DIABETES MELLITUS Management. IMPORTANT POINTS: IN HISTORY, EXAMINATION, INVESTIGATIONS AND...
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Transcript of DIABETES MELLITUS Management. IMPORTANT POINTS: IN HISTORY, EXAMINATION, INVESTIGATIONS AND...
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DIABETES MELLITUS
Management
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IMPORTANT POINTS:IN HISTORY, EXAMINATION, INVESTIGATIONS AND TREATMENT
– Control: good / poor? Treatment?
– Complications
– Cardiovascular risk factors
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HISTORY: special points
Introduction: ethnic group and age Presenting complaint
– E.g. admitted for control of diabetes History of presenting complaint
– Polyuria, polydypsia……blood glucose values, also indicates control, screening
Complications – systemic review esp. CVS, Neuro, Eye, Renal, Skin, Drug history – What medication? Duration, Side effects? Compliance? P/H/O complications esp. CVS, wound infections
F/H/O type 2 DM, IHD, CVA, HBP
Social history: smoking, diet, exercise, financial aspects
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EXAMINATION: special points General examination
– skin infections, edema, waist CVS –
– BP, postural hypotension, JVP, cardiomegaly – peripheral pulses, bruits
RS– Infections - TB
Abdomen – Fatty liver, ascites with nephrotic syndrome
CNS– Ophthalmoscopy and cranial nerves– Mononeuritis– Amyotrophy– Autonomic (postural hypotension)– Peripheral neuropathy
• Muscle wasting• Early sensory signs: vibration sense, absent jerks• Romberg’s test
FEET– Skin, bact / fungal infections, gangrene, pulses, neuropathy, ulcers, osteomyelitis,
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INVESTIGATIONS
Assess glycemic control
Extent of complications
Risk factors for CAD
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INVESTIGATIONS
Assess glycemic control: blood glc levels, HbA1c, fructosamine
Extent of complications: ECG, A/B, Renal, CXR, ECHO,
Risk factors for CAD: BP, lipids, metabolic syndrome
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PRINCIPLES OF TREATMENT
Good glycemic control Prevent or treat complications Manage risk factors for CAD
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PRINCIPLES OF TREATMENTTYPE 2 DM
Good glycemic control Prevent or treat complications Manage risk factors for CAD
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GLYCAEMIC CONTROL
A healthy lifestyle OHD Insulin
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HEALTHY LIFE STYLE
Healthy eating Weight control Exercise Smoking and alcohol
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HEALTHY LIFE STYLE
Healthy diet Exercise Weight control: BMI <23 kg / m2
Smoking and alcohol
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DIET
Carbohydrates– 60% of calories– Low glycaemic foods preferred– Restrict refined sugars and high fiber– Non-nutrient sweeteners– Avoid alcohol
Fats– <30% of calories– <7% saturated– <200 g of cholesterol– Avoid trans-fatsEat fish twice a week
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EXERCISE
Control of blood sugar Increases insulin sensitivity (danger of hypo) Weight loss Reduces body fat and maintains muscle bulk Lowers blood pressure Cardiovascular fitness
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DRUGS
Decreased absorption
Decreased hepatic glc output Increased peripheral glc uptake
Stimulate insulin release
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OHD
Decreased absorption
Decreased hepatic glc output Increased peripheral glc uptake
Acarbose
PioglitazonMetformin
Stimulate insulin releaseSulphonyluria, Repaglinide
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OHD
Biguanides: metformin Sulphonyluria: glyclazide, glipizide Thiozolidinediones: pioglitazone Alpha glucosidase inhibitor: acarbose Non-sulphonyluria secretagogues: repaglinide
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DRUG THERAPY
Asymptomatic
Life-style modification Drugs
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DRUG THERAPY
Asymptomatic
Metformin
Life-style modification Drugs
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DRUG THERAPY
Asymptomatic SymptomaticHigh HbA1C
High FPG
High RPG
Life-style modification Drugs
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DRUG THERAPY
TYPE 2 D M Asymptomatic Type 2 DM ? Metformin
Symptomatic Type 2 DM HbA1c >8% FBS > 11.1 RBG > 14.0
TYPE 1 DM Insulin
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TYPE 2 DM
Obese T2DM: Metformin If intolerant give acarbose or TZD HbA1C >10%: combination of metformin and
gliclazide (sulphonyluria)
Non-obese T2DM: Metformin or sulphonyluria
(gliclazide)
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GOALS OF GLYCEMIC CONTROL
– FBS 4.4-6.1
– Non-fasting 4.4-8.0
– HbA1C <6.5%
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Mono-therapy
Combination of metformin + gliclazide
OR metformin + acarbose / TZDs (esp in obese)
Then add third drug
Add insulin
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ADD INSULIN
If not reaching target after 3 months of optimum combination therapy (metformin, gliclazide, acarbose, pioglitazone)
FBG> 7.0 mmol/L HbA1c>6.5% Maximum doses of OHD
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INSULIN
Rapid-acting analogues Fast-acting insulin (short-acting) Intermediate-acting insulin Long-acting insulin Very long-acting analogues
Lancet 2006;367:847
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INSULINS
Rapid-acting analogues: insulin lispro, Humalog (4-6 hours) Fast-acting: soluble insulin, Actrapid, Humulin R (6-10 hours) Intermediate-acting: (10-16 hours)
– isophane; NPH, Humulin N– Humulin L (Lente insulin)
Long-acting insulin: Ultralente 24 hours Very long-acting analogues: (24 hours)
– Insulin glargine (Lantus)– Insulin detemir (Levemir)
Lancet 2006;367:847
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INSULIN REGIMES
Premixed (Mixtard) b.d. (30% soluble + 70% isophane)
Before meals rapid or short, with bedtime intermediate or long acting analog
Bedtime Long-acting or intermediate insulin, day time sulphonyluria + metformin
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INSULIN REGIMES
Basal-bolus (T1DM) Insulin pumps (continuous subcutaneous)
Twice daily mixtard (Often for T2DM)– 2/3 of total dose in morning (2/3 long acting = e.g. 30:70
Mixtard)– 1/3 of total dose in evening (1/2 long acting = e.g. 50;50 Mixtard)
Lancet 2006;367:847
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INSULIN PUMP
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COMPLICATIONS OF TREATMENT
Hypoglycaemia Hypoglycaemia unawareness
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NEWER DRUGS IN TYPE 2 DM
Exenatide– Stimulates insulin secretion
– Glucagon-like-peptide
– Given S.C
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PREVENT COMPLICATIONS OF DIABETES
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PREVENT COMPLICATIONS OF DIABETES
Nephropathy Neuropathy Retinopathy Cardiovascular: IHD, CVA/TIA. PVD Diabetic foot
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PREVENT COMPLICATIONS OF DIABETES
Good glycaemic control Screen for complications Action to prevent specific complications
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PREVENT COMPLICATIONS OF DIABETES
Good glycaemic control Screen: regular BP, lipids, eye and renal check up Action to prevent specific complications:
– ACEI or ARBs in early renal involvement– Aspirin if IHD, or high risk of IHD (microalbuminuria, metabolic
syndrome, >35, high-risk ethnic groups, family history) – Control hypertension (macrovascular, retinopathy and
nephropathy)– Treat hyperlipidaemia (macrovascular and nephropathy)– Stop smoking (IHD, CVA, TIA, PVD)– Diabetic foot
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CONTROL HBP AND HYPERLIPIDAEMIA
– LDL <2.6
– TG <1.7
– HDL >1.1
– BP <130/80
– BP <120/75 (with renal impairment or gross proteinuria)
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COMPLICATIONS: DIABETIC FOOT
Slides current until 2008
Diabetic neuropathyFoot education
Curriculum Module I I I -7cSlide 8 of 34
Wash, touch and look at feet every day
• Do not soak feet
• Test water temperature
• Wash and dry between toes
• Avoid herbs and ointments
• Examine feet in good light
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COMPLICATIONS: DIABETIC FOOT
Slides current until 2008
Diabetic neuropathyFoot education
Curriculum Module I I I -7cSlide 15 of 34
How to care for toenails
• Do not to let nail grow too long
• Cut straight across
• File sharp edges
• Ask a friend or relative
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COMPLICATIONS
Slides current until 2008
Diabetic neuropathyFoot education
Curriculum Module I I I -7cSlide 11 of 34
Learn to look for:
Hammer toe Clawed toes