Management of diabetes - National Guidelines

							Management of Diabetes
 National Guidelines

     Dept of Health
       SEMDSA
       Sep 2005
         CLASSIFICATION
• TYPE 1 Bcell destruction
• TYPE 2 Insulin Resistance
• IMPAIRED GLUCOSE REGULATION
{impaired fasting glucose, impaired tolerance}
• GESTATIONAL
• OTHER
     DIAGNOSIS DIABETES
• SYMPTOMS PLUS random gluc >11.1 mmol/l
   OR fasting glucose > 7.0 mmol/l
 { polyuria, polydipsia, weight loss, pruritis}
                 OR
• Fasting gluc > 7.0 mmol/l
• 2 hr gluc > 11.1 mmol/l
{on two separate occasions, if asymptomatic }
{ venous plasma samples }
    Impaired glucose handling
• Impaired Fasting Glucose
         6.1- 6.9 mmol/l

• Impaired Glucose Tolerance
         7.8-11.0 mmol/l
Indications for hospital level care
Inpatient referral
• Diabetic keto-acidosis
• Hyperosmolar states
• Hypoglycemia with neuroglycopenia
• Recurrent or persistent poor glycemic
  control
• Severe chronic complications of diabetes
• Initiation of intensive insulin regimens
Indications for hospital level care
Hospital OPD referrals
• All type 1 diabetics
• Chronic complications for review
• Persistent hyperglycemia
• All newly diagnosed diabetics
• All diabetic patients for annual review
          General Management

•   Lifestyle : diet and exercise
•   Glycemic control
•   Treat hypertension
•   Treat Lipids
                 TARGETS
•   Fasting gluc :4-6
•   Postprandial gluc : 6-8
•   HbA1c < 7             BP < 130/80
•   TC < 5                BMI < 25-30
•   LDL < 2.6             5-10% wt reduction
•   TG < 1.5
•   HDL > 1.2
        MANAGEMENT
• Diabetes education essential
   PLEASE LIAISE WITH YOUR DM NURSE
• Self monitoring
  Type 1 : when adjusting doses – 4X/d
           maintenance –2X/d
  Type 2 : As above?
    DRUGS AND INSULIN

• ALGORITHMS PP 11-15 IN HANDBOOK
            Insulin Regimens

• Once daily insulin:
         Protaphane nocte + OAA’s
         0.1 u/kg
• Twice daily insulin: 2/3       1/3
         Actraphane B.D

• Basal Bolus: 20 20 20 40 %
         Actrapid at mealtimes
         Protaphane at 22H00
     Total daily dose of insulin
• Type 1 :   0.4-0.6U/kg/d

• Type 2 :   0.2-0.3U/kg/d
     Oral Hypoglycemic drugs
• Gliclazide 40 bd to 160mg bd

• Metformin 500 bd to 1g tds
  [ obese pts, no major complications and
  creat< 150]
      Insulin in type 2 diabetes
• Poor control with oral drugs
• Severe infections, major surgery and any
  hyperglycemic emergency
• Consider early use for thin patients with
  very poor control
• Severe complications, Creat > 150
                   HYPO’S
• Symptoms : sweating, headache, confusion
               etc
• Gluc < 3mmol/l
• Causes : missed meal, exercise, liver disease, renal
  impairment, adrenal, dose
• Use sugar plus slow release carbs, 50 ml 50%
  dextrose, IVI 5% dextrose, glucagon
• Admit for obs. SU needs longer obs period
• If poor response to therapy, look for other cause of
  mental state
          HYPERLIPIDEMIA
•   Restrict fats to < 30 % /d
•   As low monosat fat as possible
•   Chol < 300 mg/d
•   Wt loss 5-10 %
•   Exercise 30 min X 5d per week
•   High fibre, mod alcohol
•   Control Diabetes
• Statin [ LDL> 2.6 after lifestyle mod, or
  established atherosclerotic disease]
• Fibrate for TG elevation after gluc controlled
• Exclude secondary causes : hypothyroidism,
  nephrotic syndrome and alcohol
          HYPERTENSION
• BP 130/80
• Lifestyle first, except if bp> 180/110, end-
  organ damage[ then start drugs immed]
• Drugs
  HCTZ[ Lasix,if creat>150], AceI[esp
  nephropathy], CCB
  2ND line : a blocker, b blocker[IHD]
                ASPIRIN
• All patients for secondary prevention
• Consider if other risk factors for heart
  disease, age > 30
• Age < 21 possibility of Reyes Syndrome
• 75-300 mg
• Check contra indications
                  DKA
•   Gluc > 20
•   U-dipstix 2+ Ketones
•   pH < 7.35    SB < 15
•   Underlying cause? Urine,CXR,ECG
•   U&E
                  Fluid
• IVI n/saline   2-3 l over 4 hrs
                 2l over next 8 hrs
                  then 1l every 8 hrs
• Colloid if systolic < 100
• ½ n/saline if Na > 155
• Change to dextrose saline when gluc <14
                  Insulin
• 100 u/100ml n/saline infusion
• +/- 5u/hr
• When gluc < 14, halve rate [2.5u/hr], start
  5% dextrose/saline
• Continue until ketones negative
                       K
• Omit, initially, if s-K > 6
• 20mmol/l
• Re-check K levels 2hrly
                   Bicarb
• For pH< 7, K>4

• 100mls 8%bicarb with 20mmol KCl over ½
  hour
• Rpt pH after 30 min
• Problems with Na load, K shifts,
  intracerebral acidosis
                   Other
• CVP
• Antibiotics
• Convert to regular insulin when ketone free
  and eating normally
           Hyperosmolar state
•   Gluc very high [often >50]
•   S-osm > 320
•   Profound dehydration
•   Mild ketosis, normal pH, older patient
             Management
• As for DKA
• Will need more fluid
• CVP monitoring very important
            Elective surgery
• Type 1
• Admit patient at least1day prior to surgery-
  bloods, CXR, ECG, correct K
• Schedule for first on slate in morning
• Postpone surgery if >8 [major surg]
                      >15[minor surg]
• Omit breakfast and morning insulin
• Start GKI infusion at 100ml/hr
• 500 ml 10%Dextrose water + 15U actrapid
  +10 mmol KCl
• Check glucose hrly in op, 2 hrly post op
• Aim for gluc 6-11mmol/l
• Check gluc and U & E in recovery room
• If gluc> 11, then mix new bag with 20u actrapid
  plus K in 10% d/w
• If gluc<6, then 10u actrapid in new bag

• If K >5.5, then drop KCl from bag
• If K< 4, then add 20mmol KCl to new bag

• Continue infusion till patient eating normally
• If infusion lasts for several days, then use dextrose
  saline and ½ insulin dose plus KCL.
• Diet control: if fasting gluc< 7: treat as for
  non-diabetic, if gluc>7: use GKI
• Oral drugs: stop metformin 3d prior to
  surgery and withold for 3d after,esp if
  contrast given. If fasting gluc<7treat as non-
  diab for minor surgery. The rest: GKI
• Emergency surg: try to delay if ketosis
  present for 4-6 hrs[see DKA management
  above], then GKI
                Sick Days
•   Don’t stop usual insulin
•   Drink plenty of fluids
•   Gluc 10-14 : add 10% TDD before meal
•   Gluc 14.1-22: add 20% TDD before meal
•   Gluc >22 : add 30% TDD before meal
•   If nauseous, use unsweetened and small
    amount of sweetened drinks
• Consult doc urgently if:
Gluc over 22mmol/l
Gluc not coming down
Vomiting/unable to eat for any reason
Ketonuria
               Diabetic foot
• Assess vascular, neuropathy and skin/arch
• Risk categories
 0 No sensory neuropathy
 1 Sensory neuropathy
 2 SN plus deformities/features of PVD
 3 Previous ulceration or amputation
• Re-vascularization may save the foot from
  amputation
• Annexure 5, page 50 for general measures
              Retinopathy
Risk groups
• Uncontrolled DM
• Type 1 from early age, puberty
• Long duration of diabetes
• Pregnancy with pre-existing diabetes
• Associated hypertension
             Normal retina

   Macula




Optic disc
Non-proliferative diabetic
      retinopathy


Hard exudates
       Severe non-proliferative
             retinopathy


Haemorrhage



Cotton wool
spot
        Proliferative retinopathy


New vessels



Pre-retinal
haemorrhage
        Advanced proliferative
            retinopathy

Scar tissue
Early macular oedema
                  Referrals
Urgent
• All neovascularization
• Decrease in visual acuity- mod-severe
• Preretinal haemorrhage
Soon
• Mod-severe non-prolif retinopathy
• Maculopathy
• Hard exudates within the vascular arcades
Routine
• All new diabetics
             Nephropathy
• Incipient nephropathy
  microalbuminuria [2/3 in 3 months],HPT
• Overt nephropathy
  persistent dipstix proteinuria, HPT
• Renal failure
  Raised creat, decreased clearance
            microalbuminuria
•   30-300 mg/24hr
•   Spot urinary Alb-creat ratio:3-30mg/mmol
•   Micral urine dipstix
•   Spot urinary alb conc : >20mg/l
               Management
• Treat lipids
• Glycemic control
  Change to insulin if GFR<30 or creat>150
• BP< 125/75
• Ace I: If MAlb, even if BP normal
• Restrict prot to<0.8g/kg/d
• Calcium management
• Dialysis/transplant
               Neuropathy
  Diffuse     Peripheral polyneuropathy
              Proximal Amyotrophy
              Autonomic neuropathy

  Focal      Entrapment
              mononeuritis/multiplex
Therapy: tricyclics, tegretol, gabapentin
 THE
 END
  OF
 THE
STORY
   !