diabetes mellitus management. important points: in history, examination, investigations and...

DIABETES MELLITUS

Management

IMPORTANT POINTS:IN HISTORY, EXAMINATION, INVESTIGATIONS AND TREATMENT

– Control: good / poor? Treatment?

– Complications

– Cardiovascular risk factors

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

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,

INVESTIGATIONS

Assess glycemic control

Extent of complications

Risk factors for CAD

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

PRINCIPLES OF TREATMENT

Good glycemic control Prevent or treat complications Manage risk factors for CAD

PRINCIPLES OF TREATMENTTYPE 2 DM

Good glycemic control Prevent or treat complications Manage risk factors for CAD

GLYCAEMIC CONTROL

A healthy lifestyle OHD Insulin

HEALTHY LIFE STYLE

Healthy eating Weight control Exercise Smoking and alcohol

HEALTHY LIFE STYLE

Healthy diet Exercise Weight control: BMI <23 kg / m2

Smoking and alcohol

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

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

DRUGS

Decreased absorption

Decreased hepatic glc output Increased peripheral glc uptake

Stimulate insulin release

OHD

Decreased absorption

Decreased hepatic glc output Increased peripheral glc uptake

Acarbose

PioglitazonMetformin

Stimulate insulin releaseSulphonyluria, Repaglinide

OHD

Biguanides: metformin Sulphonyluria: glyclazide, glipizide Thiozolidinediones: pioglitazone Alpha glucosidase inhibitor: acarbose Non-sulphonyluria secretagogues: repaglinide

DRUG THERAPY

Asymptomatic

Life-style modification Drugs

DRUG THERAPY

Asymptomatic

Metformin

Life-style modification Drugs

DRUG THERAPY

Asymptomatic SymptomaticHigh HbA1C

High FPG

High RPG

Life-style modification Drugs

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

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)

GOALS OF GLYCEMIC CONTROL

– FBS 4.4-6.1

– Non-fasting 4.4-8.0

– HbA1C <6.5%

Mono-therapy

Combination of metformin + gliclazide

OR metformin + acarbose / TZDs (esp in obese)

Then add third drug

Add insulin

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

INSULIN

Rapid-acting analogues Fast-acting insulin (short-acting) Intermediate-acting insulin Long-acting insulin Very long-acting analogues

Lancet 2006;367:847

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

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

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

INSULIN PUMP

COMPLICATIONS OF TREATMENT

Hypoglycaemia Hypoglycaemia unawareness

NEWER DRUGS IN TYPE 2 DM

Exenatide– Stimulates insulin secretion

– Glucagon-like-peptide

– Given S.C

PREVENT COMPLICATIONS OF DIABETES

PREVENT COMPLICATIONS OF DIABETES

Nephropathy Neuropathy Retinopathy Cardiovascular: IHD, CVA/TIA. PVD Diabetic foot

PREVENT COMPLICATIONS OF DIABETES

Good glycaemic control Screen for complications Action to prevent specific complications

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

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)

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

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

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