Management of diabetes - National Guidelines · Impaired glucose handling • Impaired Fasting...
Transcript of Management of diabetes - National Guidelines · Impaired glucose handling • Impaired Fasting...
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Management of DiabetesNational Guidelines
Dept of HealthSEMDSASep 2005
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CLASSIFICATION
• TYPE 1 Bcell destruction• TYPE 2 Insulin Resistance• IMPAIRED GLUCOSE REGULATION{impaired fasting glucose, impaired tolerance}• GESTATIONAL• OTHER
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DIAGNOSIS DIABETES
• SYMPTOMS PLUS random gluc >11.1 mmol/lOR 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 }
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Impaired glucose handling
• Impaired Fasting Glucose6.1- 6.9 mmol/l
• Impaired Glucose Tolerance7.8-11.0 mmol/l
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Indications for hospital level careInpatient 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
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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
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General Management
• Lifestyle : diet and exercise• Glycemic control• Treat hypertension• Treat Lipids
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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
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MANAGEMENT
• Diabetes education essentialPLEASE LIAISE WITH YOUR DM NURSE
• Self monitoringType 1 : when adjusting doses – 4X/d
maintenance –2X/d Type 2 : As above?
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DRUGS AND INSULIN
• ALGORITHMS PP 11-15 IN HANDBOOK
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Insulin Regimens
• Once daily insulin:Protaphane nocte + OAA’s0.1 u/kg
• Twice daily insulin: 2/3 1/3Actraphane B.D
• Basal Bolus: 20 20 20 40 %Actrapid at mealtimes Protaphane at 22H00
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Total daily dose of insulin
• Type 1 : 0.4-0.6U/kg/d
• Type 2 : 0.2-0.3U/kg/d
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Oral Hypoglycemic drugs
• Gliclazide 40 bd to 160mg bd
• Metformin 500 bd to 1g tds[ obese pts, no major complications and creat< 150]
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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
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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
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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
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• 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
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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[espnephropathy], CCB2ND line : a blocker, b blocker[IHD]
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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
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DKA
• Gluc > 20• U-dipstix 2+ Ketones• pH < 7.35 SB < 15• Underlying cause? Urine,CXR,ECG• U & E
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Fluid
• IVI n/saline 2-3 l over 4 hrs2l over next 8 hrsthen 1l every 8 hrs
• Colloid if systolic < 100• ½ n/saline if Na > 155• Change to dextrose saline when gluc <14
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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
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K
• Omit, initially, if s-K > 6• 20mmol/l• Re-check K levels 2hrly
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Bicarb
• For pH< 7, K>4
• 100mls 8%bicarb with 20mmol KCl over ½hour
• Rpt pH after 30 min• Problems with Na load, K shifts,
intracerebral acidosis
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Other
• CVP• Antibiotics• Convert to regular insulin when ketone free
and eating normally
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Hyperosmolar state
• Gluc very high [often >50]• S-osm > 320• Profound dehydration• Mild ketosis, normal pH, older patient
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Management
• As for DKA• Will need more fluid• CVP monitoring very important
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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]
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• 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
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• If gluc> 11, then mix new bag with 20u actrapidplus 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.
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• 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
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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
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• Consult doc urgently if:Gluc over 22mmol/lGluc not coming downVomiting/unable to eat for any reasonKetonuria
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Diabetic foot• Assess vascular, neuropathy and skin/arch• Risk categories0 No sensory neuropathy1 Sensory neuropathy2 SN plus deformities/features of PVD3 Previous ulceration or amputation
• Re-vascularization may save the foot from amputation
• Annexure 5, page 50 for general measures
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Retinopathy
Risk groups• Uncontrolled DM• Type 1 from early age, puberty• Long duration of diabetes• Pregnancy with pre-existing diabetes• Associated hypertension
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Normal retina
Macula
Optic disc
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Non-proliferative diabetic retinopathy
Hard exudates
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Severe non-proliferativeretinopathy
Haemorrhage
Cotton wool spot
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Proliferative retinopathy
New vessels
Pre-retinal haemorrhage
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Advanced proliferativeretinopathy
Scar tissue
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Early macular oedema
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ReferralsUrgent• All neovascularization• Decrease in visual acuity- mod-severe• Preretinal haemorrhageSoon• Mod-severe non-prolif retinopathy• Maculopathy• Hard exudates within the vascular arcades Routine• All new diabetics
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Nephropathy
• Incipient nephropathymicroalbuminuria [2/3 in 3 months],HPT
• Overt nephropathypersistent dipstix proteinuria, HPT
• Renal failureRaised creat, decreased clearance
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microalbuminuria
• 30-300 mg/24hr• Spot urinary Alb-creat ratio:3-30mg/mmol• Micral urine dipstix• Spot urinary alb conc : >20mg/l
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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
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Neuropathy
Diffuse Peripheral polyneuropathyProximal AmyotrophyAutonomic neuropathy
Focal Entrapmentmononeuritis/multiplex
Therapy: tricyclics, tegretol, gabapentin
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THEENDOF
THESTORY
!