Transcript Diabetes Melliyus Guidline - (Handout) (slide

Ministry of Health
Family Practice Residency Training Program
Diabetes Mellitus
Guideline
Prepared by:
Dr.Anam Hussain
Dr.Juhaina Bu Hindi
Dr.Rasha Al-Mahroos Dr.Wafa Al Sharbati
Revised by: Dr. Abeer ALSowair,
Dr. Eman Al-Ghawi
Dr. mariam AlJalahma
Adopted from:
American Diabetes Association.
Palestinian Diabetic Guidelines.
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Diabetes mellitus Guideline
Contents:
Clinical characteristics of Diabetes mellitus type
1 & type 2………..page 3
Classification of Diabetes Mellitus…....page 3
Screening for Type 2 Diabetes Mellitus………..page 4
Diagnostic criteria for Type 2 Diabetes
mellitus...page 4
Algorithm for diagnosis of Type 2 Diabetes
Mellitus………..page 5
Clinical assessment of Diabetes Mellitus………..page 6
Lines of treatment………..page 13
Management of complications………..page 25
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Clinical characteristics of Diabetes mellitus type 1 & type 2
Classification of Diabetes mellitus
Type 1
Diabetes
Characterized by β-cell destruction and absolute insulin
deficiency
Type 2
Diabetes
Characterized by insulin resistance and relative insulin
deficiency
Gestational
Diabetes
Diabetes Mellitus with onset or first recognition in
pregnancy
Other types
Diabetes caused by other identifiable etiologies.
3
Screening for Type 2 Diabetes Mellitus
Diagnostic criteria for Type II DM
Biochemical
Index
4
Normal
Impaired glucose
tolerance
Diabetes
FBG
< 6.1mmol/L
> 110 mg/dl
6.1-6.9 mmol/L
111-125 mg/dl
>7mmol/L
>126 mg/dl
2hr OGTT
<7.7 mmol/L
< 140 mg/dL
7.7-11mmol
140-200mg/dL
>11.1mmol/L
>200 mg/dl
Random PG
> 11.1mmol/L (>200mg/dl + symptoms)
CHART FOR DIAGNOSIS OF DIABETES MILLETUS
Fasting venous plasma glucose (FBG)
< 6.1mmol/dl
6.1- 7mmol/dl
Diabetes
unlikely
Random plasma
glucose> 11.1mmol/dl+
symptoms
> 7 mmol/dl
Repeat
FBG
Within a week
If FBG
6.1mmol/dl-7mmol/dl
Perform 75 gram OGTT
Within a week
FBG<6.1mmol/dl
or
Repeat
FBG
Within a week
If FBG
>7mmol/dl
Diabetes
mellitus
FBG=6.1-7
2h-PG=7.7-11.1
Or 2h-pg <7.7mmol/dl
mmol/dl
mmol/dl
Normal
Impaired fasting
glucose
Impaired
Glucose
tolerance test
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Diabetes
mellitus
FBG>6.1
mmol/dl Or 2h-pg
11.1mmol/dl
Diabetes
mellitus
Clinical assessment of Diabetes
Mellitus
Initial visit
page 7
Continuing care
page 9
Referral
page 12
6
Initial visit
1. Review patient’s records for the following:
•
•
•
•
History
•
history of Diabetes
onset of the disease
progression over time
previous treatment (oral hypoglycemics & or insulin), side effects of
drugs, investigations and complications.
Impact of disease on life
2.
Symptoms of both hyperglycemia (polyurea, polydipseia, polyphagia,esp.
nocturia > once per day), hypoglycemia (palpitation ,sweating ,hunger
,giddiness…,etc).especially if the patient is on therapy.
3.
Check compliance for medications, reasons for non compliance.
and whether the patient is taking the treatment in the right way (the dose
and frequency) especially if not controlled, role out drugs that raises blood
sugar
4. Assess risk factors:
•
Non modifiable (Age males <45 yrs and females <55 yrs, sex ,Family Hx of
DM, HTN ,Hyperlipidemia and premature death in Family males
<55yrs,females <65 years, other endocrine disorders(
•
Modifiable: hypertension>140/90 ,smoking ,drinking , Hyperlipidemia,
sedentary lifestyle, over weight BMI>27.
*If female H/O Gestational DM, delivery of an infant weighing
>4kg,toxemia,stillbirth,polyhydramnios,or other complications of pregnancy .
5. Complications of the disease:(end-organ damage)
Consider macro- and micro- complications ,esp those which need screening like
diabetic retinopathy, nephropathy and neuropathy, Ask if referred to SMC for
prevention.
6. What measures are taken by the patient to control his/her own illness
(Self-management education)
-lifestyle, cultural ,psychsocial,,educational and economic factors.
-Detailed Dietary History.( take one day diet as an example)
-Exercise
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7. At the end of the interview you are able to identify areas of deficiency that will
help you in your management , in order to achieve better control of the
disease.
Laboratory evaluation
Physical examination
Initial visit
8
Physical examination
History
Continuing care
9
Self Measurement of Blood Glucose
See Appendix 1: Diabetic Sheet
Laboratory evaluation
Continuing care
•
For those on insulin therapy, follow up with sugar profile is mandatory
for dose adjustment. The following is an example to be modified according
to patients injection timing & convenience.
FBS reading: Before morning injection & meal ( reflects NPH evening dose)
Pre lunch random glucose reading: 12 pm ( reflects regular morning dose)
Post lunch reading: before the evening dose & meal: 6pm ( reflects NPH morning dose)
Post dinner reading: 11pm ( reflects regular evening dose)
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Referral
12
Lines of treatment
Goals of Therapy…page 14
Education…page 14
Diet…page15
Exercise…page 16
Pharmacological therapy…page 18
13
Goals of Therapy
Education
14
Diabetic
Diet
Advice
15
Exercise
Increase energy expenditure with moderate energy exercise
Types of exercise:
• aerobic exercise
• strength training
• flexibility exercises
How To Exercise???
•Start with brisk walking 5-10 minutes /day for 3days
per week.
•Gradually increase exercising to 30 minutes /day for
5 days per week.
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Pharmacological therapy
Diabetes mellitus Type 2
management algorithm…page 19
Hypoglycemic agents…page 20
Diabetes mellitus Type 1 insulin
therapy
Human Insulin
Activity…page 21
Insulin dose…page 21
Insulin regimens…page 22
Adjusting insulin
dose…page 23
Steps of insulin
injection…page 24
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Initial Visit Management
Initial presentation
(based on presentation
of the
items listed
within each box)
Mild or no symptoms
Negative ketones AND
No acute concurrent illness
Start MNT and Physical
Activity
•
•
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FPG > 200* OR
Random > 300* AND
Does not meet criteria for
mild or severe
6-8 weeks
Start Oral Anti-hyperglycemic
Therapy
Marked hyperglycemia OR
Significant weight loss OR
Severe/significant symptoms OR 2+
or greater ketonuria OR DKA,
hyperosmoiar state OR Severe
intercurrent illness or surgery
Start Insulin Immediately**
*I f diet history reveals markedly excessive high carbohydrate intake,one may
consider initial trial of MNT and physical activity before initiating oral agent therapy
even though glucose levels are above the thershold listed.
**Some patients type 2 DM initially stabilized on insulin may be considered for
transition to oral agent therapy
Algorithm for Pharmacological management of Type 2 Diabetes
Failure on non-pharmacological measures (education, diet & exercise)
Within 2-4 months
Re-assess lifestyle interventions to
maximize benefits
Monotherapy
No
(non-obese)
Start either
BMI
1-Glibenclamide 5-10 mg once daily,
increasing dose to maximum daily dose 20
mg (two divided doses
Monotherapy
Yes
(obese)
Start Metformin 850 mg daily,
increasing dose over 3-4 weeks(
maximum daily dose 850 mg three
times daily)
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2- Metformin 850 mg daily, increasing
dose over 3-4 weeks( maximum daily dose
850 mg twice daily)
3- Gliclazide 80 mg once daily, increasing
to maximum daily dose of 320 mg over 3-4
weeks
2-4 months
Repeat HbA1c
Reassess life style
Change to maximum benefit
Combination Therapy
Add any of the following agents:
Glicazide, Glibenclamide,
metformin (Do not combine
Gliclazide & Glibenclamide
Is blood
glucose
controlled
No
Yes
Continue regimen & follow every
3 months
2- 4 months
Is blood
glucose
controlled
Repeat HbA1c
Reassess lifestyle change
to maximum benefit
Yes
Continue regimen & follow every
3 months
No
Add Insulin therapy
10-15 units evening dose Oral agent (Glicazide, Glibenclamide, metformin
2- 4 months
Repeat HbA1c
Reassess lifestyle change
to maximum benefit
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Yes
Continue Regimen
Is blood
glucose
controlled
No
Switch to insulin Therapy
1-4 times daily
Oral Hypoglycemic Agents
Drug
Dose
Glibenclamide
Daonil
Initially 5 mg daily (elderly 2.5mg)
Max. dose 15 mg daily with breakfast
Glipizide
Minidiab
Initially 2.5-5 mg daily (elderly 2.5mg)
Max. dose 40 mg daily before
breakfast in divided doses
Gliclazide
Diamicron
Side effects
Precautions
Gastrointestinal
disturbances
headache
Hypoglycemia in
elderly.
Patient with hepatic
& renal insufficiency
Breast feeding
Initially 40-80 mg daily (up to 160mg
as single dose) Max. dose 320 mg
daily in divided doses
Gastrointestinal
disturbances
headache
Patient with hepatic
& renal insufficiency
Breast feeding
Metformin
Glucophage
500 mg every 8 hours or 850 mg /12
hours with or after food. Max. dose 2g
daily
Anorexia, nausea,
vomiting, diarrhea,
decrease in vit. B
absorption, Lactic
acidosis
Patient with hepatic
& renal insufficiency
Glimepiride
Amaryl
1-2 mg once daily with breakfast. Max.
dose 8 mg
daily
Dizziness, Asthenia,
Headache, nausea
Patient with hepatic
& renal insufficiency
Breast feeding
Thiazolidinediones
Rosiglitazone
(Avandia)
4 mg daily in combination with a
sulphnylurea or metformin)
increase to 8 mg in 1-2 divided
doses after 8 weeks
GI disturbances,
headache, anemia,
fatigue, wt. gain,
dizziness
Monitor liver
function, risk of
heart failure, renal
impairment
Acarbose
Glucobay
50mg daily increase to 50mg 3 times
Daily then after 6-8 weeks to 100mg
3 times daily if needed. Max. 200mg
3 times daily
Flatulence, soft stools,
diarrhea, abdominal
distension, abnormal
liver function test and
skin reaction, edema,
jaundice and hepatitis
Pregnancy and breast
feeding, inflammatory
bowel disease, hepatic
impairment severe
renal impairment
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Human Insulin Activity
TYPE
ONSET
PEAKS
DURATION
REGULAR (SHORT)
30-60 mint
2-3 hrs
4-6 hrs
NPH (INTERMEDIATE)
2-4 hrs
6-10hrs
12-18 hrs
LENTE (INTERMEDIATE)
3-4 hrs
4-12hrs
16-20 hrs
ULTRALENATE
6-10 hrs
Mini peaking
20-30 hrs
LISPRO(HUMALOG)
<15 mint
30-90 mint
<5 hrs
Lantus(Glargine)
1.5 hours
peakless
18 to 26 hours
Premixed(70/30)
15-30 mint
2-3 hrs and 812hrs
18-24hrs
Insulin dose
• Starting dose for both types of diabetes (0.1-0.5 u/ kg/d).
• Average dose (0.5-1 u/kg /d).
• The dose increased by 2U every 2-3
days until reaching good glycemic control.
Insulin regimens
ONCE DAILY is rarely suitable.
Split –mixed regimen ;bid mix of short
and intermediate acting insulin, divided
daily dose :
•2/3 AM before breakfast
•1/3 PM before supper
Divide each dose according to age;
•Age > 5yrs 2/3 interm.+ 1/3 short acting.
•Age < 5yrs 3/4 interm. + 1/4short acting
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Action If blood glucose is usually too high
Time
Action
Before breakfast
Consider Somogyi or Dawn
Syndrome & act accordingly*
Before lunch
increase short action.
Before evening meal
increase AM delayed
action insulin
or pre-lunch short
acting insulin.
*Somogyi: Rebound Morning hyper glycemic due to nocturnal hypoglycemia. Patients
complain from nightmares & hypoglycemic symptoms. Action: Decrease evening dose.
Dawn: Morning hyperglycemia due to reduced sensitivity to insulin provoked by growth
hormone released after sleep. Patients complain from hyperglycemic symptoms. Action:
increase evening dose
If blood glucose is usually too low
Before breakfast
Time
Before lunch
Before evening meal

reduce delayed PM dose. Action
reduce AM short acting.
reduce AM delayed dos
or pre-lunch short acting.
N.B changes in dose should be by 2U or 10% of the dose at a time.
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Sites for insulin injection
Preparing for injection
23
•
Wash your hands.
•
Wipe the tops of both insulin bottles
with an alcohol wipe.
•
Turn the NPH or Lente insulin bottle
upside down and roll between your
hands to mix, but don’t shake it.
•
Pull plunger to draw in enough air to
equal your NPH or Lente insulin dose:
_____ units.
•
Push the needle through the top of the
NPH or Lente insulin bottle and inject air
into the bottle.
•
Remove empty syringe and needle from
bottle.
•
Pull plunger to draw in enough air to
equal your Regular insulin dose:
_____ units.
•
Push the needle through the top of
the Regular insulin bottle and inject
air into the bottle.
•
With the needle in the bottle, turn it
upside and pull to fill the syringe past
your dose of Regular insulin.
•
Push slowly to the line of your
correct dose of insulin: _____units.
•
Check for air bubbles. If bubbles are
present, tap the syringe to make
them rise. Then repeat steps 9 and
10 and check for bubbles again.
•
Remove the needle from the bottle with
Regular insulin in the syringe.
•
Push the needle through the top of the
NPH or Lente insulin bottle and carefully
pull plunger back to your total dose of
insulin: _____ units units NPH or Lente
+ _____ units Regular).
Remove the needle.
•
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GIVING THE INJECTION
1
2
4
3
Failure of insulin therapy
Consider
•Undetected psychosocial problems.
•Inter-current illness.
•Poor injection Tech or sites.
•Change eating habits.
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Management of Diabetic Complications
Diabetic retinopathy
The recommendations for initial and subsequent ophthalmologic evaluation of patients with
diabetes are as follows:
• Patients> 10 years of age with type 1 diabetes should have an initial and comprehensive eye
examination by an ophthalmologist within 3 -5 years after the onset of diabetes. In general,
screening for diabetic eye disease is not necessary before 10 years of age.
• Patients with type 2 diabetes should have eye examination done shortly after the diagnosis of
diabetes.
• Subsequent examination for both type 1 and type 2 diabetic patients should be repeated
annually and more frequently if retinopathy is progressing.
• When planning pregnancy, women with pre-existing diabetes should have eye examination
done in the first trimester and close follow up during pregnancy.
Peripheral neuropathy
Management of diabetic peripheral neuropathy is suggested by the following scheme:
• The main indication for intervention in neuropathy is pain and other troublesome sensory symptoms.
• Exclude other treatable causes such as cord lesions.
• Optimize glycemic control by introducing or intensifying insulin treatment, especially in cases of
intractable pain.
•.Relieve pain by using simple analgesics such as codeine, aspirin or tricyclic drugs
such as
imipramine or amitriptyline, often given together with fluphenazine at night or local counterirritant as
capsicum.
• If there is no response consider other agents such as lignocaine (IV) phenytoin,
carbamazepine, gapapentine or topimarate (0ralj).
• Other specific measures (cramps diazepam, depression tricyclic, weakness physiotherapy).
Management of autonomic neuropathy
•
Cardiovascular system:
 Treatment consists of stopping drugs known to exacerbate hypotension such as diuretics,
tranquillizers, antidepressants.
 Recommending high salt intake.
 Advising the patient to raise the head of the bed.
 Having the patient wear elastic stockings.
•
Gastrointestinal system:
 Treatment consists of multiple small meals with Iow fat contents.
 Drugs increasing gastric motility such as (metoclopramide, erythromycin).
 For diarrhea broad -spectrum antibiotics such as tetracycline and antidiarrhea
remedies (codeine phosphate, lomoti!, loperamide) can be used during acute exacerbation.
•
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Sexual dysfunction:
 Initial treatment is directed at glycemic control, counseling, giving up smoking.
 The best treatment useful in nearly all diabetics with psychogenic or neurogenic erectile dysfunction
 intracavemosal prostaglandin E1(Alprostadil10-20 I-Ig).
 Oral treatment is now available (sildenafil citrate), this drug must be taken 60 minutes before
intercourse and avoid combination with nitrites.
 Brompheniramine, imipramine or phenylephrine can be used in case of retrograde ejaculation.
Management of Diabetic Nephropathy
See attached screening guidelines for nephropathy
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Diabetic Foot Care
Hygiene of the Feet
1.
2.
3.
4.
5.
6.
Wash feet daily with mild soap and lukewarm water. Dry thoroughly between the toes by
pressure. Do not rub vigorously, as this is apt to break the delicate skin.
When feet are thoroughly dry, tub well with vegetable oil to keep them soft, prevent excess
friction, remove scales, and prevent dryness. Care must be taken to prevent foot tenderness.
If the feet become too soft and tender, tub tem with alcohol about once a week.
When rubbing the feet, always rub upward from the tips of the toes. If varicose veins are
present, massage the feet very gently; never massage the legs.
If the toenails are brittle and dry, soften them by soaking for one-half hour each night in
lukewarm water containing 1 tbsp of powdered sodium borate (borax) per quart. Follow this by
rubbing around the nails with vegetable oil. Clean around the nails with an orangewood sick.
If the nails become too long, file them with and emery board. File them straight across and no
shorter than the underlying soft tissues to the toe. Never cut the corners of the nails. (The
podiatrist should be informed if a patient has diabetes).
Wear low-heeled shoes of soft leather that fit the shape of the feet correctly. The shoes should
have wide toes that will cause no pressure, fit close in the arch, and grip the heels snugly.
Wear new shoes one-half hour only on the first day and increase by 1 hour each day following.
Wear thick, warm, loose stockings.
Treatment of Corns of & calluses
(1)
(2)
(3)
Aids
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Wear shoes that fit properly and cause no friction or pressure.
Soak the feet in lukewarm (not hot) water, using a mild soap, for about 10 minutes and then
rub off the excess tissue with a towel or file. Do not tear it off .
Do not cut corns or calluses.
in Treatment of Impaired Circulation (Cold Feet)
Never use tobacco in any form.
Keep warm. Wear warm stockings and other clothing.
Do not wear circular garters, which compress blood vessels and. Reduce blood flow.
Do not sit with the legs crossed.
Place a pillow under the covers at the foot of the bed.
Do not apply any medication to the feet without directions from a physician.
A prophylactic dusting powder should be used on the feet and stockings at least daily or
oftener.
Treatment of Abrasions of the skin
(1) Avoid strong irritating antiseptics such as tincture of iodine.
(2) As soon as possible after any injury, cover the area with sterile gauze, which may be
purchased at drugstores. Only fine paper tape or cellulose tape (Scotch Tape) should be used
on the skin if adhesive retention of the gauze is required.
(3) Elevate and, as much as possible until recovery, avoid using the foot.
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