diabetes

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Guide to diabetes
Definition
• Diabetes mellitus is a syndrome
characterised by chronic
hyperglycaemia and disturbance of
carbohydrate, fat and protein
metabolism associated with absolute or
relative deficiency in in insulin
secretion and\or insulin action.
Insulin allows glucose (sugar) to enter
body cells to convert it into energy.
Insulin is also needed to synthesize
protein and store fats. In un controlled
diabetes, glucose and lipids (fats)
remain in the blood stream and, with
time damage the body’s vital organs
and contribute to heart disease.
Classification
Diabetes is classified into three main types:
• Type 1 previously called insulin-dependent
diabetes mellitus (IDDM)
• Type 2 previously called non-insulindependent diabetes mellitus(NIDDM)
• Gestational Diabetes Mellitus(GDM)
Type 1 Diabetes
Occurrence:
• Autoimmune disease wherein the immune system
attacks B-cells of pancreas and destroys them. The
pancreas then produce little or no insulin.
• Scientists do not know exactly what causes the
body’s immune system to attack the B-cells, but
they believe that both genetic factors and
environmental factors and possibly viruses, are
involved.
Characteristics:
• Often develops in children and young adults, but
the disorder can appear at any age.
• Symptoms usually develop over a short period,
although B-cell destruction can begin year earlier.
• If not diagnosed and treated with insulin, a person
can lapse into a life-threatening diabetic coma,
also known as diabetic ketoacidosis.
Type 2 diabetes
Occurrence:
• The most common form of diabetes.
• Due to reduce insulin secretion or
peripheral resistance to action of insulin.
• The result is the same as for Type 1
diabetes, glucose builds up in the blood and
the body cannot make efficient use of its
main source of fuel.
• Often part of a metabolic syndrome
that includes obesity, elevated blood
pressure, and high levels of blood
lipids.
Characteristics:
• Contributes 90 to 95% of total diabetes and onethird not been diagnosed.
• This form of diabetes usually develops in adults.
• About 80% of people with Type 2 diabetes are
overweight.
• Increase in incidence of childhood obesity leads to
Type 2 diabetes becoming more common in young
people
Symptoms & Management for
Type 1 and Type 2 Diabetes
Symptoms:
• Increased thirst and urination.
• Constant hunger.
• Weight loss.
• Blurred vision
• Extreme fatigue.
• Slow healing of wounds or sores.
Management:
• Diet
• Exercise
• Insulin for Type 1 and OHAs or insulin in
Type 2
• Education
• Monitoring blood glucose and therapy
Gestational Diabetes:
Occurrence:
• Develops in pregnancy and disappears after
delivery, however with increased risk in
getting later in life
• Insulin resistance due to pregnancy.
• Genetic predisposition.
Management:
• Diet: provide adequate calories which will
not lead to hyperglycemia or ketonemia.
• Exercise: that does not cause fetal distress,
contractions or hypertension.
• Insulin: to maintain blood glucose,
fasting<=95mg/dl (<=5.3 mmol/l); one hour
post prandially <=120mg/dl(<=6.7 mmol/l).
Diagnosis
The fasting plasma glucose test in the
preferred test for diagnosis Type 1 or Type 2
diabetes. However, a diagnosis of diabetes
is made by an one of the three positive tests,
with a second positive on a different day:
• A random Plasma glucose value (taken any
time of day) of 200mg/dl or more, along
with the presence of diabetes symptoms.
• A plasma glucose value of 126/mgdL or
more, after a person has fasted for 8 hours
• An oral glucose tolerance test (OGTT)
plasma glucose value of 200 mg/dL or more
in the blood sample, taken 2 hours after a
person has consumed a drink containing 75
grams of glucose dissolved in water. This
test, taken in a laboratory or the doctor’s
office, measures plasma glucose at timed
intervals over a 3-hour period.
Gestational Diabetes
Diagnosed based on plasma glucose values
measured during the OGTT. Glucose levels
are normally lower during pregnancy, so the
threshold values for diagnosis of diabetes in
pregnancy are lower. If women has two
plasma glucose values equal to or more than
any of the following values after a 100gm
OGTT, she has gestational diabetes:
• 1-hour level of 180 mg/dL
• 2-hour level of 155 mg/dL or 3-hour level
of 140 mg/dL
• Fasting plasma glucose level of 95mg/dL
People with impaired glucose metabolism, a
state between normal and diabetes are at
risk for developing diabetes, heart attacks,
and strokes. There are two forms of
impaired glucose metabolism.
Impaired Fasting Glucose (IFG):
• Fasting plasma glucose level of 110 to 125
mg/dL, a level higher than normal but less
than the level indicating a diagnosis of
diabetes.
Impared Glucose Tolerance (IGT)
Means that blood glucose during the oral
glucose tolerance test is higher than normal
but not high enough for a diagnosis of
diabetes. IGT is diagnosed when the
glucose level is 141 to 199 mg/dL, 2 hours
after a person is given a drink containing 75
grams of glucose.
OGTT
• OGTT is performed using a 75 or 100 gm oral
glucose load in the morning after a noncaloric 8hour fast. Water is allowed, but not coffee or
smoking.
• Test should be performed on an individual without
underlying illness and/or interfering drugs. OGTT
is not appropriate for a patient who is
malnourished, on a restricted carbohydrate diet, or
with acute and chronic illness.
• Patient should be ambulatory and not to bed rest,
hospitalized , or immobilized. During the test,
patient should be resting comfortably.
• Patient should consume an unrestricted diet
containing at least 150g carbohydrate daily for
three days before test.
• Just a confirmatory test, not to be done regularly.
Glycated Hemoglobin (HbA1c) Test
• Indicates blood glucose control over a
period of approximately 3 months.
• Normal range varies depending on the
method the lab uses: usually 4-7%,
correlating to average blood glucose of 60150 mg/dl (3.3-8.3 mmol/l)
• Should be prescribed by health care
provider every three months for Type 1
diabetes and at 3-6 months intervals for
Type 2, to help determine overall control.
• Patient does not need to be fasting to have
this blood test performed
Ketone Test
• Ketone is by product of fat metabolism;
presence of ketone indicates that the body is
not metabolizing food properly because of
lack of available insulin or carbohydrate;
may indicate impeding or established
diabetic ketoacidosis (DKA), a condition
that requires immediate medical attention.
Method: Dipstick
When to test:
• When blood glucose level is consistently
>300 mg/dl (16.7 mmol/l).
• During period of acute illness (illness is a
stress that can cause and hyperglycemia).
• When symptoms of hyperglycemia
accompanied by nausea, vomiting and
abdominal pain are present.
Treatment strategy
Goals Of Treatment
• Control high blood glucose (hyperglycemia)
• Avoid low blood glucose (hypoglycemia).
• Treatment of associated conditions, such as high
blood pressure, cholesterol disorder and obesity.
• Prevent or retard the progression of complications
of diabetes such as blindness, kidney failure, heart
disease, stroke and amputation of legs.
Treatment Plan
1. Management of Blood Glucose:
Target Blood Glucose values:
(as recommended by the American Diabetes Association)
Pre-meal blood glucose
80-120 mg/dl
Bedtime blood glucose
*HbA1c
100-140 mg/dl
Less than 7%
• However, not every person is a candidate for such
tight blood glucose control. This should not be
attempted in:
• Frail, elderly person who have already developed
the complications of diabetes such as blindness
and end-stage kidney failure.
• Elderly patients having frequent low blood
glucose episodes.
Management of cholesterol:
Target Cholesterol Levels
(as recommended by the American diabetes association)
LDL Cholesterol
Less than 100 mg/dl
HDL Cholesterol
Greater than 45 mg/dl
Triglycerides
Less than 200 mg/dl
Management of High Blood Pressure
• Target blood pressure in diabetic patients
should be less than systolic 130/ diastolic 85
mm Hg, as recommended by the American
diabetes Association.
• The treatment strategy also involves correct
nutrition, moderate exercise and proper
medication.
Nutrition
• Nutrition is an important element in
diabetes management.
• Diet content should be 10-2-% protein, 60%
carbohydrates and 20% fats.
Do’s of diabetic diets
• Consistency in diet and meal timings
according to medicines.
• Multivitamin containing an antioxidant such
as vitamin ,beta-carotene, vitamins C and E.
• Minimum of 1200 kcal/day for women and
1500 kcal/day for men.
• Sodium level (salt intake) should be
maintained between 2.4 and 3.0 gm/day for
people without hypertension and >2.4
gm/day for people with mild to moderate
hypertension.
• Fibre of approximately 20- 35 gm/day from
a variety of food sources should be
consumed
Don’ts of diabetic diets
• Avoid alcohol especially if diabetes is not in
control.
• Avoid in-between meals. Adhere to the time
and size of the meal decided.
• Avoid fasts and fasting alters body
metabolism, adversely affecting the diabetic
state.
Exercise
• Exercise can improve the health and
outlook of life. Regular and controlled
exercise not only helps to increase glucose
utilization but also helps to maintain
desirable health.
Do’s in exercise
• Check the patients for blood pressure, blood fat
levels, HbA1c, health of heart, circulatory and
nervous systems, kidney function, eyes and feet.
• Choose exercises that fit the patient’s health.
• Exercise should be preceded and followed by 5-10
minutes of slow, continuous, aerobic activities.
• Remember the feet.Advice them to wear the
comfortable shoes for the sport.
• Watch the low blood sugar, insulin or oral
diabetes medicine may lead to low blood
sugar levels.
• Advice the patients to keep a snack handy
to avoid low blood sugar levels during the
exercise.
Don’ts in exercise
• Advise not to snack unnecessarily before
exercise.
• Uncomfortable shoes should not be worn
while exercising.
• Avoid exercising in extreme cold or heat.
• Exceeding target heart rate of 60 to 80% of
estimated maximum heart rate.
Oral Hypoglycemic Agents
• OHAs are primarily used in type 2 diabetes
adjunct to nutrition therapy and exercise.
• Oral agents are broadly classified as
follows:
First generation sulfonylureas
Generic name
Dosage
Duration of
range per day action
Side effect of class
Chlorpropomide
100-500 mg
Prolonged
hypoglycemia,
cholestatic
jaundice,
Hypersensitivity;
alcohol flush
Tolbutamide
500-3000 mg 6-2 hrs
Hypoglycemia,
hypersensitivity
Tolazamide
100-1000 mg 12-24 hrs
Hypoglycemia,
hypersensitivity
Aceohexamide
500-1500 mg 12-24 hrs
Hypoglycemia,
hypersensitivity
6-2 hrs
Second generation sulfonylureas
Generic name
Dosage
range per
day
Duration
Side effects
of
Of class
action
Glipiside
2.5-40 mg 12-24 hrs Hypoglycemia,
hypersensitivity
Glibenclamide 5-20 mg
12-24 hrs Hypoglycemia,
hypersensitivity
Glymeperide 1.8 mg
24 hrs Hypoglycemia,
hypersensitivity
Gliclazide
40-240 mg 12-24 hrs Hypoglycemia,
hypersensitivity
Agents enhancing effects of insulin
Generic name
Metformin
(Obimet)
Dosage
Range
Per day
500-2500
mg
Duratio Side effects of class
n of
action
6-8 hrs
Gi upset; diarrhea;
possible resumption
of ovulation in
premenopausal
anovolvutary
patients; acidosis (if
renal, liver, heart
impairment present).
Agents enhancing effects of insulin
Generic
name
Rosiglitazone
Dosage
Range
per day
4-8 mg
Duration Side effects of class
of action
Very long Renal and liver
function studies
should be done to
monitor liver
dysfunction, salt
and water retention,
edema, congestive
heart failure.
Agents enhancing effects of insulin
Generic name
Pioglitazone
Dosage
range per
day
15-45 mg
Duration
of action
Side effects of class
Very long Renal and liver
function studies
should be done to
monitor liver
dysfunction, salt and
water retention,
edema, congestive
heart failure
Other Oral agents
Generic name Dosage range Duration
per day
of action
Side effects of class
Repaglinide
(NovoNorm)
1.5-16 mg
2-6 hrs
Hypoglycaemia,
arthralgia, leukopenia
Acarbose
25-300 mg
< hrs
Miglitol
25-300 mg
<4 hrs
Diarrhoea,abdominal
discomfort, flatulence
Diarrhoea, abdominal
discomfort, use not
recommended when
significant renal
dysfunction present
Incidence of HOA failure
Primary failure:
About one third of of Type 2 patients fail to
respond to sulphonylurea treatment within
one month of initiation of therapy.
Secondary failure:
• Of the patients that initially achieve
satisfactory glycaemic control, about 5 to
10% go on to develop secondary failure
each year, so that after 10 years only about
half of the patients continue to have
satisfactory response.
Secondary failure: (continued)
• From the data of the UKPD study, it appears
by the sixth year,approximately 50% of the
patients randomized to sulphonylurea
needed supplemental insulin to maintain
adequate glycemic control.
Diagnosis OHA failure:
• It is a condition in which an individual does not
respond adequately/ satisfactorily with OHAs.
• Clinically, following parameters can be of great
relevance in diagnosing OHA failure:
1. Inadequate improvement in the classical signs
and symptoms of diabetes viz., polydypsia,
polyuria, polyphagia and fatigue.
2.Weight loss accompanied by rising blood
glucose and recurring infections.
3.Inadequate/deteriorating blood glucose
control. The objective to the pursued on this
front is:
Fasting blood glucose
PP blood glucose
<140 mg/100 ml
<180 mg/100 ml
4.High and increasing number of tablets with
inadequate control; especially exceeding
two to two and a half tablets in case of
commonly used OHA.
Dose at which review is essential
Oral hypoglycemic Agent Mg per day
No of tablets
Glibenclamide (Glyburide)
10
2
Gipzide
10
2
Glyclazide
120
1.5
Dose at which review is essential
• Poor performance with the above doses
indicates the necessity to review the
entire therapy and the therapeutic
alternative to be considered at this
point of time is initiation of insulin
therapy
In case of Type 2 diabetes, there
are 2 possibilities:
• Stop HOA treatment and start insulin
therapy (substitution) or
• Continue OHA treatment and add
insulin therapy (supplement)
Oral antidiabetics are contraindicated in
Type 1 diabetes and in Type 2 diabetes
undergoing surgery, serve infections, liver
and kidney disease, and gestational
diabetes.
Insulin
Insulin are always used in patients with
Type 1 diabetes and may be required in
patients with Type 2 diabetes or gestational
diabetes.
Insulin can be broadly classified on the
basis of species, action profile and strength.
Sources of insulin: human, porcine
and Bovine
Species
Structural difference
Immunogenecit
y
Human
Identical to physiological
insulin
Least
Porcine
Differs in one amino acid
from Human insulin
Negligible
Bovine
Differs in three amino
More
acids from Human insulin
Action profile of insulin:
Type
Onset
Peak
duration
Rapid-acting
½ hrs
1-3 hrs
8 hrs
Human
Actrapid
Indication
1. For dose titration, quick glycemic control
2. Emergencies like diabetic ketoacidosis (DKA),
hyperosmolar non-ketotic state (HONK)
3. Stressful conditions like surgery, labour,myocardial infraction
Type
Onset
Peak
Duration
Intermediate
2.5 hrs
7-15 hrs
24 hrs
Acting lente
Human
Monotard
Indication
1. OHA Failure
2. Pregnant diabetes
3. Chronic infections in Type 2 diabetes e.g Tuberculosis
Type
Onset
Peak
Duration
Intermediate
1.5 hrs
4-2 hrs
24 hrs
Acting NPH
Human
Insultard
Indication
1. OHA Failure
2. Pregnant diabetes
3. Chronic infections in Type 2 diabetes e.g Tuberculosis
Type
Onset
Peak
Duration
Pre-mixed (30/70
regular/NPH)
Human Mixtard
½ hrs
2-8 hrs
24 hrs
Indication
1. OHA Failure
2. Pregnant diabetes
3. Chronic infections in Type 2 diabetes e.g Tuberculosis
4. Any other indications where a mixture of rapid and
intermediate acting insulin is desired in the ratio of 30:70
Type
Onset
Peak
Duration
Pre-mixed 50/50
regular/NPH
Human Mixtard 50
½ hrs
2-8 hrs
24 hrs
Indication
1. Patients with modern lifestyles on two large daily meals
2. Patients with high post prandial blood glucose levels
Amounts of insulin
• Insulin regimen should be individualized
depending on lifestyle, activity level and eating
pattern.
• Continuous treatment and monitoring are the main
stay.
• Efforts should be taken to keep blood glucose as
close to the target range (72 mg/dl before a meal,
180 or less two hours after a meal).
Insulin Initiation
Substitutions
• Stop OHA tablets.
• Start with Intermediate insulin 0.2 units /kg
body weight before breakfast or at bed time
(upto a maximum of 20 units).
• Increases by 2-6 units every 3-4 days if
necessary.
Note:
• If post prandial blood glucose levels are too
high add Rapid action insulin. Alternatively,
Pre-mixed insulin could be used. If the dose
exceeds 30-40 units, divide the dose into
daily injections 2/3rd before breakfast and
1/3rd before dinner.
Supplement
• Continue with OHA tablet with out any
change in dose.
• Start with 0.1 to 0.2 units of
intermediate insulin per Kg body
weight before breakfast or bed time.
Supplement: (continued)
• Increase dose by 2-4 units every 3-4
days if necessary
• If more than 30-36 I.U. is required for
adequate control ( i.e FGB<140
mg/100ml), consider stopping OHA
and continue on insulin
Suggested Guidelines For Fine
Tuning Split Mix Regimens
• Response to insulin treatment may be
different in different patients may require
adjustment to the insulin regimen. The table
given below depicts a simple way to adjust
the dose.
Adjustment to morning injections
Before Lunch
If persistent
Increase fast acting
hyperglycaemia (or (soluble) insulin in
glycosuria) occur the morning
injection by 2IU
If hypoglycaemia
occurs with out
explanation
Decrease fast
acting (soluble)
insulin next
morning by 2 IU
Before Dinner
Increase
intermediate acting
insulin in the
morning injection
by 2 IU
Decrease
intermediate acting
insulin next
morning by 2 IU
Adjustment to evening injection
Before Lunch
Before Dinner
If persistent
hyperglycaemia
(or glycosuria)
occur
Increase fast acting
(soluble) insulin in
the evening injection
by 2IU
If hypoglycaemia
occurs without
explanation
Decrease fast acting
(soluble) insulin
evening injection by
2 IU
Increase intermediate
acting insulin in the
evening injection by
2 IU (after excluding
nocturnal
hypoglycaemia
Decrease
intermediate acting
insulin in the evening
injection by 2 IU
Mixing Insulin
• NPH and short-acting insulin formulations
when mixed may be used immediately or
stored up to 2 weeks.
• Mixing of regular and lente is not
recommended unless injected immediately
after preparation; binding action of regular
and lente begins immediately and effect of
regular may be blunted.
Insulin Administration
• Choose a syringe compatible with the insulin
strength (i.e.40 I.U. insulin)
• For cloudy insulin (suspension) invert the vial a
few times until the suspension has been mixed
well.
• Draw air into syringe corresponding to the
prescribed dose of insulin and slowly inject air
into vial held vertically at eye level, then draw up
insulin
Insulin Administration: continued
• Inject excess amount of insulin back into the vial
held vertically at eye level and pull out the needle.
• Lift up the skin at the injection site in a broad fold
and insert needle at an angle of 45 into the subcutaneous tissue, inject insulin slowly.
• In order not to injure the tissue beneath the skin
rotate the injection site in the chosen area.
Delivery Devises
Needle and Syringe
• A common way of administering insulin is
with a needle and syringe.
• Syringes come in a range of capacities (1ml,
0.5ml, or0.3ml) and different strengths.
• Most suitable size can be selected to deliver
the insulin dosage as per the requirement.
• Needles also come in different gauges and
lengths, and have very fine points and
special coatings to make them relatively
pain-free although some people find them
daunting and not very convenient.
Insulin Pens (NovoPen 3)
• Easiest and the most convenient way of
administrating insulin.
• Accurate even at extremely low dosage.
• NovoPen 3 reduces the insulin
administration to mere two step procedure:
Dial the dose and inject.
Advantages:
• Combination of insulin pens and Penfills
completely eliminates the need to handle
syringes and vials.
• No need to mix and measure and therefore
improves dosage accuracy.
• NovoPen 3 is compact enough to fit easily
into a purse or pocket and convenient to
carry anywhere.
• Launch of single penfills has further
enhanced convenience to buy and has also
offered economy to the patient by avoiding
huge investment at one single time.
Disposable Pens (NovoLet):
• Premixed, prefilled and ready to use
disposable insulin delivery devices.
• Patients just have to dial dose, inject and
dispose the pen after use of 300 units of
insulin.
NovoLets useful in initiating insulin therapy
in
• OHA inadequacy and failure
• Pre and post operative conditions
• Gestational diabetes mellitus
NovoLets are available in all the varieties of
insulin viz.
Mixtard 30 NovoLet, Mixtard 50 NovoLet,
Actrapid NovoLet, Insulatard NovoLet
Storage of Insulin
• Refrigerate unopened insulin (will be good until
the expiration date on the vial).
• The vial of insulin is used within 30 days of
opening, may be stored at room temperature (>2
degree Celsius and <30 degree Celsius); insulin ac
activity decreases after 30 days at room
temperature.
• Unlike other medications insulin requires a special
storage and transportation arrangement.
• Needs to be stored between 2 degree
Celsius to 8 degree Celsius without
dampness and direct exposure to
sunlight.
• In transportation it is to be dispatched
with coolants and thermocol boxes.
• Neutral insulin should be a clear solution
whereas premixed and intermediate
insulin are suspensions.
• Magnus Novo Nordisk offer complete
range of insulin with C4 (Complete care
cool chain) guarantee.
Diabetes Treatment Chart
Define individual Aims of therapy
Diet and Exercise
Glycemic goals
Monotherapy
Repaglinide
Sulphonylurea
Biguanide Alphaglucosidase inhibitor
Thiazolidinedione
Insulin
Very symptomatic
Severe
hypoglyceamia
Ketosis Pregnancy
Glycemic goals
achived
Traditional Medicines
Due to chronic nature of the disease, patients
try various therapies available in the market,
which are clinically not proven. The basis of
the usage of these medicines is “no sideeffects” but then “efficacy” is always a
question mark. Some of the traditional
medicines used in the treatment are:
• Better substances like Neem leaves, Bittergourd,
Methi etc.
• Ayurvedic drugs viz. Vijasar, Bittergourd, Jamoon
Seeds and Nisha Amlakki are used commonly.
However their clinical results have not been either
conclusive or not published.
• Spirulina (fresh water algae) that grows in water
tanks is used, but not significant effect seen on
blood sugar.
Precautions
• It is essential to provide the efficacy and
safety of traditional medicines in wide
variety of patents and to look for long term
safety and efficacy in human beings.
• Any system of medicine that claims that it
has cure or relief for Diabetes has to under
go the clinical safety tests before it is
accepted.
• Scientific proof and clinical study
should authenticate any such claims in
magazines and newspapers.
Drugs that may alter the
glycemic control of sulfonylureas
A. Enhance hypoglycemic effect (decrease
blood glucose)
Alcohol (acute use)
Methyldopa
Allopurinol
Androgens
Monoamine Oxidase
(MAO) inhibitors
Phenobarbital
Anticoagulants
Phenylbutazone
Chloramphenicol
Probenecid
Clofibrate
Salicylates
Fenfluramine
Sulfinpyrazone
Flucanazole
Sulfonamides
Gemfibrozil
Ticuclic antidepressants
Histamine H2 antagonists Urinary acidifiers
Decrease hypoglycemic
effect(increase blood glucose)
Beta-blockers
Rifampin
Cholestyramine
Urinary alkalinizers
Diazoxide
Diuretics
Drugs that interact with insulin
• Enhance hypoglycemic effect (decrease blood
glucose)
Angiotensin-converting
enzyme (ACE)inhibitors
MAO inhibitors
Alcohol
Mebendazole
Anabolic steroids
Octreotide
Beta-blockers(delay recovery Pentamidine
from hypoglycemia)
Calcium
Phenylbutazone
Chloroquine
Pyridoxine
Clofibrate
Salicylates
Fenfluramine
Sulfinpyrazone
Guanethidine
Sulfonamides
Lithium carbonate
Tetracyclines
Decrease hypoglycemic effect
(increase blood glucose)
Acetazolamide
Empinephrine
AIDS antivirals
Estrogens
Asparaginase
Enthacrynic acid
Calcitonin
Isoniacid
Contraceptives, oral
Lithium carbonate
Conticosteroids
Morphine sulfate
Cyclophosphamide
Niacin
Dextrothyroxine
Phenothiazine
Diazoxide
Nicotine
Diatiazem
Thiazide diuretics
Dobutamine
Thyroid hormone
Low Blood Sugar (Hypoglycemia)
• A common problem in diabetic patients
whether on oral antidiabetics Or insulin.
• Hypoglycemia can be longer & serious with
some oral antidiabetics because of their
longer duration of action and unpredictable
pharmacokinetics.
Symptoms of Hypoglycemia:
•
•
•
•
•
Sweating
Palpitations
Shakiness
Blurry vision
Headache
• Frequent hunger
• Feeling of “passing out”
• Decreased
“concentrating ability”
• Inappropriate behavior
• Loss of conciousness
Treatment of Hypoglycemia:
• Check blood glucose to exclude other reasons.
• If glucose meter not readily available, then
presume hypoglycemia and institute testament
immediately.
• Provide glucose tablets, fruit juices,candy,etc.
• If the patient becomes unconscious, a Glucagon
injection (GlucaGen Hypokit) Should be
administered.
• Recheck blood glucose after 30 minutes.
• Hypoglycemia can be recurrent on
administration of long acting insulin or
drugs such as Glyburide, Glipizide
especially if patients also have kidney
disease.
• Patients are generally monitored in the
hospital for 24 48 hours for any recurrent
hypoglycemia.
Diabetic ketoacidosis
Symptoms:
• Anorexia, nausea, vomiting
• Thirst, Polyuria
• Weakness
• Abdominal pain
• Visual disturbance
• Weight loss
Signs:
•
•
•
•
•
•
•
•
Elevated blood glucose (>250mg/dl)
Ketonuria/Ketonemia
Plasma bicarbonate <15meq/L
Dehydration
Warm dry skin
Tachycardia
Rapid/deep breathing, acetone odour
Somnolence, coma
Treatment:
• Replacement of fluid loss to correct dehydration &
hyperosmolarity
• Replacement of electrolysis with potassium
containing saline
• Correction of hyperglycemia by insulin and fluid
replacement
• Ketosis and acidosis are simultaneously corrected
by above measures
• Identification and correction of precipitatory
causes.
Complications: Long Term
• Diabetes is the silent killer as it affects
almost all the organs of the body and
usually leads to a host of complications if
not controlled aggressively.
Kidney Disease
Symptoms:
• Hypertension, edema, proteinuria and renal
insufficiency
Diagnosis:
• Urinary microalbumin excretion testing
• Spot urine sample testing
Treatment:
• Tight control of blood glucose in most diabetic
patients.
• Dietary protein restrictions.
• Excessive urinary microalbumin excretion should
be treated with an ACE-inhibitor agent (provided
there are no contraindications) even if their blood
pressure is not elevated. This helps to control
intraglomerular hypertension.
• High blood pressure should be aggressively
treated in diabetic patients and target blood
pressure should be less than 130/85mg Hg.
Monitoring:
• Urinary albumin excretion test on a yearly
basis
Eye Disease
• Symptoms:
• Diminished visual activity; frequent change
in power of lens, painful eye
Diagnosis:
• Check visual acuity with Snellens chart,
seperately for each eye
• Dilate pupils
• Examine fundi by ophthalmoscope
• Microaneurysms, retinal hemorrhages,hard
exudates from eye.
Treatment:
• Aggressive control of blood glucose and
blood pressure in most diabetic patients.
• Laser photocoagulation surgery for diabetic
macular edema or proliferative retinopathy.
• Vitrectomy surgery for vitreous hemorrhage
or severe progressive neovascularization.
Monitoring:
• Yearly eye examination of the diabetic
patient by an ophthalmologist
Foot Problem
Symptoms:
• Tingling, pins & needle sensation, burning
sensation, numbness or pain.
Diagnosis:
• Carefully inspect the feet (whole foot, nails)
• Check peripheral pulses
• Examine for neuropathy i.e touch and
vibration
Treatment:
• Best treatment is regular care of the feet.
• Tight blood glucose control is crucial.
• The mode of treatment depends upon
– the degree of lesions,
– neuropathic & vascular assessment
– and X-ray.
• Treatment can range from bed rest, antibiotics
according to culture and sensitivity, plaster, special
shoes to ampulation.
Mentoring:
• A podiatrist should be visited for regular
foot checking.
Erectile Dysfunction
• Erectile dysfunction is the most common
male sexual dysfunction in diabetes.
Treatment options for diabetic
erectile dysfunction
General measures
• Improving diabetic control
• Reduce alcohol intake
• Withdraw causative drugs
Nonhormonal therapy
• Alpha-2-adgrenergic blocking agents (yohimbine
hydrochloride)
• Type-specific phosphodiesterase inhibitors
(sildenafil citrate)
Noninvasive Therapy:
• Vacuum erection devices
• Intracavernosal injection of vasoactive
agents (mixture of papaverine,
phentolamine, prostaglandin E1)
Invasive therapy:
• Penile prosthesis (malleable versus
inflatable device)
• Microvascular arterial bypass surgery
Heart Disease
• Symptoms:
• Augina symptoms: chest, arm, and/or jaw
pain (discomfort), Shortness of breath, cold
clammy sweat
• Myocardial infraction (ML)- “silent”ML
more common.
Diagnosis:
• Examine blood pressure
• Electrocardiogram monitoring particularly
ambulatory
• ECG monitoring for silent ischemia
• Stress testing for coronary heart disease
• Echocardiography (with Doppler)
• Testing of cholesterol
Treatment
• Antiplatelet / anticoagulants:
• Start Aspirin 80 to 325mg/d if not
contraindicated Manage warfarin to
international normalised ratio 2 to 3.5 for
post ML-patients not able to take aspirin
ACE inhibitors in post-ML patients:
• Start early post-ML in stable high risk
patients (anterior ML, previous ML, Killip
class II
• Continue indefinitely for all with LV
dysfunction
• Use as needed to manage blood pressure or
symptoms in all other patients
Beta-blockers:
• Start in high risk post-ML patients
(arrhythymia, LV dysfunction, inducible
ischemia) at 5 to 28 days with continuation
for six months minimum
• Use as needed to manage angina, rhythym,
or blood pressure in all other patients
Pregnancy and Diabetes
Insulin treated diabetes
Planned Pregnancy
• Good glycemic control be obtained before
conception. In some situations intensive
stabilization pre-pregnancy may be
necessary
• Good glycemic control before and
throughout pregnancy reduces the risk of
complications for the mother and foetus.
• For pre-pregnancy stabilization use at least
a twice daily mixtures of short and
intermediate acting insulin.
• Reinforce education on diet and insulin self
adjustment.
Preconception goal for glycemic
control
• Premeal glucose 70 to 100 mg/100 ml (3.8
to 5.5 mmol/l)
• 1 to 2 hour post meal glucose at or below
150 mg/100ml(< 8.3 mmol/ol)
• Serial H BA1c levels to be maintained at the
normal or near normal value.
Other Assesments
• Asses for any diabetic complications
(hypertension, ischemic heart disease,
nephropathy, neuropathy, retinopathy and
severe gastroenteropathy).
• Obsteric assessment
• Thyroid function test as per local practice
Optimal Target Index for Glycemic
Control During Pregnancy with diabetes
• Blood Glucose Goals in Diabetic Pregnancy
Fasting
60-90 mg/100 ml (3.3-5.0 mmol/l)
Premeal
60-105 mg/100 ml(3.3-5.0 mmol/l)
1 hour postprandial
100-120 mg/100ml(5.5-6.7 mmol/l)
2 a.m 6 a.m Hours
60-120 mg/100 ml(3.3-6.7 mmol/l)
Oral hypoglycemic treated diabetes
• Oral hypoglycemic drugs should be
discontinued and human insulin therapy
instituted.
• Planning for pregnancy; preconceptions
goals for glycemic control; other
assessment; and Optimal Target Index for
glycemic control during pregnancy with
diabetes.
Gestational diabetes
• Gestational diabetes mellitus develops in
approximately 2-5% of pregnant women.
GDM are at increased risk for the
development of Type 2 diabetes later in life
and their infants are at risk for macrosomia.
Screening, diagnosis and
treatement
• All pregnant women should be screened for
glucose intolerance between 24th and 28th
week
Diagnosed GDM
Diet; monitor glycemia, foetus
Fasting blood glucose < 105
mg/100ml (<5.8 mmol/l) and
2-hour postprandial <120
mg/100 ml (< 6.7 mmol/l)
Continue diet and monitor
glycemia and foetus
Fasting blood glucose > 105
mg/100ml (>5.8 mmol/l) and 2hour postprandial >120 mg/100
ml (>6.7 mmol/l)
Initiate Human Insulin
treatment; monitor
glycemia and foetus
• Diabetes is frequently associated with
infections as seen in clinical practice, but
not clearly proved. Defects in both cell
mediated immunity and polymorphonuclear
functions have seen experimentally shown,
but their exact role in human beings is yet to
be clearly shown.
• A decreased perfusion due to abnormality in
microvascular circulation and neuropathy
may worsen the prognosis as infection sets
in.
• The entire immune system is altered to
defense against microbial invasion, certain
defects may be more directly associated
with certain infections in diabetes.
Skin infections
• Due to compromised host defense and high
blood sugars, microbes withy low virulence
easily cause infections of the damaged skin.
• Staphylococcus aurous infection causing
boils, carbuncles and abscesses are the most
common skin infections.
Diagnosis:
• Confirmation is by biopsy of the affected
area
Treatment:
• Board-spectrum antibiotics, antifungul
agents
Tuberculosis
• Tuberculosis is common with diabetes in
India.
Diagnosis:
• Chest X-ray
• Sputum and urine examination
• Hematology
Symptoms:
•
•
•
•
Weight loss
Fever with chills
Weakness
Excessive urination
Treatment:
• Antitubercular therapy of INH, Rifampicin,
Ethambutol and Pyrazinamide.
• Rifampicin and INH interact with OHAs
and therefore choose insulin to initiate
antidiabetic treatment.
Surgery
• During surgery utmost care is required from
the family physician in co-ordination with
anesthetist to achieve proper glycemic
control and avoid complications. The
management differs as per the current
treatment and status of diabetes. Broadly
surgery management in diabetics is
undertaken in following three phases:
Pre-operative Management
• In patients managed on diet, assess for metabolic
control with proper diet. If uncontrolled, admit
patient 1-2 days before operation and initiate
Human Actrapid.
• In patients managed on oral anti-diabetics, shift to
shorter acting sulphonylurea. Biguanide should be
stopped one week before and the patient should be
shifted to insulin for stabilisation
• In patients on insulin, shift from
intermediate acting insulin to short acting
insulin (Human Actrapid)
• Frequent monitoring is required.
• If optimal control is not achieved with
subcutaneous Human Actrapid, considered
intervevous infusion.
Peri-operative (during surgery)
Management
• In patients only managed on diet institute insulin if
hyperglycemia develops & persists post
operatively.
• In patients managed on oral medication, avoid
breakfast and no medication on day of treatment.
Treats as non diabetic if blood glucose is<126
mg/dl.
• If blood glucose increase more than 126mg/dl then
initiate insulin (human Actrapid)
• In major surgery set up Human Actrapid insulin
infusion.
• In patients managed on insulin,set up i.V,
infusion (10% Dextrose 500ml + I.U.
Human Actrapid+10 mmol KCL) and
regimen adjust as per patient’s requirement.
• Monitor patient frequently (1-2 times every
hour) during operation.
Post-operative (after surgery)
Management
• In diet treated diabetics, return to preoperative dietary management incase of
minor surgery. In major surgery, treat with
Human Actrpid (8-12 units) t.d.s before
each meal. Further titrate the dose as per the
requirement.
• In patients managed on oral medication
recommence sulphonylureas with first meal
in case of minor surgery. In major surgery,
treat with Human Actrapid (8-12 units) t.d.s.
before each meal. Further titrate the dose as
per the requirement.
• In patients managed on insulin, continue the
infusion at the same rate until oral feeding
commences. If infusion is prolonged (24 hrs),
check electrolytes daily (Na/K).
• Initiate Human Actrapid (equivalent to preoperative dose) with oral feeding
• After 2-3 days, restabilise on suitable regimen for
the patients.
• Measure Ketone bodies and blood glucose
frequently
• Being sick can make the blood glucose level
go up very high.
• It can also cause serious conditions that can
put up the patient in a coma.
What Happens When the Patient
is Sick
• Patient when sick is under stress leading to release
of hormones, which raises blood glucose levels,
and interferes with the glucose-lowering effects of
insulin.
• Easy to lose control of the diabetes leading to
ketoacidosis and diabetic coma particularly in
people with Type 1 diabetes.
• People with Type 2 diabetes, especially older
people, can develop a similar condition called
hyperosmolar hyperglycemic nonketotic coma.
Diabetes Medicines
• Type 1 diabetes, it is advisable to take extra
insulin to bring down the higher blood sugar
levels.
• Type 2 diabetes, may be able to take pills,
or may need to use insulin for a short time.
Food
• Eating and drinking can be a big problem.
But it is important to stick to the normal
meal plan.
• Easy to run low on fluids when one is
vomiting or has fever or diarrhea. Extra
fluids will also helps get rid of the extra
sugar (and possibly ketones) in the blood.
Medicines to Watch Out For
• Advice to check the label of over- the-counter
medicines before buying them to see if they have
sugar. Small doses of medicines with sugar are
usually okey.
• Many medicines when taken for short-term
illnesses can affect blood sugar levels, even if they
don’t contain sugar. For example, aspirin In large
doses can lower blood sugar levels
• Some antibiotics lower blood sugar levels in
people with Type 2 diabetes who take
diabetes pills.
• Decongestant and some products for
treating colds raise blood sugar levels.
Monitoring Glucose level
• Regular / frequent monitoring required
Travel
• Before a long trip, medical examination is
necessary to make sure diabetes is in good
control.
Packing Tips
Whether traveling by car, plane, boat, bike, or foot,
the patient will want keep this “carry-on” bag with
him at all times. Pack this bag with:
• All the insulin and syringes needed for the trip
blood and urine testing supplies (include extra
batteries for the glucose meter)
• All Oral medications (an extra supply is a good
idea)
• Other medications or medical supplies, such as
glucagon, antidiarrhea medication, antibiotic
ointment, antiemetic drugs
• ID and Diabetes identity card
• A well-wrapped, air-tight snack pack of crackers
or cheese, peanut butter, fruit, a juice box, and
some form of sugar (hard candy or glucose tablets)
to treat low blood glucose.
Insulin During Travel
• Insulin stored in very hot or very cold temperature
may lose strength. Don’t store insulin in the glove
compartment or trunk of the car
• Insulin used in India are of the strength 40 and 100
I.U.
• In foreign countries, insulin may come as I.U.40
or I.u.80. If the patient needs to use these insulin,
one must buy new syringes to match the new
insulin to avoid mistake in the insulin dose.
Crossing Time Zones
If one takes insulin shots and will be crossing the
time zones, remember:
• Eastward travel means a shorter day, less insulin
may be needed.
• Westward travel means a longer day, so more
insulin may be needed.
• To keep track of shots and meals through changing
time zones, advice the patient to keep his watch on
his home time zone until the morning after he
arrives.
After Arrival
• After a long flight, it is advisable to take it easy
for a few days. Test the blood sugar often.
• If one takes insulin, plan the activities so that one
can adjust insulin dose and meals.
• Ask for a list of ingredients for unfamiliar foods.
Some foods may upset the stomach and hurt the
diabetes control.
• Always advice to wear comfortable shoes and
never go barefoot. Check the feet every day.
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