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					                                Symptoms of Diabetes Mellitus       No    Pregnancy/Hx of GDM
                                                                          Hx of HT/IHD                No
                                                                                                             Random Urine for Sugar
                                                                          Obesity                                     (-)ve
                                                                         Yes                      (+)ve
                                                                                                                       Reassured
                Yes                                               Check spot H’stix
                                                                                                                      Opportunistic
                                                                                                                    education on diet /
                                                                                        H’stix ≦6mmol/L
                            H’stix 6-15mmol/L           H’stix≧15mmol/L                                                 exercise

                                                                           (+)ve   Ketoacidosis Yes
    Confirm DM if                                                                  or type I DM      Admission
                                                        Urine for Ketone
      FBS ≧ 7.0 mmol/L                                                                         No
    or RBS ≧ 11.1 mmol/L                                              (-)ve                       Appropriate Mx
    IFG: FBS 6.1 -7 mmol/L                                                                        Early F/U
    Perform 75g OGTT if                                                  Age < 40                 Recheck Urine Ketone
      FBS 6.1- 7.0 mmol/L                                                Type I DM               No          Yes
    or normal plasma sugar but with                                      Pregnancy
                                                        Yes
     symptoms of DM and glycosuria                                       Unstable angina/ AMI/
                                                                         CVA within 6 months                                                        Yes
Normal                       IFG/IGT
                                                                                  No
   Reassured                  Educate on life-                                  Initial management
  Opportunistic               style and diet              1. Screen for co-existing proteinuria and HT (<140/90)
education on diet /           Weight reduction            2. Check for occult infection (esp. TB)
    exercise                  Exercise                    3. Determine treatment goal
                              Annual review                   HbA1c ≦ 7% if age < 65
                                                              HbA1c ≦ 8% if age ≧ 65 or ESRF
                                                          4. Lifestyle modification
 Annual Complication Screening                                Dietary advice
                                                              Exercise 30min 3x/week
1. Glycaemic control                                          Smoking/drinking cessation
•Check compliance/self care                               5. DM education for self care
knowledge                                                 6. Drugs
•FBS / HbA1c                                                  Obese: start Metformin (normal Creatinine level)
2. Coexsiting                                                 Thin : start Sulphonylurea
•Obesity:BMI, WHR                                             Avoid Daonil if abnormal creatinine or age ≧ 70
•HT :BP/P                                                     Add ACEI /Ca Channel Blocker for HT (ACEI esp. for
•Cardiac disease: ECG                                               Microalbuminuria,
•Hyperlipidemia : fasting lipid                                      2nd line: low dose thiazides or beta-blockers)
3.Complications:                                          7. Consider role of obesity and co-existing diseases
•Nephropathy: RFT,12 hour urine
for microalbumins/protein &                                                      FU cases
Creatinine                                                   Check symptoms of hyper/hypoglycemia
•Retinopathy:VA, Fundoscopy                                  Check any home sugar monitoring (blood/urine)
•DM foot                                                     Check associated risk factors (including Lipid)
4.Smoking Cessation Advice                                   General medical condition: BP/Pulse/BW
       (Details refer to P.2)                                                                                                   Over-Rx
                                                                                                                             HbA1c 4-6
                                                                               Glycaemic Control
                                                                                                                             Symptoms of
                                                                                                                             hypoglycemia

                                                            Optimal                   Fair                      Poor
                                                        HbA1c ≦ 7%             HbA1c 7-9 % if              HbA1c>9%
                      1. Start ACEI if                  if age < 65            age < 65                    if age < 65
                      microalbuminuria for 2            HbA1c ≦ 8%             HbA1c 8-10% if              HbA1c > 10%
                      specimens                         if age ≧ 65            age ≧ 65                    if age ≧ 65
                      2. Stop or decrease dose of
                      Metformin if Creatinine
                      elevated
                                                                                                                    Any of the followings
                      3. For BP and Lipid problem,                       -Reinforce diet compliance
                                                                                                                    1. HbA1c> 9% on at least 2
                      refer corresponding protocol                       -Encourage regular exercise
                                                                                                                    occasions over 6 months
                      4. FU as scheduled                                 -Check drug compliance
                                                                                                              No    2. Secondary failure of oral
                                                                         -Step up treatment if necessary
                                                                                                                    hypoglycemic agent
                                            Check H’stix every visit
                                            if no blood taken                                                 Check H’stix every visit
                                            Follow up 2-3monthly           Check H’stix every visit           if no blood taken
                                            Check HbA1C 1-yearly           if no blood taken                  Follow up 1-monthly                  Yes
                                            (6 monthly in long term)       Follow up 6-8 weekly               Check HbA1C 3-monthly
 Any of the followings                                                     Check HbA1C 6-monthly              Check other medical
 .Retinopathy                                                              (3 monthly in long term)
 .Foot ulcer                                                                                                  conditions that may affect
                                                                                                              glycaemic control (occult
 .Severe PVD+Neuropathy
 .Significant or worsening                           Private GP                                               infection-CXR, MSU;
                                                                                                              Drug, Thyroid…..)
 nephropathy
  (serum creat > 200umol/L                                                                                                                   Refer Specialist:
   or proteinuria > 1g/day)                                                                                                                  Private/HA
                                             Footnote:
                                             Interpretation of OGTT
                                             Normal: Fasting glu< 6.1mmol/L & 2hr OGTT < 7.8mmol/L
                                             DM Fasting glu ≧ 7.0mmol/L or 2hr OGTT≧ 11.1mmol/L
                                             IGT Fasting < 7.0mmol/L & 2hr OGTT 7.8-11.1mmol/L

				
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