Diabetes and Diabetes and hypertension hypertension

One of the activities of the PHC centre is One of the activities of the PHC centre is diagnosis , management , follow up and diagnosis , management , follow up and

referral of patients with chronic diseases such referral of patients with chronic diseases such as diabetes and hypertension . These two as diabetes and hypertension . These two diseases are precipitated by some general diseases are precipitated by some general risk factors ( see 4th year lecture ) .Type-2 risk factors ( see 4th year lecture ) .Type-2

diabetes , hyperlipidaemia and hypertension diabetes , hyperlipidaemia and hypertension are strongly associated with obesity . The are strongly associated with obesity . The prevalence of obesity in KSA is 6% among prevalence of obesity in KSA is 6% among

preschool children , 20-30% in school children preschool children , 20-30% in school children , 25-45 % in adolescent , 48-60 % in adult , 25-45 % in adolescent , 48-60 % in adult

females and 45-70 % in adult males females and 45-70 % in adult males ( Madani ,WHO ,2000 ) .( Madani ,WHO ,2000 ) .

Diabetes is a chronic disease that occurs Diabetes is a chronic disease that occurs when the pancreas does not produce enough when the pancreas does not produce enough insulin or the body cannt effectively use the insulin or the body cannt effectively use the

insulin it produces . Prevalence of the disease insulin it produces . Prevalence of the disease , worldwide 180 million ( WHO, 2000 ) this , worldwide 180 million ( WHO, 2000 ) this

number is likely to be double by 2030 . In KSA number is likely to be double by 2030 . In KSA 890000 ( 2002 ) and 2523000 ( 2030 ) . In 890000 ( 2002 ) and 2523000 ( 2030 ) . In

Sudan 447000 ( 2002 ) and 1275000 Sudan 447000 ( 2002 ) and 1275000 ( 2030 ) . Worldwide 1.1 million died from ( 2030 ) . Worldwide 1.1 million died from

diabetes ( 2005 ) . 80 % of diabetes deaths diabetes ( 2005 ) . 80 % of diabetes deaths occur in low and middle income countries .occur in low and middle income countries .

Dx , Rx , complications and health education Dx , Rx , complications and health education in diabetes :in diabetes :

There are three types . Type-1 ( IDD or child-There are three types . Type-1 ( IDD or child-onset ) is due to lack of insulin production . Its onset ) is due to lack of insulin production . Its

symptoms are polyuria ( in difference from symptoms are polyuria ( in difference from UTI , the amount of urine is large ) , UTI , the amount of urine is large ) ,

polydipsia , polyphegia , weight loss , vision polydipsia , polyphegia , weight loss , vision changes , fatigue . These symptoms may changes , fatigue . These symptoms may

occur suddenly .occur suddenly .Type-2 ( NIDD or adult-onset ) results from Type-2 ( NIDD or adult-onset ) results from

the body s ineffective use of insulin . It the body s ineffective use of insulin . It comprises 90 % of diabetics around then comprises 90 % of diabetics around then world , and largely a result of obesity and world , and largely a result of obesity and

physical inactivity . physical inactivity .

Its symptoms may be similar to type-Its symptoms may be similar to type-1 ,but less marked . As a result , it may 1 ,but less marked . As a result , it may be diagnosed several years after onset be diagnosed several years after onset

when complications have already when complications have already arisen . It was seen only in adults , but arisen . It was seen only in adults , but now it also occurs in obese children . now it also occurs in obese children .

Gestational diabetes is a Gestational diabetes is a hyperglycaemia , which is first hyperglycaemia , which is first

recognized during pregnancy .Its recognized during pregnancy .Its symptoms are similar to type-2 symptoms are similar to type-2

diabetes , often is diagnosed during diabetes , often is diagnosed during prenatal screening rather than reported prenatal screening rather than reported

symptoms .symptoms .

Investigations to diagnose diabetes :Investigations to diagnose diabetes :

Fasting blood sugar ( FBS ) > 126 mg \ Fasting blood sugar ( FBS ) > 126 mg \ 100 ml ( 7 mmol \ L ) 100 ml ( 7 mmol \ L )

Blood glucose , 2 hours after 75 gm of Blood glucose , 2 hours after 75 gm of glucose meal 11.1 mmol \ Lglucose meal 11.1 mmol \ L

Random blood sugsr ( RBS ) > 200 mg Random blood sugsr ( RBS ) > 200 mg \ 100 ml ( 11 mmol \ L ) . \ 100 ml ( 11 mmol \ L ) .

Two readings on different days are Two readings on different days are needed for diagnosis , or one reading needed for diagnosis , or one reading

with obvious symptoms .with obvious symptoms .

Impaired fasting glucose ( IFG ) is 7 Impaired fasting glucose ( IFG ) is 7 mmol \ L mmol \ L

Impaired glucose tolerance ( IGT ) after Impaired glucose tolerance ( IGT ) after 2 hours meal is 7.8-11.0 mmol \ L 2 hours meal is 7.8-11.0 mmol \ L

IFG & IGT are intermediate conditions IFG & IGT are intermediate conditions between normality and disease , between normality and disease ,

people with these conditions are at people with these conditions are at high risk of developing type-2 high risk of developing type-2 diabetes , but not inevitable . diabetes , but not inevitable .

Treatment of diabetes , chronic Treatment of diabetes , chronic complications , causes of referral to complications , causes of referral to advanced health care , follow up at advanced health care , follow up at health centre , health education for health centre , health education for

diabetics , a diabetic patient identical diabetics , a diabetic patient identical card ( group discussion ) card ( group discussion )

Treatment : Three methods . Diet , oral Treatment : Three methods . Diet , oral hypoglycaemics( used in type-2 ) hypoglycaemics( used in type-2 ) sulphonlyureas e,g, glibenclamides sulphonlyureas e,g, glibenclamides and biguanides ( long acting ) e,g, and biguanides ( long acting ) e,g,

metformin is the only one available , metformin is the only one available , insulin . insulin .

Chronic diabetic complications : retinopathy , Chronic diabetic complications : retinopathy , nephropathy , neuropathy , diabetic nephropathy , neuropathy , diabetic

foot .Cause for referral : chronic complications foot .Cause for referral : chronic complications and \ or uncontrolled diabetes .and \ or uncontrolled diabetes .

Acute diabetic complications are Acute diabetic complications are hyperglycaemia , hypoglaecima and hyperglycaemia , hypoglaecima and

ketoacidosis ketoacidosis Hyperglycaemia : Symptoms in diabetes are Hyperglycaemia : Symptoms in diabetes are

thirst , dry mouth , polyuria , notcuria , thirst , dry mouth , polyuria , notcuria , tiredness , fatigue , irritability , apathy , tiredness , fatigue , irritability , apathy ,

blurring of vision , pruritis vulvae , genital blurring of vision , pruritis vulvae , genital candidiasis , nausea , headache , candidiasis , nausea , headache ,

hyperphagia , predilection for sweet foods . hyperphagia , predilection for sweet foods . RBS >11.0 mmol\ L . Management group RBS >11.0 mmol\ L . Management group

discussion . discussion .

Hypoglcaemia in diabetes : Its symptoms are Hypoglcaemia in diabetes : Its symptoms are sweating , trembling , hunger , anxiety , pounding heart sweating , trembling , hunger , anxiety , pounding heart

, confusion , inability to concentrate , drowsiness , , confusion , inability to concentrate , drowsiness , incoordination , speech difficulty , nausea , headache , incoordination , speech difficulty , nausea , headache ,

tiredness . It often occurs in diabetics treated with tiredness . It often occurs in diabetics treated with insulin , but relatively rare in those taking insulin , but relatively rare in those taking

sulphonylurea drugs . RBS < 3.5 mmol \ L . Its causes sulphonylurea drugs . RBS < 3.5 mmol \ L . Its causes are : Missed , delayed or inadequate meal . are : Missed , delayed or inadequate meal .

Unexpected or unusual exercise . Alcohol overdose . Unexpected or unusual exercise . Alcohol overdose . Errors in oral hypoglcaemic drug or insulin dose . Errors in oral hypoglcaemic drug or insulin dose .

Poorly designed insulin regimen especially at night . Poorly designed insulin regimen especially at night . Unrecognised endocrine diseases e.g. Addison Unrecognised endocrine diseases e.g. Addison

disease . If hypoglycaemia is frequently occurring , disease . If hypoglycaemia is frequently occurring , reduce dose by 20 % and seek medical advice for reduce dose by 20 % and seek medical advice for

dose adjustment .dose adjustment .

Diabetic ketoacidosis ( DKA ) is a major medical Diabetic ketoacidosis ( DKA ) is a major medical emergency and a serious cause of morbidity and emergency and a serious cause of morbidity and

mortality especially in type-1 patients . It is caused by mortality especially in type-1 patients . It is caused by insulin deficiency and an increase in catabolic insulin deficiency and an increase in catabolic

hormones , leading to hepatic overproduction of hormones , leading to hepatic overproduction of glucose and ketone bodies . Biochemical features of glucose and ketone bodies . Biochemical features of

DKA are hyperglycaemia , hyperketonaemia and DKA are hyperglycaemia , hyperketonaemia and metabolic acidosis . Hypewrglycaemia causes metabolic acidosis . Hypewrglycaemia causes

profound osmotic diuresis leading to dehydration . profound osmotic diuresis leading to dehydration . Haemoconcentration leads to a decrease in blood Haemoconcentration leads to a decrease in blood

volume and fall in blood pressure with associated renal volume and fall in blood pressure with associated renal ischaemia and oliguria . Fluid and electrolytes loss ischaemia and oliguria . Fluid and electrolytes loss

especially potassium . The severity of DKA is assessed especially potassium . The severity of DKA is assessed by plasma bicarbonate ( < 12 mmol \ L indicates by plasma bicarbonate ( < 12 mmol \ L indicates

severe acidosis ) .severe acidosis ) .

Average loss of fluid and electrolytes in adult DKA of Average loss of fluid and electrolytes in adult DKA of moderate severity ; Water 6 L , sodium 500 mmol , moderate severity ; Water 6 L , sodium 500 mmol ,

chloride 400 mmol , potassium 350 mmol . chloride 400 mmol , potassium 350 mmol . Complications of DKA : Cerebral oedema , which may Complications of DKA : Cerebral oedema , which may

be caused by rapid reduction of blood glucose , be caused by rapid reduction of blood glucose , hypotonic fluids and \ or bicarbonate . It causes high hypotonic fluids and \ or bicarbonate . It causes high

mortality . It is treated by mannitol and oxygen . Acute mortality . It is treated by mannitol and oxygen . Acute respiratory distress syndrome . thromboembolism , respiratory distress syndrome . thromboembolism ,

disseminated intravascular coagulation ( rare ) , acute disseminated intravascular coagulation ( rare ) , acute circulatory failure . Treatment of DKA by i\m short-circulatory failure . Treatment of DKA by i\m short-

acting insulin ( soluble ) , fluid replacement by normal acting insulin ( soluble ) , fluid replacement by normal saline , potassium and bicarbonate replacement , saline , potassium and bicarbonate replacement ,

antibiotics if infection is present . antibiotics if infection is present .

Screening for diabetes : The reason for Screening for diabetes : The reason for screening is the assumption that early screening is the assumption that early

detection and effective control of detection and effective control of hyperglycaemia in asymptomatic diabetics hyperglycaemia in asymptomatic diabetics

decreases morbidity . RBS is used as a decreases morbidity . RBS is used as a screening test , FBS and 2 hours after meal of screening test , FBS and 2 hours after meal of 75 gm of oral glucose as a confirmatory test . 75 gm of oral glucose as a confirmatory test .

Target population : screening is conducted Target population : screening is conducted among high risk groups such as those in age-among high risk groups such as those in age-

group = or> 40 years , those with positive group = or> 40 years , those with positive family history , obese persons , women with a family history , obese persons , women with a

history of a big offspring , patients with history of a big offspring , patients with premature arteriosclerosis .premature arteriosclerosis .

Hypertension ( HYN ) : WHO ( 1978 ) defined HYN in Hypertension ( HYN ) : WHO ( 1978 ) defined HYN in adults as a systolic pressure ≥ 160 mm Hg and \ or adults as a systolic pressure ≥ 160 mm Hg and \ or

diastolic pressure≥ 95 . There are two types of HYN , diastolic pressure≥ 95 . There are two types of HYN , primary ( essential ) when the cause is unknown , it primary ( essential ) when the cause is unknown , it

accounts for 90% of cases and secondary which accounts for 90% of cases and secondary which accounts for 10% . Secondary HYN when other accounts for 10% . Secondary HYN when other

diseases or abnormalities such as chronic diseases or abnormalities such as chronic glomerulonephritis and chronic pyelonephritis , tumors glomerulonephritis and chronic pyelonephritis , tumors of adrenal glands , congenital narrowing of the aorta of adrenal glands , congenital narrowing of the aorta and toxemia of pregnancy . Prevalence and toxemia of pregnancy . Prevalence

of HYN : In idustrialized co25 % in adults , in of HYN : In idustrialized co25 % in adults , in developing countries and some European ranging developing countries and some European ranging from 10 to 20 % . HYN is a major cause for stroke , from 10 to 20 % . HYN is a major cause for stroke ,

CHD , heart or kidney failure , the majority of mortality CHD , heart or kidney failure , the majority of mortality associated with HYN is due to CVD associated with HYN is due to CVD

Measuring Bp : Have patient rest for 5 mins before Measuring Bp : Have patient rest for 5 mins before taking measurement . Take Bp in both arms with taking measurement . Take Bp in both arms with

patient seated comfortably with back and arm patient seated comfortably with back and arm supported . Take 2 or more readings separated by 2 supported . Take 2 or more readings separated by 2

mins and repeat if readings differ by > 5 mm Hg . Have mins and repeat if readings differ by > 5 mm Hg . Have patient refrain from smoking or having coffee 30 mins patient refrain from smoking or having coffee 30 mins

before measuring Bp . Make sure before measurement before measuring Bp . Make sure before measurement that patient is not cold neither anxious .his bladder is that patient is not cold neither anxious .his bladder is empty , he has not recently exercised . Place cuff as empty , he has not recently exercised . Place cuff as

high on arm as possible and support arm positioned at high on arm as possible and support arm positioned at heart level . Be sure that the width of cuff inflatable heart level . Be sure that the width of cuff inflatable

bladder is > 2\3 arm width and its length is > 2\3 arm bladder is > 2\3 arm width and its length is > 2\3 arm circumference . Auscultate using stethoscope bell . circumference . Auscultate using stethoscope bell .

Determine SBP as point at which sound is first heard Determine SBP as point at which sound is first heard ( Korotkoff-1 ) , determine DBP as point at which sound ( Korotkoff-1 ) , determine DBP as point at which sound disappears ( Korotkoff-5 ) rather than when it changes disappears ( Korotkoff-5 ) rather than when it changes

in quality ( Korotkoff-4 ) . Average 2 successive in quality ( Korotkoff-4 ) . Average 2 successive measurements in each arm . Confirm HYN Dx by measurements in each arm . Confirm HYN Dx by taking multiple determinations over several visits .taking multiple determinations over several visits .

There are three sources of error in There are three sources of error in recording BP : a. observer error recording BP : a. observer error

due to hearing acuity and due to hearing acuity and interpretation of Korotkoff interpretation of Korotkoff

sounds ,b. instrumental error e.g. sounds ,b. instrumental error e.g. leaking value , cuffs that do not leaking value , cuffs that do not

encircle the arm , c, subject errors encircle the arm , c, subject errors , these include the physical , these include the physical

environment, patient position , environment, patient position , external stimuli such as fear and external stimuli such as fear and

anxiety anxiety

BP evaluation :BP evaluation : systolic diastolicsystolic diastolic

Normal < Normal < 130 < 85130 < 85

High normal High normal 130-139 85-89130-139 85-89

HYNHYNStage 1 ( mild ) Stage 1 ( mild )

140-159 90-99140-159 90-99Stage 2 ( moderate ) Stage 2 ( moderate )

160-179 100-109160-179 100-109Stage 3 ( severe ) ≥ Stage 3 ( severe ) ≥

180-209 ≥ 110-119180-209 ≥ 110-119Stage 4 ( malignant ) > Stage 4 ( malignant ) >

210 > 120 210 > 120 ( Goroll , 2002 .USA ) page 82 )( Goroll , 2002 .USA ) page 82 )

. . HYN Management :HYN Management :

For all patients : Salt restriction < 5 gm \ day . For all patients : Salt restriction < 5 gm \ day . Advise weight reduction , esp. if wt is > 15% Advise weight reduction , esp. if wt is > 15%

above ideal wt . Complete smoking above ideal wt . Complete smoking cessation . Exercise program . cessation . Exercise program .

For patients in stage 1 , with no complications For patients in stage 1 , with no complications : Full non-pharmacological measures . : Full non-pharmacological measures .

Repeat BP determination regularly for 6 mos , Repeat BP determination regularly for 6 mos , if no improvement , continue non- if no improvement , continue non-

pharmacological measures and BP pharmacological measures and BP determination for another 3 mos , if no determination for another 3 mos , if no

improvement after 6-12 mos , add first-line improvement after 6-12 mos , add first-line antihypertensive agent to non-antihypertensive agent to non-pharmacological measures .pharmacological measures .

For pts with stage 1 + CVD risk factors or For pts with stage 1 + CVD risk factors or signs of target-organ disease : Non –signs of target-organ disease : Non –pharmacological program , regular BP pharmacological program , regular BP

determination for 3 mos , if BP not determination for 3 mos , if BP not normalized add first line agentnormalized add first line agent. .

For pts with stage 2 esp if with CVD risk factors or For pts with stage 2 esp if with CVD risk factors or target-organ damage : Non –pharmacological target-organ damage : Non –pharmacological

program , if after 1-2 mos , not normalized , add program , if after 1-2 mos , not normalized , add first-line agent and then advance first-line agent and then advance

pharmacological program as needed , monitor pharmacological program as needed , monitor BP closelyBP closely. .

For pts with stage 3 immediately give full doses of For pts with stage 3 immediately give full doses of first-line agent and consider early use of second first-line agent and consider early use of second

first-line if necessary , if BP improved ,but not first-line if necessary , if BP improved ,but not normalized within 1 week , add second first-line normalized within 1 week , add second first-line agent . If no response to initial first-line agent agent . If no response to initial first-line agent

within a few days , begin second first-line agent within a few days , begin second first-line agent from different class at full doses and consider from different class at full doses and consider adding second drug at same time . Full non –adding second drug at same time . Full non –pharmacological program with closely follow uppharmacological program with closely follow up. .

For pts with stage 4 : Consider emergency hospitalization For pts with stage 4 : Consider emergency hospitalization esp if evidence of acute target-organ injury ( papilledema esp if evidence of acute target-organ injury ( papilledema , retinal hemorrhage , heart failure , altered mental status , retinal hemorrhage , heart failure , altered mental status

) , start 2- 3 drug regimen and follow up in a few days) , start 2- 3 drug regimen and follow up in a few days. . First-line agents : Thiazides ( hydrochlorothiazide 12.5-25 First-line agents : Thiazides ( hydrochlorothiazide 12.5-25 mg\day ) . beta blockers for pts with high CVD risk c\i in mg\day ) . beta blockers for pts with high CVD risk c\i in pts with bronchospasm . ACE inhibitors preferred for pts pts with bronchospasm . ACE inhibitors preferred for pts with DM c\i in pregnancy and bilateral renal stenosis , with DM c\i in pregnancy and bilateral renal stenosis , calcium channel blockers ( amlodipine 5 -10 mg\ day )calcium channel blockers ( amlodipine 5 -10 mg\ day ) . . Screening and prevention of HYN : Screen all adults Screening and prevention of HYN : Screen all adults regularly for HYN by measuring BP at every health regularly for HYN by measuring BP at every health

encounter , pay esp attention to persons with DM , heart encounter , pay esp attention to persons with DM , heart failure , coronary disease , or renal disease , because failure , coronary disease , or renal disease , because HYN can markedly worsen prognosis and treatment HYN can markedly worsen prognosis and treatment

can greatly improve itcan greatly improve it . .