Management of diabetes - National Guidelines · Impaired glucose handling • Impaired Fasting...

Management of DiabetesNational Guidelines

Dept of HealthSEMDSASep 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/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 }

Impaired glucose handling

• Impaired Fasting Glucose6.1- 6.9 mmol/l

• Impaired Glucose Tolerance7.8-11.0 mmol/l

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

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 essentialPLEASE LIAISE WITH YOUR DM NURSE

• Self monitoringType 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’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

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[espnephropathy], CCB2ND 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 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

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 ½hour

• 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 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.

• 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/lGluc not coming downVomiting/unable to eat for any reasonKetonuria

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

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-proliferativeretinopathy

Haemorrhage

Cotton wool spot

Proliferative retinopathy

New vessels

Pre-retinal haemorrhage

Advanced proliferativeretinopathy

Scar tissue

Early macular oedema

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

Nephropathy

• Incipient nephropathymicroalbuminuria [2/3 in 3 months],HPT

• Overt nephropathypersistent dipstix proteinuria, HPT

• Renal failureRaised 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 polyneuropathyProximal AmyotrophyAutonomic neuropathy

Focal Entrapmentmononeuritis/multiplex

Therapy: tricyclics, tegretol, gabapentin

THEENDOF

THESTORY

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