Advanced Management of Diabetes Mellitus by jgu62056

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									     Process of
Disease Management
         on
 Diabetes Mellitus
                 By

          Elaine L Y Leung
Nurse Consultant (Diabetes Care) HKWC
          Diabetes Mellitus
• Diabetes mellitus is a chronic disorder
  characterised by raised blood glucose
  levels, secondary to a complete or
  relative lack of insulin
• Affects almost 10% of HK adults
New Trends in DM Managment
Emphasis on prevention:
 Prevention of diabetes
   life-style modifications in prediabetic states (IGT/IFG)
   58% ↓ in DPT (US) and Finnish DM Study
Subjects at Increased Risk of DM
DM in first degree relatives
History of gestational diabetes
Age over 45
Other components of the Metabolic or Insulin
Resistance syndrome:
  Obesity, hypertension, dyslipidaemia
New Trends in DM Managment
Emphasis on prevention:
 Prevention of diabetes
   life-style modifications in prediabetic states (IGT/IFG)
   58% ↓ in DPT (US) and Finnish DM Study
 Prevention of complications
   early DM Dx; effective control of glycaemia, BP, etc.
 Current Treatment Targets
                  ADA             IDF-WPR
HbA1c             < 7%             < 6.5%
Blood pressure    < 130/80 mmHg    < 130/80
LDL cholesterol   < 2.6 mmol/l     < 3.0
HDL cholesterol
    Men           > 1.1 mmol/l     > 1.1
      Women       > 1.3 mmol/l     > 1.3
Triglycerides     < 1.7 mmol/l     < 1.5
    Action of commonly used oral anti-
              diabetic agents
                                                                                   Sulphonylureas and
 Stomach                                                                               meglitinides
                        α-glucosidase inhibitors                                     stimulate insulin
 Gut                                                                                    secretion1

                                      Glucose
                                                                                     Pancreas
Metformin primarily                                                   Insulin
  reduces hepatic
glucose production1

                                                          Adipose tissue

                              Liver                                                 Rosiglitazone
                                                                                  decreases insulin
                                                                                   resistance2 and
                                    Muscle                                         improves β-cell
                                                                                      function3
                                    Adapted from 1Kobayashi M. Diabetes Obes Metab 1999;1(Suppl. 1):S32–S40.
                      2
                        Nattrass M & Bailey CJ. Baillieres Best Pract Res Clin Endocrinol Metab 1999;13:309–329.
                                              3
                                                Del Prato S & Marchetti P. Diabetes Technol Ther 2004;6:719–731.
Algorithm for the Metabolic Management of T2DM
               ADA Position Statement. Standards of Medical Care in Diabetes. Jan 2007

                                                  Diagnosis


                                   Lifestyle intervention and metformin


                              No                 HbA1c ≥7%                  Yes*

     Add basal insulin−                      Add sulfonylurea −                       Add glitazone −
      most effective                          least expensive                         no hypoglycemia


No     HbA1c ≥7%           Yes*      No          HbA1c ≥7%          Yes*      No         HbA1c ≥7%           Yes*


     Intensify insulin             Add glitazone+               Add basal insulin            Add sulfonylurea+


          No         HbA1c ≥7%            Yes*                       No         HbA1c ≥7%           Yes*

                                                                Add basal or intensify insulin#


                          Intensive insulin + metformin +/− glitazone

                  * Check A1C every 3 months until <7% and then at least every 6 months
      + Although 3 oral agents can be used, initiation and intensification of insulin therapy is preferred
                                    based on effectiveness and expense
 New Trends in DM Managment
Emphasis on patient self-care

 Empowerment / patient education
 Education on self-management of diabetes
 mellitus is important since more than 95% of
 diabetes care is self-care.
New Trends in DM Managment

Emphasis on prevention:
  Prevention of diabetes
    life-style modifications in prediabetic states
  Prevention of complications
    early DM Dx; effective control of glycaemia, BP, etc.
  Prevention of severe sequelae of DM complications
    Cx screening & its management
Diabetic Complications
                     腦
 眼



心臟


                      腎


足部

               香港大學內科部 瑪麗醫院糖尿病中心 提供
     Diabetic Complications
It is a major public health problem in both
developing and developed countries.

Costs of treating diabetes and its complications
are high.
 Workflow of complication screening
Patient          Doctor / Nurse                                           Regular
Recruitment                                                    NAD
                                                                            Cx
                                        Retinal photo                    screening
                                        reviewed by
Background                              Diabetologist
DM information       Nurse
collection                                                                  Refer
                                                              Abnormal
                                                                            Eye
                                                                            Clinic



Arrange blood test      Nurse
                                        VA
                                                                HCA / Nurse
                                        Retinal phtotgraphy
Measure          HCA
BP, BMI,WHR
                                  Foot
                                                   HCA/ Podiatrist
                                  assessment
Current Challenge for Management
        of Chronic Disease
Prevalence:
 10% population in 1995, > 700,000 today
 increase with time and ageing population


More referrals with ↑ public awareness:
 50% undiagnosed, expect more referrals as
 population become more health conscious
             Current Status of Diabetes Clinic
                                    inadequate information

                                       ? continue                   ? early appt
                                         to wait

                                                                               SOPD
                                                                                DM
New DM patients                                                                Clinic
                  fulfill predefined criteria, but still long waiting time




                            Unplanned                   Develop
                           hospitalized               complications
   Pre-clinic Case Management Program
              A Nurse-led clinic
     Visit 1 (45 mins)        Visit 2 (30 mins)       Visit 3 (30 mins)
Baseline assessment       Review Ix results        Assess progress
Blood Ix                  Assess progress          Modification of Rx
Infection screening       Modification of Rx       FU planning
Complication assessment   FU planning                     New case
Foot assessment                  New case                 Admission
DM Education                     Admission                Other clinic FU
Dietitian advice                 Other clinic FU
FU planning
       New case
       Admission
       Other clinic FU
           Waiting Time for
Pre-clinic Case Management Program

                       n = 104
    Waiting Time for
DM Clinic First Consultation

                        n = 300


           > 6 months
              69%
                 Conclusions
Pre-clinic Case Management Program is:
  a triage program with incorporated risk
  stratification, ensuring high risk patients have
  timely access to specialist care
  a form of implicit rationing for the limited
  resources, in preparation for the expected
  increase in service need
  able to minimize the risk of deterioration in
  condition while awaiting appointment
Thank You


            香港大學內科部 瑪麗醫院糖尿病中心 提供

								
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