Diabetes update

Content

• Diagnostic criteria

• Nutritional management

• Oral Hypoglycaemic agents

• Insulin in Type 2 diabetes

• Hypoglycaemia

• Foot care

Diagnosis• Symptoms + 1 abnormal blood

glucose valueor

• 2 abnormal blood glucose values

(not using a home blood glucose monitoring kit)

Symptoms

• Polyuria• Polydipsia/nocturia• Tiredness• Weight loss (Type 1)• Blurred vision• Ketones in urine (Type 1)• Dehydration

Diagnostic blood glucose values

• FBG >= 7 mmol/l

• RBG >= 11.1mmol/l

• IFG >6mmol/l and <7 mmol/l

• OGTT

• IGT 2 hour BG >7.8 mmol/l and <11.1mmol/l

Nutritional management

Dietary recommendations for diabetes

• Eat starchy foods regularly

• Eat more fruit and vegetables

• Reduce animal or saturated fat

• Cut down on sugar

• Reduce salt

Balancing food choices

Eat starchy foods regularly

• Bread• Potatoes• Rice• Pasta• Cereals• Chapatis

Eat more fruit and vegetables

• Fresh• Frozen• Tinned• Dried• Juice

Reduce animal or saturated fat intake

• Use low fat milk

• Use low fat spread

instead of butter

• Use oil high in

unsaturated fat, eg

olive oil, rapeseed oil

Use less fat in cooking

• Grill

• Dry-roast

• Microwave

• Steam

Choose the right sort of fat

SATURATED

• Full fat dairy produce (eg cheese, butter, full cream milk)

• Pies

• Biscuits

• Savoury snacks

• Lard

• Hard vegetable fat

MONO- UNSATURATED

• Olive oil

• Rapeseed oil

• Groundnut oil

POLY- UNSATURATED

• Sunflower oil (products)

• Oily fish

Cut down on sugary foods

• Not a sugar free diet

• Cut out sweets• Cut out sugary

drinks

Choose low sugar products

• Use diet or low calorie, sugar free drinks

Intense sweeteners

• Tablet• Liquid• Granulated

Avoid diabetic products

• Cost

• Laxative effects

• Focus on ‘sugar free’

• Still raise blood glucose levels

• Still contain same calories

Reduce salt intake• Cut down on

added salt• Use alternative

seasonings• Look out for

reduced/low sodium foods, eg bread

• Avoid salt substitutes

Eat regular meals based on carbohydrate:

Breakfast

Lunch or snack meal

Main meal

Drink alcohol in moderation1 unit of alcohol =

1/2 pint beer or lager or

cider

1 standard glass of

wine

1 pub measure of

sherry, vermouth, aperitif or

liqueur

1 pub measure of

spirit, eg gin, vodka or whisky

Oral agents

Oral agents

• Sulphonylureas

• Biguanides

• Thiazolidinediones (the glitazones)

• Post-prandial glucose regulators

• Acarbose

Sulphonylureas

• Augment insulin secretion from beta cells, so must be some activity remaining.

• Hypoglycaemia may occur • Glipizide and gliclazide most

commonly used

• Can be used in combination

Sulphonylureas…..side effects

• Can cause weight gain, metformin 1st choice in obese

• Care in renal or hepatic failure

• Contraindicated in breast feeding and change to insulin if pregnant or other severe illnesses.

Sulphonylureas…..more side effects

• Hypoglycaemia• weight gain• GI disturbances• Liver disturbances, cholestatic

jaundice, hepatitis• Hypersensitivity reactions

including photosensitivity• Blood Disorders.

Biguanides (well….metformin!)

• Inhibits gluconeogenesis

• Increases peripheral utilisation of glucose

• (Reduces appetite??)

• Dose

Metformin……..

• Drug of choice in obese Type 2 patients

• Not associated with weight gain

• Is effective as monotherapy as well as in combination with an SU, TZD, nateglinide or insulin

• Used alone it can reduce FBG by 22 - 26%

• Used alone it can reduce HbA1c by 12 - 17%

• UKPDS demonstrated a reduction in macrovascular complications and mortality with the use of metformin in obese Type 2 DM

Slide No. 4 • •

UKPDS 34: relative risk reduction withmetformin vs conventional treatment

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Metformin……..contraindications

• Renal failure (local consensus at serum creatinine >150mol/L)

• Acute renal failure may lead to lactic

acidosis

• Hepatic impairment

• Alcohol abuse

• Significant cardiac disease

• Pregnancy and lactation

• Age not proven to be an independent risk factor for metformin use.

Metformin………the side-effects

• Dose requires titration to minimise GI side-effects

• 20 - 30% of patients experience abdominal discomfort, nausea, anorexia or a metallic taste

• Significant proportion of these patients go on to tolerate metformin well

• Evidence of malabsorption of vitamin B12

although very rarely clinically manifested.

Thiazolidinediones (TZDs, the glitazones)

Mode of action

• These act by activating PPARγ (a nuclear receptor responsible for activating insulin-sensitive genes) and hence reducing insulin resistance and increasing the uptake of glucose by the tissues.

• Rosiglitazone (Avandia)

Prandial Glucose Regulators(the meglitinides)

The Meglitinides……...

• Repaglinide (Novonorm™) and Nateglinide (Starlix™)

• Both stimulate insulin release but are chemically distinct and have different mechanisms of action

• Both compounds have very short actions which deal effectively with postprandial glycaemic peaks, and are omitted if a meal is missed

Mode of action…….

Repaglinide…….

Stimulates the same secretory mechanism as SUs, but does not promote insulin release in the absence of glucose.

Licensed for monotherapy and combination

Nateglinide……

Works by restoring early phase insulin release within the cells, and has a synergistic action with metformin.

Licensed for combination with metformin only.

Acarbose

– alpha glucosidase inhibitor

– delay digestion and absorption of starch and sucrose

– use on own or as adjunct

– cause GI upset, flatulence common

– cannot cause hypoglycaemia

Insulin Management

Those requiring insulin

• Type 1 patients• Type 2 – deteriorating control• Prevention of progression of

complications• Poor tolerance of OHAs• Acute situations• Pregnancy

Employment issues

• Group II licence• Services• Police• Fire service• Diving/deep sea work• High work/scaffolding• Planes/boats/trains

Hypoglycaemia

Hypoglycaemia

• Blood glucose below 3.0 mmol/L

• Hypoglycaemic unawareness is a major risk

factor

• Shaky, sweaty, tingling in lips, heart pounding,

irritability and confusion

• Hypos and alcohol

• Hypos in Type 2 Diabetes

Treatment of Severe Hypoglycaemia

• Oral glucose - Lucozade, Hypostop followed by more complex CHO - bread

• IV dextrose 50%• IV, IM S/C Glucagon 1 mg

Complications of severe hypoglycaemia

• Transient hemiplegia• Dysphasia• Pulmonary oedema• Cerebral oedema• Permanent brain damage

‘The diabetic foot’

• Neuropathy

• Ischaemia

• Combination of neuropathy and ischaemia

Ischaemia

• Reduced/absent pulses

• Dry shiny atrophic skin

• Intermittent claudication

• Nocturnal cramps

• Rest pain

Neuropathy

• Nerve damage

• Reduced sensation

• Ulceration

• Not noticed by the patient

Signs of neuropathy

• Lack of sensation

• Numbness/parasthaesia

• Painful neuropathy

• Foot deformity

• Bounding pulses

• Venous distension

• Warm pink skin

Ischaemia and Neuropathy

• Co-exist in diabetic foot• Ulceration• Infection• Gangrene• Amputation

Foot ulceration – risk factors

• History of previous ulceration• PVD• Neuropathy• Foot deformity• Nephropathy

Foot ulceration – risk factors

• Smoking• Footwear• Self treatment• Poor sight• Living alone• Immobility• Male sex

Clinical features of ulceration:

Neuroischaemia has features of bothNEUROPATHIC

ISCHAEMIC

PAIN PAINLESS PAINFUL

CALLOUS YES NO

OUTLINE CIRCULAR IRREGULAR

GRANULATION HEALTHY UNHEALTHY

SITES METS/APEX/ID

HEELS/BORDER DORSUM

Patient education

• Daily foot check• Avoid walking barefoot• Moisturise dry skin• No self-treating• Avoid direct heat• Suitable footwear• If in doubt, seek professional help

Prevention

• Perform a simple foot assessment• Check bare feet• Determine risk• Refer urgently to podiatrist or doctor if:

UlcerationInfectionNecrosis