood
sugarsarenotcontrolled.
12
3.5GENERALAPPROACHTOTHEMANAGEMENTOFDIABETES
ThegeneralapproachtothemanagementofdiabetesisoutlinedbelowinFigure1.
All patients with type 1 diabetes besides lifestyle modifications (SNAP) require insulin therapy.
Adultscanbemanagedasanoutpatient.(Note:childrendiagnosedwithType1diabetesshould
bereferredtoaspecialistpaediatricunitforfullassessmentandthemanagementisdiscussedin
sectionunderDiabetesinChildren).
Forallpatientswithtype2diabetes,NonͲPharmacological(SNAP)interventionisessential.This
approach can produce good glucose control. Drug therapy should only be consideredifblood
sugarlevelsremainuncontrolledafter6weeksoflifestylemodifications.
Thedecisiontocommenceglucoseloweringmedicationsisbasedonthedegreeofhyperglycaemia
andthepresenceorabsenceofsymptoms.
Ingeneral,theuseoforalglucosemedicationsshouldbeconsideredifdespiteSNAPintervention
thefastingglucoselevelsareabove7mmol/Land/orHbA1cis>7.0%.
Thefigurebelowshowsthetargetstobeachievedthatensuesgooddiabeticcontrol.
Aimfor:
Fasting
4Ͳ 6mmol/l
Bloodglucosecontrol
Random
5Ͳ 9mmol/l
targetsforpersonswith
7%
Type2Diabetes
HbA1c
NOTE:Asdiscussedabovetheglycaemictargetforolderpatientswithcardiovasculardisease
andmultiplevascularriskfactorswarrantslevelshigherthanthatmentionedabove(8Ͳ10mmol/l)
Metformin is now generally considered to be first line treatment unless contraindicated. A
sulphonylureagroupofagentlikeglipizideorglibenclamideisaddedlaterifthebloodsugarlevels
are still not adequately controlled. Treatment with other oral glucose lowering medications
(glitazones, alpha glucosidase inhibitors) and/or insulin needs to be determined on an individual
basis.
Glucose control progressively deteriorates over time requiring an increase in drug therapy to
maintainglycaemiccontrol.About50% ofpatientswillrequireinsulintherapyinadditiontooral
medications within 5 to 10 years of diagnosis of Type 2 diabetes (secondary failure). In these
patientscombiningoralglucoseloweringmedicationswithinsulinminimizestheamountofinsulin
required.
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
Physical activity carries additional risks in diabetic patients on insulin therapy.
Hypoglycaemiaisamajorconcerninthissituation.
For mild to moderate physical activity (e.g. fast walking on a flat surface, mopping the
floor)for30minutes,extracarbohydratesshouldbetakenbeforehand.
For “short bursts” or longer strenuous physical activity (e.g. scrubbing the floor, moving
heavyfurniture),itisadvisabletoreducedosageofshortͲactinginsulin.
3.6.2FASTING
Manypatientswithdiabetesfastforreligiousorotherreasons.
ForType1diabeticpatients:theirusualdailyinsulindosecanbedividedintotwodosesgiven
beforeeachofthetwomainmealsoftheday.
ForType2diabeticpatients:Thetimingofthedoseoftheoralhypoglycemicagentisimportant.
Forthosepatientsonmetformin,dosescanberearrangedtocoincidewiththetwomainmealsof
theday.
For those patients on sulfonylureas especially Glibenclamide: for once daily dosage, give
medicationwiththefirstmainmealandforthoseontwicedailydosage,givethemedicationwith
thetwomainmeals.
3.6.3ILLNESS
Metaboliccontrolmaydeterioraterapidlyduringillnessofanykind.
Aspartoftheireducationprogramallpatientsshouldhaveacontingencyplanonwhichthey
canworkonifanillnessupsetstheirdiabetescontrol.
Thereshouldbeclosemonitoringofbloodsugarlevels.
InsulindosesshouldbeadjustedaccordingtobloodsugarlevelsandchangedtoshortͲacting
insulinforbettercontrol.Insulinmustnotbestopped.Ifthereisaneedtoreducethedose,it
shouldnotbemorethan30%.
Oralhypoglycaemicdrugsshouldnotbestoppedunlessthepatientcannoteat.
Maintenanceoffluidintakeisimportant.
If the patient is unable to take in solid food, substitute with fruit juices, regular soft drinks, or
otherfluidscontainingglucose.
Patientswhohaverepeatedvomitingshouldcontactmedicalhelpearlyasbothintakeoffluids
andcarbohydratesneedtobemaintained.
The patient should have thorough knowledge of when, how and where to contact a specialist
healthcarefacility.
15
3.6.4TRAVELING
Patientsoninsulincantraveloverseasaslongthereisproperadjustmentoftheirfoodandinsulin
dosestoadapttothechanginglocaltimes.
Journeysshouldbecarefullyplanned.Enoughinsulinforthewholetripwithsomesparesshould
becarried.Insulinshould be kept cool inside a wellͲinsulated bag. It is advisable to carry a
medical report from the doctor with treatment details to facilitate customs clearance. The
reportwillassistindealingwithanymedicalproblemsthatmayariseduringtraveling.
Easilyabsorbedsugaryfoods(e.g.lollies,fruitjuice)shouldbeavailablewhiletravelingaswellas
foodthattakesalittlelonger(e.g.crackers)toabsorb.Thesecanbetakenifthereisanindication
ofimpendinghypoglycaemia.
16
4.0TreatmentofAssociatedMetabolicConditions
4.1Hypertension
Thisisamajorriskfactorforbothcardiovasculardiseasesandrenalcomplications.
BloodpressurecontrolismoreimportantthanthechoiceofantiͲhypertensivedrugs.However,
angiotensin converting enzyme inhibitors (ACEIs) are the firstͲline drugs in controlling
hypertension.OtherantiͲhypertensivedrugssuchasbetaͲblockers(e.g.atenolol),slowrelease
calcium channel blockers (e.g. nifedipine), and loop diuretics (e.g. furosemide) can also be
used. In Fiji, methyldopa is available and can be used if the above drugs are not available. A
combinationoftheabovedrugsmightbeneededtoachievedesiredbloodpressurecontrol.
WhenACEIsareusedtocontrolhypertension,itisimportanttomonitortherenalfunctiontwo
weekslater.Aslightincreaseinserumcreatinineisgenerallyexpectedandisusuallylessthan
30% of baseline values. If there is more than 30% rise in serum creatinine from the baseline
values, it is recommended that ACEIs should be stopped and replaced by another antiͲ
hypertensivedrugafterconsultationwiththespecialistatthedivisionalhospital.Thisriseinserum
creatininemightindicateunderlyingrenalarterystenosis.
Treathypertensionasfollows:
i) If renal function is normal (regardless of blood pressure) but microalbuminuria is
present,startenalapril5Ͳ40mgdaily.ThetargetofBPcontrolislessthan130/80mmHg.
ii)Inthepresenceofrenalimpairmentand/orsignificantproteinuria(>1g/dayor++++ondipstick),
theBPshouldbelowerthan120/80mmHg.
Caution is required with ACEIs therapy because of the risk of development of hyperkalemia.
When possible, it is advisabletomonitorelectrolytesatleastonceeverysixmonthsorearlierif
required.AcommonsideeffectofACEIsiscough.AnalternativeistouseACEreceptorblocker(not
availableintheFijiMedicineFormulary).
4.2Hyperlipidemia
Thisisacommonoccurrenceindiabeticpatients.
Elevated triglycerides and LDL (lowͲdensity lipoprotein) cholesterol with reduced HDL (high
densitylipoprotein)cholesterolisacommonpatternandmaywarranttreatment.Gettingthebest
possible control of blood glucose is an important first strategy. If lipid abnormalities persist
despitethis,theymayneedtobetreatedintheirownright.Therecommendeddrugsarestatins
(e.g. simvastatin, atorvastatin , pravastatin, lovastatin ). The common side effects of lipid
loweringdrugsaremuscleandliverproblems.
ItisadvisabletodoLFTsbeforestartingstatinsandamonthaftercommencementofstatins.
Lipid lowering drug therapy with simvastatin 40 mg or atorvastain 10 mg is recommended for
primary prevention in patients with type 2 diabetes aged > 40 yrs regardless of baseline
cholesterol.Patientsunder40yearsandotherimportantriskfactorsshouldalsobeconsidered
forantiͲlipidtreatment.
4.3Antiplatelettherapy
Unless *contraindicated Aspirin is recommended for adults with diabetes and a history of
cardiovascular diseases (CVD). In the absence of CVD, it is “reasonable” to consider Aspirin in
thosepatientswhoareatanincreasedriskbasedonage(males>50yearsandfemales>60years)
and at least one additional CVD risk factor such as smoking, dyslipidemia, hypertension, family
historyofdiseaseandalbuminuria.
*CommoncontraindicationstoAspirintherapyare:
Historyofpepticulcerdisease
intracranialbleed
GIbleed
Bleedingdisorder
Lowplateletstates
17
5.0ManagementofacutecomplicationsofDiabetes
5.1HYPOGLYCAEMIA
Hypoglycaemiaisaconditiondefinedasafallinthebloodsugarleveloverashortperiodoftime
causingsymptoms.Diabeticpatientsaremorepronetohypoglycaemicsymptoms,mainlybecause
oftheuseoforalhypoglycaemicagents,insulinandtheriskofsepsis.
However, the threshold varies from person to person. A diabetic patient who is subject to low
bloodsugarlevelsmostofthetimemaynotexperienceanysymptomsforseveralhoursevenwith
bloodsugarlevelsaslowas1.0mmol/l.
Ontheotherhandadiabeticpatientwithpersistentlyelevatedbloodsugarlevelmayexperience
hypoglycaemicsymptomsifthebloodsugarlevelfallsquicklybutisstillabovethenormalrange.
Hypoglycaemiapresentsas:
sweating,tremor,tachycardiaandpallorfromadrenalandsympathetic
activity triggered by the low blood glucose and/or hunger, and can
proceedtomentalconfusion,comaandseizures.
Patientssuffering from preͲexisting autonomic neuropathy maynothaveany warning symptoms
thatmanifestswithneurologicalsymptomsstraightway.
Thefactorsthatprecipitatehypoglycaemiainclude:
x highinsulindose
x highdosesofsulphonylureas
x presenceofrenalfailure
x liverfailure
x septicaemia
x missedordelayedmeals
x hormonaldisturbances,and
x vigorousphysicalactivity.
Patientsshouldbetreatedurgently.
Ifthepatientisconsciousandabletoswallow,giveasugaryfoodordrinkfollowedbyfoods
thattakelongertobeabsorbede.g.crackers.
Ifthepatientisunabletoswalloworbecomesunconsciousathome,givesugarpasteorhoney
into the mouth and transfer immediately to the nearest health care facility for intravenous
glucosetherapy.Atthehealthcarefacility,ifthepatientisunconsciousorunabletoswallow:
x Give 50 ml of 50% dextrose intravenously followed by continuous
intravenousinfusionof5%dextroseforupto24hours.
Hypoglycaemiaintheelderly,particularlyasaconsequenceofaccumulationofsulphonylureain
theplasma,maybedifficulttoreverseandmayreoccurforseveraldaysafterstoppingthedrug.
Itisimportanttoeducatealldiabeticpatientsonthesymptomsofhypoglycaemia,thefactorsthat
mayprecipitateit,thepreventivemeasuresandthetreatmentthatcanbeundertakenincasesof
mildattacks.Inseverecasesitisimportanttoadvicetherelativestoseekimmediatehelpfrom
thenearesthealthfacilitytoavoidanyirreversiblebraindamage.
18
5.2DIABETICKETOACIDOSIS(DKA)
5.2.1Generalconsiderations
Diabeticketoacidosis(DKA)ischaracterizedbythetriadofketosis,hyperglycemiaandacademia.
ThepresenceofketonebodiesisaconsistentfindinginDKA.DKAoccurspredominantlyinType
1diabeticpatientsbutcanoccurinType2diabetes.Itmightbethefirstpresentationinan
unknowntype1personwithdiabetes.
Thediagnosticfeaturesinclude:
x
x
x
vomiting,
abdominalpain,
Kussmaul’sbreathing,
x
x
x
dehydration,
ketoticbreath,
mental confusion progressing to
coma.
Itisnecessarytotesturineformoderatetolargeketonebodies.Venousratherthanarterialblood
pHandbicarbonatearenowpreferred.
ThecommonprecipitatingfactorsofDKAinclude:
x historyofomissionofinsulin;
x drugs,e.g.corticosteroids;sepsis;
x 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
thatpatienthas2Intravenousaccesses.
Transferpatienttoanappropriatehealthfacilityoncehis/herconditionhasbeenstabilized.
a.Fluids:Administerintravenousinfusionofnormalsalineasfollows:
•
•
•
•
Firstliterfor30minutes
Secondliterforonehour
Thirdliterfor2hours
Fourthliterfor4hours
Further infusion should be administered according to clinical assessment of the
patient.
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. Caution is required in the elderly, pregnant, and those with renal and/or
cardiacdysfunction.
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,insulincan
bechangedtomultiple–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
concentrationsfall.Potassiumshouldbeadministereddependingontheserumlevelsas
follows:
o ifremainsabove5.5mmol/L–donotgivepotassium
o iflevelbetween3.5–5.5mmol/l
ƒ Initiate intravenous potassium at a rate of no more than 10 – 20
mmol/hour(addedtoIVinfusionfluidbag)onceinsulinandfluidshave
beenstartedandrenalfunctionandurinaryoutputhavebeenassessed
assatisfactory.
o Iflevelisbelow3.5mmol/L
ƒ Reviewpotassiumrequirement.
ƒ Aseparatepotassiuminfusionlineshouldbestarted
Potassiuminfusionshouldnotexceed20mmolperhour.
(ii)Bicarbonate
Measure venous rather than arterial bicarbonate and PH. Sodium bicarbonate should not be
givenroutinely.ItisonlygivenwhenthebloodpHislessthan7.0.Insuchcases,infuse50mmol
ofsodiumbicarbonateoveronehour.
d.Treatmentofunderlyingcause
Treattheunderlyingcauseespeciallyinfections.
20
e.Othermeasures
x Anindwellingcathetershouldbeinsertedtomonitorurineoutput.
x Oxygentherapyifrequired
x Insertionofnasogastrictubeifparalyticileusdevelops.
f.PatientEducation
x reͲeducateaboutavoidanceofthecomplication
x therecognitionofearlywarningsignsandsymptoms.
5.3HYPEROSMOLAR,HYPERGLYCAEMICSTATE
This is a relatively uncommon event usually occurring as a dramatic presenting feature or as a
complicationoftype2diabetes.
It presents with a history of thirst, polyuria and progressive impairment of consciousness
commonly in a patient who is 60 years or older. It differs from DKA in that patients with
hyperosmolar,hyperglycaemicstatedonotdevelopketoacidosis.
Investigationsrevealveryhighbloodglucose,usuallyhigherthan30mmol/L,theserumsodiumis
oftenelevatedandthecalculatedserumosmolality>320mOsm/l.6
Management
ThetreatmentissimilartothatinDKA(seeabove).
Intravenous isotonic saline, low dose intravenous insulin infusion (as discussed under
managementofDKA)andcarefulattentiontoserumpotassiumconcentrationsarethecentral
strategies.
CarefulmonitoringisrequiredasinDKA.
On recovery, the patient may not need longͲterm insulin therapy. After an initial period of
stabilization with insulin, most patients with type 2 diabetes who present in a hyperosmolar,
hyperglycaemicstatecanbecontrolledwithoralhypoglycaemicdrugscombinedwithdiet.
21
6.0ManagementofLatecomplicationsofdiabetes
Diabetes mellitus is associated with a variety of late complications that are either vascular or nonͲ
vascular.Thevascularcomplicationsare broadlyclassifiedasmicroͲvascular or macroͲvascular.The
microͲvascular complications are Retinopathy, Nephropathy and Neuropathy and macroͲvascular
CoronaryHeartdisease,CerebrovascularDiseaseandPeripheralVascularDisease.
(Forcommunityeducationpurposes,theacronym‘SNAKE’isusedtoidentifythelatecomplications
intheskin,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. However
with good management visual impairment due to diabetes can be avoided for the vast
majorityofpatients.HenceallpatientswithdiabetesneedregulareyecheckͲup.
Importantpointstonoteare:
x DiabeticRetinopathyisasymptomaticinitsearlystage
x Screeningistheonlywaytoidentifypeoplewithdiabeticretinopathy
x Timelytreatmentcanpreventvisionlossfromdiabeticretinopathy.
Therearetwomaincategoriesofdiabeticretinopathy:
x NonͲproliferativediabeticretinopathyͲpreviouslycalledbackgrounddiabeticretinopathy.At
thisstagethebloodvesselsleakandwithprogressiontheymaygetoccluded.
x Proliferativediabeticretinopathy(whennewbloodvesselsgrow).
Somepatientsdevelopmaculaoedemaandthiscanbepresentineithercategories.
Bothproliferativeretinopathyandmaculaoedemaifuntreatedcanleadtovisualimpairment.
Thereisalsoanincreasedriskofcataractindiabeticpatients.
6.1.1 Riskfactorsfordiabeticretinaldisease(clinicalmodifiers)
poorglycaemiccontrol
raisedbloodpressure
Pregnancy
raisedtriglycerides&serumcholesterol
Longerdurationofdiabetes
MicroͲalbuminuria&proteinuria
Patientswithmultipleriskfactorshaveahigherriskofdevelopingdiabeticeyedisease.
22
6.1.2Symptomsofdiabeticretinopathy
Diabeticretinopathyoftenhasnoearlywarningsignsandvisionmayremainunaffecteduntilthe
diseasebecomessevere.Also,diabeticretinopathyprogressesrapidlywithoutmuchwarning.
Thereforeitisimperativethatregulareyeexaminationsarecarriedouttomonitorprogressionof
thedisease,toidentifyandtreatvisionthreateningdiabeticretinopathy(DR).
6.1.3 Screening
TherearetrainedscreenersatDivisionalHospitalEyeClinicsandonoutreach.Theytakefundus
photographs,graderetinopathyandonlyrefertoOphthalmologiststhosecasesthatneedfurther
assessment.ThegradingisdoneaccordingtothePacificIslandDiabeticRetinopathyGuidelines.
Therecommendedscreeningtoolinorderofpreferenceisafundusorretinalcamera,followedby
anindirectophthalmoscopeandlastlyadirectophthalmoscope.Forthelattertwo,thepupilshave
tobedilated.
A.PeoplewithType1diabetes:
Initiatescreening5yearsafterdiagnosisofdiabetesismade,oratpuberty,whicheveristhe
earlier.
B.PeoplewithType2diabetes:
Initialscreeningisdoneoncediagnosisisconfirmed.Ongoingscreeningisdoneatleasteveryyear
ifnodiabeticretinopathyisdetected.
C.Pregnantwomenwhohavediabetesi.e.alreadyhavediabetesandbecomepregnant:
Screeningisdoneearlyinthefirsttrimesterofthepregnancy,regardlessofprevioushistoryof
screening.Ifthere’snoretinopathyandnoclinicalmodifierspresent,annualscreeningcan
continueasusual.Ifminimalretinopathyispresent,frequentscreeningthroughoutthepregnancy
isindicated,andhastobeseenbyanOphthalmologist.Giventhatdiabetesmellitusishighly
prevalentinFiji,pregnantwomenwithraisedbloodsugarshouldbescreenedaswellatbooking.
D.Followup
OnͲgoingscreeningiscarriedoutbetween1to2yearsifnodiabeticretinopathy(DR)isdetected.
RefertoOphthalmologistonceanydiabeticretinopathyisdetected.Thefrequencyofthe
assessmentsisincreaseddependingontheseverityoftheretinopathyandtheriskfactorsfor
progressiontovisionͲthreateningdisease.
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
23
6.1.4EyeAssessment
x Check visual acuity with Visual Acuity (Snellen’s) chart – unaided or aided (with
presentglasses).Checkwithpinholeifvisualacuity6/12orworse.
x Checkpupilreactioninbotheyes[directandconsensual]
x Checkdepthofanteriorchamberwithlightdirectedfromthelaterallimbus
x Checkredreflexwithophthalmoscope;ifpresent,dofundusphotography.
IFFUNDUSCAMERANOTAVAILABLEORPOORREDREFLEX
x
x
x
Dilatepupilswithtropicamideeyedrop.Addphenylephrineeyedropifavailable.
Checkforcataractorvitreousbleed/opacity
AssessRetinausinganindirectophthalmoscopeoradirectophthalmoscope.
What everyone can do !
Askif
Eyes
examined
for
Diabetes
eye
problem
Yes
No
Ask
when?
Geteye
examined
>1year
Defaulted
clinic
Compliant
GetEye
examined
GetEye
examined
Check
appointment
date
6.1.5 Managementofdiabeticretinopathy
LasertreatmentisavailableinalldivisionsinFiji.Thistreatmentcanslowdowntheprogression
ofdiabeticretinopathyandcanstabilizevision.Casesrequiringlasertreatmentaretobereferred
totheEyeClinicinthe3DivisionalHospitalsifthisserviceisnotavailableinyournearestsub
divisionalhospitalonoutreach.
6.2NEPHROPATHY
Diabeticnephropathyusuallytakes10Ͳ15yearstodevelopaftertheonsetofhyperglycemiaand
itencompassesallthelesionsoccurringinthekidneysofpatientswithdiabetesmellitus.
Microalbuminuria is the earliest manifestation of diabetic nephropathy and is a marker of
progressivedeteriorationofrenalfunction.Microalbuminuriaisdefinedasurinaryalbumin
losstobetween30and300mgperday.Inpracticeamorepracticalassessmentisbasedon
albumin/creatinineratio(ACR),>2.5mg/mmolinmenand>3.5mgs/mmolinwomenisoften
usedtodefinemicroalbuminuria.
Proteinuria is present with raised urinary albumin excretion of >300 mg/day. An ACR >30
mg/mmolinaspoturineisconsistentwithadiagnosisofdiabeticnephropathy.
Glomerularfiltrationrate(GFR).ThisisoftencalculatedbyusingCockcroftand
Gaultformulaasshownbelowandusefulinassessingkidneyfunction.
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
Endstagerenal
disease
GFR(ml/min)
ш90
60Ͳ90
30Ͳ59
15Ͳ29
<15
6.2.2Assessment
ƒ Testurineformicroalbuminuriaiffacilitiesavailable.Ifpresentrepeatin6weeksto
confirmthatitispersisting
ƒ Testurineforproteinuriaifmicroalbuminuriafacilitiesnotavailable
ƒ Arrangeforbloodureaandcreatinineifproteinuriapresent
ƒ YearlyassessmentofrenalfunctionisimportantintheabsenceofmicroͲalbuminuria
6.2.3Management
(i)
ManagementofMicroalbuminurium
(ii)
ManagementofEstablishedDiabeticNephropathy
The literature recommends treatment with angiotension converting enzyme inhibitors
(ACEIs)oncemicroalbuminuriaisdetected.InFiji,therecommendeddrugis:
Enalapril2.5Ͳ5mgdaily.
Ingeneral,treatmentofestablisheddiabeticnephropathyincludesthefollowing:
x controlofproteinintake
- isnotrecommendedinearlystagesofchronickidneydisease(stages1Ͳ3)
- isforstages4Ͳ5
x useofACEInhibitorsandACEreceptorblockerstoreduceproteinuria
- Theuseofabovedrugscancausemicroalbuminuriatoregresstonoalbuminuria
in diabetes. All attempts should be made to reduce proteinuria immaterial of
baselineproteinexcretion
x controlofbloodpressure
Ͳ blood pressure lowering is associated with a reduced rate of chronic kidney
diseaseprogression
Ͳ refertothesectionunderbloodpressurecontrolindiabetes
x controlofhyperglycaemia
- meticulouscontrolofhyperglycaemiashouldbemaintained
x controlofhyperlipidaemia
- lipid disorders may contribute to the development and progression of diabetic
kidneydisease
- refertothesectionunderlipidcontrolindiabetes
x controlofothervascularriskfactorsi.e.cessationofsmoking.
For end stage renal disease, renal replacement therapy in the form of dialysis or renal
transplantneedstobeconsidered.Refertoconsultantphysicianforadvice.
25
Goodbloodpressurecontrolaswellasgoodglucosecontrolisessentialinalldiabetic
patientstoreduceprogressionofcomplications.
6.2.4Referral
ƒ
RefertophysicianifeGFR<30ml/min
6.3NEUROPATHY
Several different types of neuropathy can develop in diabetic patients. The
commonlyseenonesareperipheralsensoryͲmotorandautonomicneuropathy.
6.3.1PeripheralsensoryͲmotorneuropathy
SymptomsofperipheralsensoryͲmotorneuropathyinclude:
ƒ numbness,
ƒ paresthesia,
ƒ pain,and
ƒ weakness.
If pain is prominent, several treatments have been shown to be effective and improving the
qualityoflife.
Tricyclicantidepressantsandanticonvulsantsshouldbeconsidered.
Amitriptyline50Ͳ150mgorallyatbedtime
OR
Carbamazepineupto600mgorallydailyintwodivideddoses.
Carbamazepineshouldbeintroducedgraduallystartingat100mgtwicedailyandthedosetobe
increasedgraduallyuntilthemaximumdosethatcancontrolthepaincanbeachieved.
Gabapentin,anotheranticonvulsantnotavailableonFMFisalsoeffective.Itcanbecombinedwith
opiateanalgesiainpatientsnotcontrolledonmonotherapy.
Goodglycaemiccontrolisessentialforcontrolofsymptoms.
6.3.2Autonomicneuropathy
Autonomicneuropathycanpresentas:
ඵposturalhypotension,
ඵdysphagia,
ඵintermittentdiarrhoea
ඵimpotence,
ඵbladderatony.
Posturalhypotensionrequiresspecialistassessmentbutthepatientmayrespondto:
Fludrocortisone0.1to0.3mgsorallydaily.
26
6.4DIABETICFOOTDISEASE
Diabeticfootproblemsareacommoncomplicationofdiabetesandincludeneuropathy,peripheral
vasculardiseaseandfootulceration.Peripheralneuropathywithorwithoutvasculardamageputs
feet at risk from ulceration and infection which may lead to gangrene and the need for
amputation.Diabeticfootinfectionsinvolvetheskinandsofttissueaswellasunderlyingmuscle
andbone,andshouldalwaysberegardedasserious.Amputationratesarehigherforpatientswith
diabetesthanpatientsforwithoutdiabetes.Diabeticfootscreeningiseffectiveinidentifyingthe
level of risk of developing foot ulceration in patients with diabetes. Knowing the level of risk is
important in providing correct advice to patients on foot care. An annual screening from the
diagnosis of diabetesisappropriate. Howevermore frequent screeningmay be warranted if the
riskofdevelopingfootulcerationremainshigh.
6.4.1FootAssessment
History
PhysicalExamination
x Inquireaboutanyprevious
x Examinethefeetforanyhighriskcharacteristicssuch
footproblems,symptomsof
as
cornandcallus,toedeformitiessuchasclawtoes,
pain,tingling,numbness.
hammertoes,bonyprominences,anyinfectionin
x Anyhistoryofintermittent
betweenthetoes,andpoorperfusion;
claudicationandrestpain
x Testsensationusinga10grammonofilamentor128Hz
tuningfork;
x Testanklereflexes;
x Palpatepedalpulsesandpoplitealpulse;
x MeasureAnkleͲBrachialIndex;
x Assessfootwearandgeneralfootcare.
6.4.2RiskFactorsforDiabeticFootProblems
Themajorriskfactorsfordiabetesfootproblemsare:
x PeripheralNeuropathy–peripheralneuropathyandinparticularsensorylossisasignificant
riskfactorforthedevelopmentofdiabeticfootproblems;
x PeripheralArterialDisease
–poorarterialbloodsupplyisalsoasignificantriskfactorfor
diabeticfootulceration;
x PoorGlycaemicControl –poorbloodglucoselevelcontrolincreasestheriskofneuropathy,
vasculardiseaseandinfection;
x FootDeformities – Foot deformity is a risk factor for ulceration. Hammer toe, claw
toes and bony deformities subject the foot to high pressure and trauma that can lead to
ulceration;
27
6.4.3RiskClassification
Assessing the risk of developing foot ulcers and subsequent complications determines the
frequencyofclinicreview.
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
6.4.4 ManagementofDiabeticFoot
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
Tightglycaemiccontrol(HbA1cbelow6.5%)isimportanttoreducetheriskofvasculardisease,
neuropathyandinfection.
28
iii)AggressiveTreatmentofInfection
Recognize and treat infection early and aggressively with proper antibiotics. 50% of diabetic
patientswillnotshowclassicsignsofinfection.Diabeticinfectionsareoftencausedbyamixture
oforganisms(aerobesandanaerobes).
x
x
Formildtomoderateinfections,giveMetronidazole400mgorally8hourly
PLUS
Flucloxacillin500mgorally6Ͳhourly.
Forsevereinfections,refertothesurgicaldepartmentofthedivisionalhospitals.
iv)WoundCare
Earlyandregulardebridementofdeadanddevitalizedtissueswillprovideaneffectivewoundbed
forhealing.Sharpdebridementbyaskilledpractitionerisveryuseful.Amoistwoundenvironment
willencouragehealing.Awouldbedthatistoomoistortoodrywilldelaywoundhealing.
v)MultidisciplinaryApproach
The benefit of multidisciplinary approach is well established. The contributions from Surgeons,
Physicians,FootClinicNurses,Podiatrists,Physiotherapistandhealtheducatorsmustbesoughtto
enhancethecarefordiabeticfeet.
7.0Targetsforcontrolindiabetes
Itisimportanttohaveasetoftargetsfordiabetescontrol.Thesetargetsareusuallysetby
internationaldiabetesagenciesbasedonmajorresearchfindings.Seetablebelow.Thesetargets
needtobediscussedbetweenthepatientandthedoctorbeforeinitiatingtreatmentandduring
each follow –up visit. (This can be documented in the personal diabetes record book for the
patients).
Indicator
Targetsforcontrol inDiabetes.
Good
Fair
Poor
Fasting Blood glucose
(mmol/L)FBS
Random Blood Sugar
(mmol/l)RBS
4.0Ͳ6.0
6.1Ͳ7.0
4.0Ͳ8.0
8.1Ͳ10.0
*HbA1c(%)
Total
cholesterol
(mmol/L)
<6.5
<4.0
6.5Ͳ 7.5
4.1Ͳ 4.9
>7.5
>5.0
HDLͲcholesterol
(mmol/L)
>1.0
1.0Ͳ0.9
<0.9
LDLͲcholesterol(mmol/L)
Triglycerides(mmol/L)
<3.0
<1.5
3.0Ͳ 4.0
>4.0
>2.0
Bloodpressure(mmHg)
**Body mass index
(kg/m2)
IdealBMI:20Ͳ25kg/m2
<130/80
M:<25
F:<24
>130/80Ͳ <140/90
1.6Ͳ2.0
M:<27
F:<26
>7.0
>10.0
>140/90
M:>27
F:>26
*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:
TherecognitionofType1ishighlighted,onpage2ofthisguideline.Belowaresomeoftheimportant
featuresofdiabeticketoacidosiswhichachildoradolescentmightpresentwith.
I.
Ia)
Clinicalpresentation:
Emergencypresentations
Theusualemergencypresentationofdiabeticketoacidosisinachildoradolescentincludesthe
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 Hyperventilationofdiabeticketoacidosis(Kussmaulrespiration)ischaracterizedbya
highrespiratoryrateandlargetidalvolumeofeachbreath,whichgivesitasighing
quality
x Disorderedsensorium(disoriented,semiͲcomatosedorrarelycomatosed).
Ib)
NonͲEmergencyPresentationofdiabetesincludes:
x Recent onset of enuresis in a previously toiletͲtrained child, which may be
misdiagnosedasaurinarytractinfectionortheresultofexcessivefluidingestion
x Vaginalcandidiasis,especiallyinprepubertalgirls
x Vomiting,whichmaybemisdiagnosedasgastroenteritis
x Chronicweightlossorfailuretogainweightinagrowingchild
x Irritabilityanddecreasingschoolperformance
x Recurrentskininfections
30
II
MedicalManagement
Themajorityofchildrenwithtype1diabetespresentatdiagnosiswithDKA.Management
ofDKAiscoveredinthePICUguidelines.ManagementwillincludeABCplusconsultyour
divisionalpaediatricianforfurthercarebeforereferral.
ChildrenwithDKAmustbereferredtoDivisionalHospitalforspecialisedcare.
Onthefollowingpageisanalgorithmonmanagement,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
Wtloss(Weigh)
Diagnosisconfirmed
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
Bloodglucose17mmol/l
Or
Bloodglucosefalls>5mmol/l/h IVFTherapy
ReͲevaluate
IVfluidcalculations
Changeto0.45%saline+5%glucose Insulindeliverysystem&dose
Improvement
Clinicallywell,toleratingoralfluids
TransitiontoSCinsulin
StartSCinsulinthenstopIVinsulinafter30minutes
Minimaldehydration
Toleratingoralfluids
Therapy
StartwithSCinsulin.Continue
oralfluids
Noimprovement
Neurologicaldeterioration
Warningsigns:
headache,slowingheartrate,
irritability,decreasedconsciouslevel
Incontinence,specificneurological
signs
Excludehypoglycemia
Management
Givemannitol0.5/kg
RestrictIVfluidsby1/3
Callseniorstaff(DivHosp
Consultant)
32
IIa)Diagnosis&Assessment:
Thediagnosisandassessmentissimilartothoseinadults,andisdocumentedinpage2of
thisguideline.
IIb)InsulinTherapy:
ConsultationswiththeDivisionalHospitalneedtobesoughtaspreviouslymentionedinthe
managementofDKA.Thisisalsoadvisableincasesofinsulindoseadjustments,inorderto
avoidsideͲeffectsandcomplications.
1.Nutrition
NutritionisafundamentalcomponentinType1Diabetesmanagementinchildren.Thisis
notdifferentfromadultnutritionashighlightedonpages5&6ofDMG.
However, in children adequate energy and nutritional intake for normal growth and
developmentisalsoapriority.
2.MonitoringofGlycaemicControl
ThisincludesͲHomebloodglucosemonitoring
Ͳ MonitoringHbA1C&
Ͳ MonitoringKetones
3.PhysicalActivity
AspartofthefightagainstnonͲcommunicablediseases,physicalactivityisverymuchakey
component. This is well documented on page 7 of this guideline. However, special
precautions need to be taken especially to avoid complications which are highlighted on
page18.
4.PsychosocialIssues
PsychosocialstressesarecommonandhaveadverseeffectondiabetescontrolduetononͲ
adherence with treatment regimes. They are commonly experienced where educational
levelofparentsarelow,nonͲcohesioninthefamily,autonomyisimpededorpromotedat
aninappropriatetime.Adolescentyearsareparticularriskperiods.Arrangefrequentfamily
conference and involve counsellors, other support networks and psychiatrist where
appropriate.
5.SpecialSituations:Hypoglycaemia:
HypoglycaemiaisacommonoccurrenceinDiabetes,andneedstobewelladdressed.Refertopage
18oftheseguidelinesforfurtherinformation.
6.DiabetesComplicationsandScreening
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
theseguidelinesformoredetails.
7.ClinicFollowUp
Minimal of three monthly reviews per year at the divisional level is required, and more
frequent reviews may be needed if diabetes control is poor. At least one subͲdivisional
review per year, either as an outreach clinic or at the subdivisional clinic. Review will
includemonitoringofhomeglucose,HbA1candurinaryketones.
33
8.School
Allchildrendiagnosedwithdiabetesshouldparticipateinnormalschoolactivities.Aletter
shouldbesenttotheheadteacherorprincipalhighlightingthefollowing:
ͲEmergencymanagementofhypoglycaemia
ͲMedicalemergencycontact,carerscontactand
Ͳneedforcertainprivilegessuchasallowingfoodconsumptionduringexamsand
sports.
8.2Type2DiabetesMellitus:
Diagnosis & Treatment of Type 2 Diabetes in children (please refer to Adult diabetes
protocol):Beginningonpage3oftheseguidelines.
I
Diagnosis–asintype1diabetes
II Who To Screen: Is highlighted on page 2, however other risks to note in
childrenincludethosebelow:
x Obesity
x StrongfamilyhistoryofTypeIIDiabetes
x Highriskethnicgroup
x Presenceofclinicalsignssuchasacanthosisnigricans
x Diagnosisofpolycysticovariansyndrome
(RefertoAdultdiabetesprotocolforfurtherinformationonscreening)
34
9.0Diabetesinpregnancy
Theterm“gestationaldiabetes”hasbeenusedtodefinewomenwithonsetorfirstrecognitionof
abnormalglucosetoleranceduringpregnancy.MorerecentconsensusfromtheInternational
AssociationofDiabetesandPregnancyGrouphaverecommendedachangewherediabetes
diagnosedduringpregnancyisclassifiedasovertorgestationalbasedonspecificbiochemical
parameters.OurlocaldatasupportstheuseofthischangeinFijiinthatmanyofoursocalled
GDMcasescanberedefinedasOvertDiabetes.
Theriskofadversepregnancyoutcomesincreasescontinuouslyasmaternalfastingplasma
glucoselevelincreasesfromtheч75mg/dL[4.2mmol/L],andastheonehourandtwohouroral
GTTvaluesincrease;thereisnoclearthresholdthatdefinespatientsatincreasedrisk.Adverse
outcomesinclude:Preeclampsia,Hydramnios,Foetalmacrosomia,Foetalorganomegaly
(hepatomegaly,cardiomegaly),birthtrauma,operativedelivery,perinatalmortality,neonatal
respiratoryproblemsandmetaboliccomplications(hypoglycemia,hyperbilirubinemia,
hypocalcemia,erythremia)
TodatediabetesscreeninginpregnancyinFijiisdoneselectively.Currentevidencebasedona
localstudyandinternationalevidenceindicatesthatuniversalscreeningneedstobeintroduced
inamannerthatissuitedtolocallyavailableresources.TheObstetricsandGynaecologyCSN
suggestssuchscreeningforallbasedonhistoricalriskmarkersandbiochemicalscreeningas
follows:
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)orsignificantweightgaininearlyadulthoodandbetween
pregnanciesPreviouslargebaby>4.0kgbirthweight
x Pasthistoryofrecurrentmiscarriageш3miscarriages
x Glycosuriainfirstantenatalclinic
x PreͲexistingHypertension
35
ScreeningandDiagnosticCriteriaforGDM
InitialRiskAssessment
OvertDiabetesshouldbeimmediatelymanagedasDiabetesinPregnancy.
ScreeningforGDMFlowChart
HighRisk
RISKMARKERASSESSMENTOFALLPREGNANTWOMENATBOOKING
NonHighRisk
• 2 or more Moderates risk Markers
Performfull75gGTTatbooking
AbnormalNormalAbnormal
•1 or more High risk factor(s) or
No High Risk Factors
DoFBS/RBSatbooking
Normal
Nomoderaterisk
factors
Atleast1Moderate
ManageasDiabetesRepeat75gGTTatManageasperinthetablebelowRepeat50gGCTNofurthertest
Inpregnancy26Ͳ28weeks
at26Ͳ28weeks
x
The50gGCTscreeningtestcanbereplacedbyafull75gGTTifthisispreferredbythe
patientandiseasiertoorganizelocally.
NOTE:AtANYstageofpregnancy,ifthereisclinicalsuspicionthatdiabetesmaybe
present,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,adiagnosisofovertdiabetesismadeinwomenwhomeetanyofthe
followingcriteriaattheirinitialprenatalvisit:
*Fastingplasmaglucoseofш126mg/dL[7.0mmol/L],or
*HbA1cш6.5%usingastandardizedassay,or
*Randomplasmaglucoseofш200mg/dL[11.1mmol/]thatissubsequentlyconfirmedby
elevatedfastingplasmaglucoseorHbA1c,asnotedabove.
Currentrecommendationsarethatthediagnosisofgestationaldiabetesismadeattheinitial
prenatalvisitifthefastingplasmaglucoseisш92mg/dL[5.1mmol/L],but<126mg/dL[7.0
mmol/L].However,thishaswardworkimplications,thustheaboveisrecommendedfornow.
Theresourceimplicationsoftheserecommendationswillneedtobereviewedbeforefully
adoptingthisrecommendation.
Currentrecommendationsindicatethatifovertdiabetesorgestationaldiabeteshasnotbeen
diagnosedwithinitialtestingatthefirstprenatalvisit,a75gramtwohouroralGTTshouldbe
administeredat24to28weeksofgestationtoallpatients.WhilstthiswouldbeidealtheCSN
concernswithresourcerestrictionshaveresultedinrecommendationsforGCTscreeningat24to
28weeksforthesubͲgroupwithnormalFBSbutmoderateriskfactors.
AllabnormalscreeningtestsusingCapillaryBloodSamples(CBGorCapillaryBloodGlucose
Testing)mustberepeatedwithavenousbloodsamplebeforefurthercourseofactionisdefined.
HencetheneedtoensurethatvenousbloodglucosetestingfacilitiesareavailableateverySDH
andmajorhealthcentres.
37
CAUTION:About1%ofwomenwithGestationalDiabetesinaclinicsettingareatriskof
developingType1Diabetes.
Type1DiabetesshouldbesuspectedinwomenwhohaveminimalornoriskfactorsforGDM,
presentwithhighBGL(e.g.>20mmol/L),+significantketonuria.Thesewomenshouldbe
followedupforatleast2yearspostpartum.Notethat,theirpostpartumGTTmaybenormalor
onlyshowIGTinthefirstyearpostpartum.
Womenwithknownimpairedglucosetolerance(IGT)
Womenwithknownimpairedglucosetolerance(IGT)preͲpregnancyshouldgenerallybe
treatedasGDMoncepregnantanddonotneedtoundergoafurtherGTTinpregnancy.
ScreeningTest:50gGlucoseChallengeTest(GCT)
*Dietarypreparation(e.g.3daydiet/fasting)arenotrequired
*Shouldbedoneinthemorning
*Clienttobeseatedforthedurationofthetest
*The50gglucoseloadshouldbeconsumedwithin5minutes
*BloodglucoseMetersareNOTtobeused
*Venousbloodshouldbetaken1hourafterglucoseload,timedaccurately,andthe
specimensenttothelabassoonaspossible
NOTE18%falsenegativerateatthesecutͲoffs
DiagnosticTest:75gGlucoseToleranceTest(GTT)
*3daypreparation–highcarbohydratediet
*Fastfor8Ͳ12hourspriortotest,usuallyfrom10PM(onlyWATERmaybeconsumed–no
tea,coffee,etc.)
*Nosmokingonthemorningofthetest(from12MNuntiltestcompleted)
*Shouldstartinthemorningbefore9.30AM(glucosetoleranceworsenslaterintheday)
*Clienttobeseatedforthedurationofthetest
*Abaselinevenousbloodglucoseleveldetermined
*The75gglucoseloadshouldbeconsumedwithin5minutes
*BloodglucoseMetersshouldNOTbeused
*Venousbloodshouldbetakenat1hourand2hoursaftertheglucoseload,timed
accurately,andthespecimenssenttothelabassoonaspossible.
GlycosuriapresentbutGCTorGTTwerenormal
IfnormalGCTorGTTandsubsequentlyglycosuriaorPolyhydramniosdevelops,orifthereare
anyotherclinicalconcernsthatGDMmaybepresent,reͲtestwith75gGTT
x IfGTThasbeenrepeated,andBGLsareclearlybelowcutͲofflevels,andthereis
glycosuriaͲrepeatGTTin4Ͳ6weeks.
ElevatedRandomBGLbutGCTorGTTwerenormal
IfnormalGCTorGTTandsubsequentlyanelevatedbloodglucose(>7.0mmol/l)develops,orif
thereareanyotherclinicalconcernsthatGDMmaybepresent,reͲtestwith75gGTT
x IfGTThasbeenrepeated,andtheBGLsareclosetocutͲofflevels,nofurtheraction
shouldbeneededevenifthereisglycosuria
38
x
IfGTThasbeenrepeated,andtheBGLareclosetocutͲofflevels,andthereisas
elevatedbloodglucose(>7.0mmol/l)–repeatGTTin4Ͳ6weeks.
VomitingduringtheGCT/GTT
x IfthereisvomitingwithGCTorGTT,thetestshouldberepeatedthenextweekafter
givingtheclientMaxolononthemorningofthetest
x Ifthewomanvomitsduringtherepeattest,organiseforhertocometoAntenatalClinic
forsomepostprandialbloodtestlevelsandassessment
Ramadan
x Ideally,womenshouldbescreenedforGDMjustbeforeorimmediatelyafterRamadan.
However,ifscreeningisrequiredduringRamadan,GCTshouldbeperformedinthe
evening.
x IftheGCTisabnormal,adiagnosticGTTshouldbeperformedimmediatelyafter
Ramadan.Inthemeantime,womenshouldbeadvisedtoavoidsimple,carbohydrate
(softdrinks,fruitjuice,etc.)Randombloodglucoselevelsshouldbemeasuredat
AntenatalClinicvisits.
5.2MANAGEMENT
AllpatientsdefinedasGestationalDiabetesneedtobereferredtoadivisionalHospitalfor
initiationoftherapy.OngoingtherapycanbeconductedinSubdivisionalHospitalsettingsas
longasthereisongoingclosesupervisionbythedivisionalhospitalObstetricsand
GynaecologyUnit.
TreatmentFlowChart
Continuecurrent
treatment
Commencebloodglucosemonitoring
(fastingand2hrpp)
Encouragehealthydietandexercise
Isglycaemiccontrolsatisfactory?
Fasting<5.2mmol/L
CommenceInsulintherapy
Ͳshot/rapidacting,1Ͳ3timesperday
+/_
- Nocteintermediate
- ReviewBGLs–timingofreviewneedstobe
determinedonanindividualbasisbutusually
1Ͳ2/weekly
- Titrateinsulinasrequiredtomaintaingoal
BGLs
39
NOTE:Duetosevereinsulinresistance,asmallpercentageofwomenwillrequirein
excessof350unitsofinsulinaday.Thesewomenarelikelytorequiretheadditionof
morningintermediateactinginsulintotheirtreatmentregimen.
UseofMetformininGestationalDiabetes
InselectedcasesMetformincanbeusedinPregnancyforGDMcaseshoweverthiswillbebased
onconsultationwithdivisionalhospitalconsultants.Metforminisnottobeusedinpeoplewith
type1Diabetes.
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.WomenwithGDMshouldalsobeprovidedwithpositiveencouragement
tominimizetheiremotionalstress.
OncediagnosedwithGDM,womenneedtomonitortheirBGLfasting(preͲbreakfast)and2hour
aftermealstimedfromthebeginningofthemealsfortherestofthepregnancy.Thereforeclients
shouldbeinstructedtopurchaseabloodglucosemeter.Theyshouldberegisteredwiththe
divisionalhospitaldiabetesinpregnancyregistryandeffortstoensurecompliancewithreview
schedulesneedtobedocumented.
BGLsinpregnancyareapproximately20%lowerthanoutsidepregnancytherefore,women
shouldbegiventhefollowingBGLtargetranges.
Fasting:3.5–5.2mmol/l
2hrp.p:5.0–7.0mmol/l(theupperlimitsetbytheADAandACOGis6.7)
HbA1candfructosaminelevelsmayprovideadditionalinformationregardingtheadequacyofthe
glycaemiccontrol.Ingeneral,HbA1cshouldbemeasuredatdiagnosisandmonthlythereafter.It
shouldbenotedthatHbA1c/fructosamineresultsareapproximately20%lowerbymidpregnancy
comparedtooutsidepregnancy.
40
NOTE:Forclientsonahomeglucosemonitoringscheme,theaccuracyofcapillarybloodglucose
testingandvenousbloodglucosetestingshouldbereviewedregularlyatleasteverymonth.
DIETARYASSESSMENTANDADVICE
Nutritionaladviceshouldbeculturallyappropriateandindividualizedtoincorporateeachclient’s
specificneeds.Theadviceshouldcoverbothdiabeticdietrecommendationsandspecific
pregnancyrequirements.
Adequatedietaryintakeisimportanttoavoidfoetalgrowthretardation–ketonuriamayhelp
detectinadequatecarbohydrateintake.Lackofmaterialweightgain(particularlyinnonͲobese
women)mayalsoindicateexcessiverestrictionoffoodintake.
EXERCISE
Womenshouldbeadvisedthatamoderatedegreeofexerciseisbeneficial,unlessthereare
othermedicalorobstetriccontraindications.
INSULIN
AtthisstageitisnotgenerallyacceptedpracticetouseoralantiͲhyperglycaemicagentsin
pregnancy.Thereforeinsulintherapyisindicatedifthebloodglucoselevelsarenotadequately
controlledondietalone.
Insulintherapyshouldalsobeconsideredifthereisevidenceofreducedoracceleratedfoetal
growthonfundalheightorultrasound.
ShortͲactingorrapidactinginsulingivenpreͲmeal(onetothreeinjections/day)shouldbe
commencedif2hrpostprandialBGLsareelevated(>7mmol/l).Ingeneral,individualinsulin
dosesofbetween5to10unitsshouldbecommenced,dependingonthedegreeof
hyperglycaemia.PreͲbedintermediateinsulinshouldbecommencediffastingBGLsareelevated
(>5.5mmol/L).Frequentdoseadjustmentsareoftenrequired.Thisinsulinstartingregimeis
basedontheAlfredHospitalDiabetesProtocolandistheonecurrentlyinuseatCWMHospital.
TIMINGOFDELIVERY
Inwomenwithunfavourablecervices,excellentglycaemiccontrol,novasculardiseaseor
preeclampsia,normalfoetalgrowth,reassuringantepartumfoetalsurveillance,andnohistoryof
stillbirth,inductioncanbesafelydelayeduntil40weeks.Iftheaboveconditionsremainandthe
cervixisfavourablethereislittlebenefitincontinuingthepregnancybeyond39weeks.Delivery
asearlyas37weeksisindicatedifthereissuboptimalglucosecontroland/orevidenceof
evolvingmaternalorfoetalconcerns.Itispreferredtodocumentfoetalmaturityby
amniocentesisfornonͲurgentinductionsbefore38weeksorthosewithunsuregestation.
NOTE:Dailyinsulinrequirementaloneisnotadeterminantoftimingfordelivery.Themain
determinantisoverallqualityofdiabetescontrol.
POSTPARTUMMANAGEMENTOFWOMENWITHGDM
WomenwithGDMareatmarkedincreaseriskoffuturediabetesandshouldbeadvisedregarding
optimumlifestyleandappropriatefollowͲup.Somewomenwillcontinuetohaveabnormal
glucosetoleranceintheearlypostpartumperiod.Therefore,womenshouldbeadvisedtosee
theirgeneralpractitioners6weekspostpartumtoundergoarepeatOGTT,andOGTTshouldbe
performedannuallythereafter.
41
10.0References
1.AmericanHeartAssociation&AmericanCollegeofCardiology(jointstatement2006)
2.AustralianDiabetesinPregnancyGuidelinesonDiabetes:UpdatedDecember2002
3.AustralasianPaediatricEndocrineGroupClinicalPracticeGuidelinesforDiabetesinchildren,2005
4.2008Ͳ2013ActionPlanforGlobalStrategyforPreventionandControlofNCDs,WHO
5.InternationalAssociationofDiabetesandPregnancyStudyGroupsConsensusPanel,MetzgerBE,Gabbe
SG,etal.Internationalassociationofdiabetesandpregnancystudygroupsrecommendationsonthe
diagnosisandclassificationofhyperglycaemiainpregnancy.DiabetesCare2010;33:676.
6.ObstetricalmanagementofpregnancycomplicatedbypreͲgestationaldiabetesmellitus;2012Upto
Date
7.JointBritishdiabetessocietyinpatientcaregroup–ManagementofDKAinadults,March2010
8.Proceedingsofthe4thInternationalWorkshopͲConferenceonGestationalDiabetesMellitus.Chicago,
Illinois,USA.14Ͳ16March1997.DiabetesCare1998;21Supp2:B1.
9.Screeninganddiagnosisofdiabetesmellitusduringpregnancy;2012UptoDate
10.TheAlfredHospitalDiabetesManagementProtocolLatestUpdate:19November2009
11.GlobalGuidelineforType2Diabetes,IDF2012,ClinicalGuidelinesTaskForce
12.ManagementofDiabetesbyScottishIntercollegiateGuidelinesNetwork2010
13‘HealthyEatingGuidelinesinDiabetes’Booklet,MOHFiji2012
14.ApelqvistJ,BakkerK,vanHoutumWH,NabuursͲFranssenMH,SchaperNC.“Internationalconsensus
andpracticalguidelinesonthemanagementandthepreventionofthediabeticfoot”,International
WorkingGroupontheDiabeticFoot,DiabetesMetabResRev.2000SepͲOct;16Suppl1:S84Ͳ92
15.FrykbergR,“PreventingAmputations:TheComprehensiveDiabeticFootExamination”FootNotes,
PresentDiabetesFootnotepublications,retrievedfromwww.presentdiabetes.com;
16.McIntoshC,“DiabeticFootUlcerations:“ReviewofBestPractice”Review,WoundEssentials,Volume
4,2009
17.TheNationalCardiovascularandNCDsurvey1980
18.TheFijiNationalNCDStepsSurvey2002,WHO,MOH,FSMed,MenziesCenterforPopulationHealth
Research,Uni.OfTasmania&AusAID
19.InsulinPenref:www.bd.com/us/diabetes/page.aspx?cat=7001&id=7254&www.insulinpens.com/
20.InsulinPumpref:diabetes.webmd.com/insulinͲpump;en.wikipedia.org/wiki/insulin_pump;
www.medtronicͲdiabetes.com.au
42
11.0Annexes
Annex1
43
Annex2
FijiAssociationofMentalHealth's12S'stoLessenStress:
1.
SMILE
2.STRETCH&EXERCISE
3.SOOTHING&CALMINGMUSIC
4.SING&DANCE
5.SHAREWORRIES&TASKS
6.SPIRITUALITY(PRAYER/MEDITATION)
7.SIMPLIFY&PRIORITIZETHINGS
8.SLEEPWELL
9.SELFͲCARE&ESTEEM
10.SOCIALIZE
11.SLOW&DEEPBREATHING
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(personal
targetsforcontrol)
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