Upload
reid-force
View
212
Download
0
Tags:
Embed Size (px)
Citation preview
T McD Kluyts 1
GUIDELINES FOR THE FOLLOW-UP OF DIABETES
MELLITUS TYPE 2 PATIENTS
byT McD Kluyts
University of Pretoria
T McD Kluyts 2
PRE-TEST List the target organs in
DM2
Indicate the main reasons for routine urinalysis
Indicate the principle lifestyle modification measures that should be employed in DM2.
CNS including autonomic system, Eyes, Kidney, C-V system
Proteinuria, Ketonuria, Occult infection
Diet, exercise, weight loss, addiction management.
T McD Kluyts 3
CRITERIA FOR THE DIAGNOSIS OF
DIABETES MELLITUS
Fasting plasma glucose 7.0 mmol/l. or
Symptoms of diabetes plus:
casual plasma glucose concentration 11.1 mmol/l.1
or2-h PG 11.1 mmol/l during an OGTT.
T McD Kluyts 4
Diabetes Mellitus Type 2
Previously NIDDM, Adult type DM, type 2 DM
DM 2 • Not insulin dependent for survival• Age 30+ at diagnosis• Usually obese• Few classic symptoms• Ketoacidosis rare
T McD Kluyts 5
The following measures are directed towards :
Glycaemic control and
Prevention of complications
T McD Kluyts 6
SUBJECTIVECompliance
ComplicationsPatients questions
OBJECTIVEExaminations
Sideroom proceduresSpecial investigations
MONTHLY FOLLOW-UP
T McD Kluyts 7
SUBJECTIVE
Compliance:
•Check the patients medicines
•Discuss the taking of medicines
•Establish supervision and
•monitor bloodglucose, diet and exercise records
SUBJECTIVE
Complications:Ask about: Vision Feet Infections Pains and Sensations
T McD Kluyts 9
SUBJECTIVE
Questions from the Patient:
• Encourage patient to talk and to ask questions
• Re-affirm treatment schedule
• Explore family situation
T McD Kluyts 10
OBJECTIVE
Physical examination:• Pulse, bloodpressure, temperature,
respiratory rate.• Eyes: Cataracts and vision• CVS: Heart and peripheral circulation• CNS: Muscle strength, reflexes,
sensation, proprioception• BMI
OBJECTIVEObjective
Sideroom procedures:•Blood glucose•Urine Labstix•Urine microscopy
Special investigations:
•Never routinely, only as and when indicated by examination
T McD Kluyts 12
OBJECTIVE
Urine: • glucose and ketones are
important Blood glucose:
• measure with glucometer Foot examination:
• skin,circulation, shoes Look at home monitoring chart
T McD Kluyts 13
Three- to six monthly :
As monthly + lab tests:
• HbA1c – measurement• Urine for proteinuria• Snellen test, visual fields• ECG• Lipid profile• Feet examination
T McD Kluyts 14
ANNUALLY
Monthly examination + Lab tests Neurological status Cerebral function Micro-circulation Lipid profile Micro-albuminuria ECG Fundoscopy
T McD Kluyts 15
KEY TESTS
TEST OR EXAM FREQUENCY
Glycated Hb 2x per year
Fundoscopy 1x per year
Foot exam Quaterly
Lipid profile 1-2 yearly
S-createnine Yearly
Microalbuminuria Yearly
Blood pressure Each visit
BMI Each visit
ECG 2x per year
T McD Kluyts 16
PATIENT EDUCATION
This is the cornerstone of effective diabetes care.
Sufficient time and resources should be made available in order to do this effectively.
T McD Kluyts 17
RECORD DEGREE OF CONTROL
Patients with poor or brittle control, should be seen at least once a month.
Well controlled diabetics can be seen at longer intervals eg 2-4 monthly.
T McD Kluyts 18
Criteria for intervention
CRITERIA OPTIMAL ACCEPTABLE ACTION NEEDED
BLOOD GLUCOSE
FASTING 4-6 6-8 >8
POST-PRANDIAL
4-8 8-10 >10
GLYCATED Hb %
<7 7-8 >8
T McD Kluyts 19
WEIGHT
As obesity virtually always accompanies type 2 diabetes, it should be targeted in its own right.
A weight loss of 5-10% should be the initial aim. It has been shown to improve insulin resistance and all its associated parameters
T McD Kluyts 20
Weight
Body Mass Index (BMI) = Mass in kg/Length in meter2
Optimal Acceptable
Action needed
BMI <25 20 - 26 >27
T McD Kluyts 21
WEIGHTEvidence demonstrates
that:• structured, intensive
lifestyle programs
involving participant education,
• reduced dietary fat and energy intake,
• regular physical activity• and frequent participant
contact are necessary to produce long-term weight loss of >5% of starting weight.
T McD Kluyts 22
GLUCOSE TREATMENT
RECOMMENDATIONS FOR DM2 Always provide or refer for dietary and
lifestyle advice at diagnosis If random glucose values > 15 mmol/L ~
consider starting oral agents together with lifestyle modification from the start
If overweight (BMI > 25) ~ consider metformin unless contra-indicated
If postprandial glucose values constitute the major abnormality or sulphonylureas contra-indicated (e.g. renal failure) ~ acarbose or meglitinides may be considered
T McD Kluyts 23
GLUCOSE TREATMENT (Continued)
If insulin resistance is the major abnormality , metformin should be considered as first line or add on therapy. If metformin is contra-indicated or poorly tolerated (e.g. raised serum creatinine or major cardio-pulmonary risks),then thiazolidinediones may be used.
Always start with monotherapy and titrate dosage to maximum over 1-3 months
T McD Kluyts 24
GLUCOSE TREATMENT (Continued)
If goals still not reached, add second agent (lowest dose, titrate when necessary).
If goals still not attained despite good
compliance and absence of major stressors such as infection, consider insulin therapy
In such cases, insulin therapy may be initiated as intermediate or long-acting insulin at bedtime (titrate against pre-breakfast reading), with or without oral agents. If possible, self glucose monitoring should be done in all patients on insulin.
T McD Kluyts 25
GLUCOSE TREATMENT (Continued)
Initial insulin dose is 0.2-0.3 U/kg
If more than 30 U per day are required or clinical judgment indicates, use twice daily biphasic insulin (2/3 intermediate, 1/3 short acting). Consider referral.
T McD Kluyts 26
BLOOD PRESSURE GOALS
SYSTOLIC <130
DIASTOLIC <80
With Proteinuria
SYSTOLIC <120
DIASTOLIC <70
T McD Kluyts 27
BLOOD PRESSURE TREATMENT
Angiotensin converting enzyme (ACE) inhibitor based
Low dose diuretics, eg hydrochlorothiazide (HCTZ) 12.5mg or Indapamide 1.25 -2.5 mg/day may be appropriate first line agents
Most patients will require at least 2
agents
T McD Kluyts 28
BLOOD PRESSURE (continued)
ACE inhibitors or angiotensin II receptor antagonists are indicated in the presence of micro- or macroalbuminuria
In patients over age 55 yrs with or without hypertension, but with another cardiovascular risk factor, an ACE inhibitor should be considered to reduce the risk of cardiovascular events.
T McD Kluyts 29
LIPID GOALS
TotalCholesterol <5.0
LDL <3.0
HDL >1.2
Triglycerides <1.5
T McD Kluyts 30
LIPID TREATMENT
LDL-cholesterol above 3 mmol/l ~ consider a statin as therapy
Triglycerides above 1.5 mmol/l ~ check for secondary causes, consider using a fibrate
LDL-cholesterol and triglycerides elevated ~ statin and fibrate if persistant
Fibrates contra-indicted with impaired renal function ~ refer.
T McD Kluyts 31
ASPIRIN RECOMMENDATIONS
As a primary prevention strategy in high-risk men and women with type 1 or type 2 diabetes including diabetic subjects with the following:
• a family history of coronary heart disease, • cigarette smoking, • hypertension, • obesity, • albuminuria (micro or macro), • age >30 years or • dyslipidaemia.
T McD Kluyts 32
ASPIRIN RECOMMENDATIONS(continued)
Use aspirin therapy as a secondary prevention strategy in individuals who have evidence of large vessel disease, eg • a history of myocardial infarction, • vascular bypass procedure,• stroke or transient ischaemic attack,• peripheral vascular disease,• claudication and/or • angina.
T McD Kluyts 33
ASPIRIN RECOMMENDATIONS(continued)
Use 150-300 mg aspirin per day (enteric coated if possible)
People with aspirin allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease are not candidates for aspirin therapy.
T McD Kluyts 34
ASPIRIN RECOMMENDATIONS (continued)
Aspirin therapy should not be recommended for patients under the age of 21 years because of the increased risk of Reye’s syndrome
associated with aspirin use in this population
T McD Kluyts 35
Exercise Record
The exercise parameters are as follow:• To reach a pulse rate of max – 20%
for age and sex and maintain for 20 minutes at least
• 3 times per week at least• Walking or running or cycling or
swimming or any combination thereof
T McD Kluyts 36
Weight and diet record
This should include weekly weight measurements
Dietary notes where indicated to explain weight changes
Doctor/dietician’s comments
T McD Kluyts 37
Glucose control record
The ideal would be twice daily blood-glucose recording: morning and evening. This might be impossible for unsubsidised patients
to attain, and daily urine testing will have to suffice as a minimum requirement.
Blood glucose should be done fasting in the mornings, and 2 hours postprandial at night.
Urine glucose should be measured fasting in the morning 1 hour after emptying the overnight bladder, and/or 15 minutes after emptying the 2 hour postprandial bladder in the evening.
T McD Kluyts 38
SCENARIO 1
A 24 year old male student presents to you with a history of Diabetes Mellitus 2 for 2 years, complicated by systolic hypertension. He tells the story that he suddenly became ill while attending a rugby training camp 2 years ago. He has never before been ill in his life except for a chronic seasonal rhinitis for which he has been taking numerous treatment regimes in the past.
T McD Kluyts 39
SCENARIO 1 (Continued)
At the moment he is taking Glucophage and Diamicron one each twice daily
On examination he is well built, weighs 110kg and is 1,8m tall
His BP is 128/84
His father’s sister is a diabetic
T McD Kluyts 40
SCENARIO 1 (Continued)
He is still participating in sport, but had to retire from provincial level participation since the start of his illness
He is complaining of tiring easily His random blood glucose today is
8.6mmol/l He is not keeping record of his exercise
efforts or his diet
T McD Kluyts 41
SOLVING THE PROBLEM
Main problem Additional factors
Help seeking Education
T McD Kluyts 42
SCENARIO 2
A 38 year old lady with Diabetes Mellitus 2 on insulin replacement therapy visits you for a renewal of her medication
She has been on Humoloc Mix 25 but when she went to the chemist last month for a repeat, she was told that it was no longer “on code”
T McD Kluyts 43
SCENARIO 2 (Cont)
She was not given any instruction on how to use it
She is using 46 Units nocte On examination her blood pressure is
160/90; blood glucose = 18,6; she has 1+ oedema of the legs; her BMI = 31,5
She is also taking Coversyl 4mg daily with Natrilix 2,5mg daily for her blood pressure
T McD Kluyts 44
SOLVING THE PROBLEM
Main problem Additional factors
Help seeking Education
T McD Kluyts 45
ACKNOWLEDGEMENT
Parts adapted from SEMDSA guidelines 2002 (Prof Paul Rheeder)
ADA clinical practice recommendations 2002. Diabetes Care 2002; 25(1) supl 1
WEBSITE:
http://www.novonordisk.com
T McD Kluyts 46
Thanks !