Diabetes Mellitus -

Management

Jan Szewieczek

Katedra i Klinika

Chorób Wewnętrznych i Metabolicznych

Śl.A.M. Katowice

Principals



Prevention of diabetes



Early recognition



Complex management



Education



Monitoring



Clinical



Self-monitoring



Regular treatment



Non-pharmacological (nutrition, body mass control,

physical activity)



Pharmacological (oral hipoglicaemic drugs, insulin)



Secondary prophylaxis



Management in acute complications

Education (1)

A salient goal for diabetes care

is to enable each person with

diabetes to lead

the health-care team involved

in the management of their

diabetes

Education (2)



It is the right of each person with diabetes

to become empowered to derive the

maximum benefit from the health-care

system



It is the responsibility of the diabetes team

to ensure that the person with diabetes

can follow the life-style of their educated

choice, based on the three elements

of empowerment: knowledge, behavioural

skills, and self-responsibility

Education (3)



The aims of education and

training are to provide

information in an acceptable

form,

in order that people with diabetes

develop the knowledge to self-

manage their diabetes

and empower them to make

informed choices in their life

Schedule for clinical monitoring at
different types of visit (1)

Review topics

Initial

review

referral

Regular

review

Annual

review

Long-term and/or recent diabetes

history

Social history / lifestyle review

Diabetes understanding / self-

management

Self-monitoring skills / results

Complications history and/or symptoms

Smoking

problem

Other medical history / systems review

Family history diabetes / arterial disease

Drug history / current drugs

Schedule for clinical monitoring at
different types of visit (2)

Review topics

Initial

review

referral

Regular

review

Annual

review

Weight / body mass index

General examination

Foot examination / injection sites

problem

Eye / vision examination

problem

Blood pressure

problem

Glycated haemoglobin

Lipid profile*

problem

Urine protein

Urine albumin excretion**

problem

Serum creatinine

problem

Nutritional management



Nutritional management is an

integral part of initial and

continuing education

programmes

Healthy eating



Advise

carbohydrate intake should be higher, and fat intake

lower than that of most Europeans, but not different from

recommendations for the population in general



The proposed contribution to energy intake should be :





Fat:

saturated fat <10 %; replace excess saturated fat

with monounsaturates, or polyunsaturates ( up to 10 % ), or

carbohydrate





Carbohydrate:

around 50-55 %. Use foods containing

soluble fibre in a carbohydrate rich diet. Simple sugars need

not be rigorously excluded from the diet, but often need to

be limited





Protein:

around 15 %



Recommend

fresh fruit and vegetables

Nutritional management in
DM 1

Meal patterns



Multiple injection regimens



Advise

snacks will help to attain better blood glucose control,

but use self-monitoring to learn what is necessary and

desirable



Advise

on flexibility to adjust meal timing and content

( together with insulin doses ) without affecting blood glucose

control. But

warn

about the temptations of extra total calories



Rapid-acting insulin analogue regimens



Advise

snacks only if self-monitoring suggests a need; check

particularly if a high insulin analogue dose is needed to

correct hyperglycaemia present pre-prandially

PHYSICAL EXERCISE



Advise

that physical exercise :





can benefit insulin sensitivity, hypertension, and blood lipid control





should be taken at least every 2-3 days for optimum effect





may increase the risk of acute and delayed hypoglycaemia



Manage

physical exercise using :





self-monitoring to learn about the exercise response, and the effects

of insulin and dietary changes on this





a prospective reduction in insulin dose for regular exercise





additional carbohydrate as necessary





warnings :



about delayed hypoglycaemia, especially with more prolonged,

severe, or unusual exercise, and a possible need for less insulin overnight

and the next day



that exercise during insulin deficiency will raise blood glucose and

ketone levels



that alcohol may exacerbate the risk of hypoglycaemia after exercise

Glucose control assessment
levels in DM 1

Non-

diabetic

Adequate

Inadequa

HbA

%Hb

<6.1

6.2-7.5

>7.5

Fasting / pre-

prandial

mmol/

4.0-

5.0

5.1-6.5

>6.5

mg/dl

70-90

91-120

>120

Post-prandial

(peak)

mmol/

4.0-

7.5

7.6-9.0

>9.0

mg/dl

70-

135

136-

160

>160

Pre-bed

mmol/

4.0-

5.0

6.0-7.5

>7.5

mg/dl

70-90

110-

135

>135

Insulin, injections, and
associated education

(1)

Advise





the use of unmodified ( soluble, regular ) human

insulin before each meal, and human NPH insulin in

combination unless :



multiple injection therapy is not wanted by the person

with diabetes



flexibility of life-style is not important



insulin secretory capacity is high ( honeymoon period )



insulin analogue therapy is indicated ( see below )





the use of pen systems for insulin delivery



the use of the abdominal wall for meal-time injections, and

the thigh for extended-acting insulin; advise also rotation of

sites within these areas

Insulin, injections, and
associated education

(2)

Enable

the person with diabetes to :





handle the injection device proficiently and confidently,

including re-suspension of NPH crystals, insulin storage, and disposal





self-monitor

accurately and easily at appropriate times





place insulin consistently into deep subcutaneous tissue,

usually by means of a lifted skin flap with the injection device at a

45° angle





prevent, recognize and manage hypoglycaemia





understand the absorption characteristics of the two insulin

preparations used, and changes of insulin requirement with meal

size and physical activity, thus allowing them to learn insulin dose

self-adjustment





access the

diabetes professional team

freely for advice



manage sickness and travel successfully

Insulin, injections, and
associated education

(3)

Expect





overnight basal requirements to

require up to 50 % of total dose





unmodified insulin to last for 6-8

hours, and therefore sometimes to

overlap into the next meal or into the

night; reduce doses accordingly





high pre-breakfast insulin

requirements, due to insulin deficiency at

the end of the night

Rapid-acting insulin
analogue regimens

Make

the following changes when using rapid-acting

analogues compared to unmodified human insulin:





monitor the effect of a short-acting analogue post-

prandially ( at 1-2 h ), and always less than 4 h after injection





expect to use lower pre-meal insulin doses than with

human insulin





use combined NPH + analogue injection before meals,

if the between-meal interval is to be greater than 5 h





use a higher late-evening NPH dose ( unless the aim is

specifically to deal with a problem of night-time

hypoglycaemia )



use late-evening NPH no longer than 4 h after the evening

analogue injection

Vascular risk in people
with Type 1 diabetes

Manage arterial risk

aggressively in people with

Type 1 diabetes

if any other risk factor is

abnormal including family

history of arterial disease

Blood glucose control
assessment levels, DM 2

Low risk

Arterial

risk

Microva

scular

risk

HbA

%Hb

<=6.5

>6.5

>7.5

Venous plasma

Fasting / pre-

prandial

mmol/

<=6.0

>6.0

>=7.

mg/dl

<110

>=11

>125

Self-monitored

Fasting / pre-

prandial

mmol/

<=5.5

>5.5

>6.0

mg/dl

<100

>=10

>=1

Self-monitored

Post-prandial

(peak)

mmol/

<7.5

>=7.

>9.0

mg/dl

<135

>=13

>160

Using oral glucose-lowering
drugs (1)

Begin

oral agent therapy when :



an adequate trial of life-style intervention /

education has been given



either

( usually ) :





HbA

>6.5 %, fasting venous plasma

glucose >6.0 mmol/l ( >=110 mg/dl )



( occasionally ) if thin and no other

arterial risk factor :



HbA

>7.5 %, fasting venous plasma glucose

>=7.0 mmol/l ( >125 mg/dl )

Using oral glucose-lowering
drugs (2)

Use

metformin

insulin secretagogues

(sulphonylureas and repaglinide)

alpha-glucosidase inhibitors

thiazolidinediones and related

PPARgamma-agonists

Metformin

strong evidence base in the overweight,

lowers LDL cholesterol, but gastro-

intestinal side effects in some patients;

dose titration may help tolerance

contraindicated ( risk of lactic acidosis )

if renal impairment, overt liver

disease,

or severe cardiac failure; monitor

renal function at least yearly

Sulphonylureas

good evidence base, provided patient has

useful islet B-cell function

hypoglycaemia a significant problem

glibenclamide > glipizide =

chlorpropamide > gliclazide > tolbutamide

(some other agents lack data);

avoid glibenclamide / chlorpropamide

particularly if renal impairment or in the

thin insulin-sensitive patient ( especially if

elderly )

Repaglinide

new rapid-acting insulin

secretagogue; possible advantage

in hypoglycaemia avoidance and

control of post-prandial glucose

excursions

Alpha-glucosidase
inhibitors

effective control of post-prandial

hyperglycaemia, but poorly

tolerated by many patients; dose

titration may help tolerance

PPARgamma-agonists

new agents, offering effective glucose-

lowering particularly in combination

with insulin and insulin secretagogues

contraindicated

if any history of liver

disease, and require organized

monitoring of

liver function tests until hepatic

safety assured

Maintaining good blood glucose
control with oral glucose-lowering
drugs

Expect :



continuous deterioration of

glucose control with time



a need to increase therapy and

add new agents with time



insulin therapy to be needed in

many patients after a variable

number of years

Insulin therapy in Type 2
diabetes (1)

Begin

when HbA1c has deteriorated to >7.5 %

after maximum attention to dietary control

and oral glucose-lowering therapy ( unless

poor life-expectancy and asymptomatic )

Arrange dietary review when starting

insulin therapy

Review ( or start ) self-monitoring of

blood glucose before starting insulin

Continue therapy with metformin / insulin

secretagogues / PPARgamma-agonists

Insulin therapy in Type 2
diabetes (2)

Use

NPH insulin at night with oral glucose-

lowering drugs in people with good

insulin secretory reserve

pre-mixed insulin twice daily in the

majority of people

twice daily NPH insulin in people with high

pre-breakfast blood glucose

concentrations relative

to their HbA

Adjust therapy

frequently at first, using self-monitored results,

until insulin dose is adequate to

reach

blood glucose targets,

or hypoglycaemia

becomes a risk

Consider more intensive insulin regimens



in the more active patient if control remains

sub-optimal



if control remains sub-optimal due to

hypoglycaemia ( but not if due to insulin

insensitivity )

to assist achievement of more flexible life-styles

Diabetes control (1)

Good diabetes control means:



Good control of glycemia



Good control of hypertension (if exists)



Good control of other concomitant

metabolic disorders (lipid profile,

hyperuricemia)

Diabetes control (2)

Good control of glycemia means:



Maintenance of normoglycemia or near-

normoglycemia



Low incidence of episodes of

hyperglycemia



Low incidence of episodes of

hypoglycemia

Diabetes control (3)

The more intensive pharmacological

treatment, the lower values of

HbA

, and the more pronounced

risk of hypoglycemia

Diabetes control (4)

The more intensive pharmacological

treatment, the more important

self-control

Using blood lipid lowering
drugs

a statin

: LDL cholesterol >=3.0 mmol/l ( >=115 mg/dl )

( >4.0 mmol/l ( >155 mg/dl ) if low risk including thin elderly )

a fibrate

: triglyceride >2.2 mmol/l ( >200 mg/dl )

and

LDL cholesterol <3.0 mmol/l ( <115 mg/dl )

a fibrate first

if triglyceride markedly elevated ( >6.8

mmol/l (>600 mg/dl ) );

check thyroid, renal, and liver function ( and apoE genotype if

available );

consider combination therapy with a statin if LDL cholesterol

remains elevated

combination therapy

beginning with statin for high LDL

cholesterol and triglyceride

Using anti-hypertensive
drugs (1)

Monitor

dietary quality and quantity

( including alcohol ), physical

exercise level, body weight

sitting blood pressure ( after 5 min

rest, 1st and 5th phase )

Using anti-hypertensive
drugs (2)

Use

single agent therapy at rising

doses until target achieved ( or

intolerance )

multiple therapy if targets not

reached on maximum doses of single

agents

once daily drug administration regimens

ACE-inhibitors

good evidence base in diabetes,

advancing renal disease, cardiac

failure

monitor renal function / K+ ( risk of

renal artery stenosis with arterial

disease )

Beta-adrenergic
blockers

good evidence base in diabetes and

useful where angina or previous

myocardial infarction

avoid combination with thiazides

( metabolic deterioration ), and if

peripheral

vascular disease. Ask about

tiredness and impotence

Calcium channel
antagonists

some evidence base in diabetes and

in advancing renal disease



use only long-acting

preparations

fluid retention a problem with some

agents (avoid if history of foot

ulceration)

Thiazides

some evidence base in diabetes

use low doses only and avoid

combination with beta-adrenergic

blockers ( metabolic

deterioration ). Ask about

impotence

Loop diuretics

useful synergistic action with ACE-

inhibitors

Alpha-adrenergic
blockers

effective blood pressure lowering

and metabolically beneficial

use only long-acting drugs

( postural hypotension )

Angiotensin II receptor
blockers

no special advantages

Choice of agents -
summary



Multiple therapy is often required; add loop

diuretic to ACE-inhibitor, and avoid thiazides with

beta-adrenergic blocker; otherwise most

combinations neutral



Many older and less expensive agents are as

effective as newer agents



If abnormal albumin excretion, particularly if

progressive, begin with ACE-inhibitor, or calcium

channel

antagonist if ACE-inhibitor not tolerated

If ischaemic heart disease, consider beta-

adrenergic blocker first </UL< DL>

Planning the treatment (1)

Each patient needs individual plan of

non-pharmacological and

pharmacological treatment, the should

be modified according to current

situation

Planning the treatment (2)

Specific targets of treatment, given in

standards, but also some patient’s

conditions should be taken into account:



Patient’s level of education



Compliance in aspects of self-control, and the

treatment :



Acceptation for the particular targets and kind of the

treatment



Mental, physical, and financial ability to realize the

necessary control, and treatment or a sufficient support

from his/her family other persons or medical / social

institutions

Planning the treatment (3)

In young patients the maintenance of

near-normoglycemia is the most

important target of treatment

In elderly – avoidance of hypoglycemic

episodes is more important

Hypoglycemia

Symptoms of developing hypoglycemia can

be atypical (inadequate) or difficult to

notice especially:



In elderly



When



-adrenergic blockers

are used



During and after prolonged intensive physical

exercise



During mental stress



In acute ilness



During the sleep

Acute decompensation of diabetes
(1)



Terms of ‘hyperglycemic hyperosmolar

nonketotic coma’ and ‘hyperglycemic

hyperosmolar nonketotic state’ shoul be

replased with the term ‘hyperglycemic

hyperosmolar state’ (HHS)



The term ‘ketotic coma’ shoul be replased

with the term ‘diabetic ketoacidosis’ (DKA)



Both are reffered as ‘hyperglycemic crises’

Acute decompensation of diabetes
(2)

Clinical manifestations of ‘

hyperglycemic

crises’:



Circulatory (dehydration,hypovolemia,

hyperosmolarity,shock)



Impared renal function



Abdominal

(Pseudoperitonotis)

Acute decompensation of diabetes
(3)

Management:



Fluids i.v

. (start with 1,0 l of 0,9% NaCl, 15-20

ml/kg/h, determine hydration status, evaluate

corrected serum Na

, continue 0,9% NaCl 4-14

ml/kg/h if serum Na

is normal or low; 0,45% NaCl

if serum Na

is high); change to 5% dextrose with

0,45% NaCl with adequate insulin (0,05-0,1 U/kg/h

i.v.or 5-10 U. every 2h to keep the serum glucose

between 150-200 mg/dl until metabolic control is

reached)



Insulin

(Start with Regular 0,15 U/kg as i.v. bolus,

then 0,1 u/kg/h i.v.insulin infusion utill glycemia

reaches 250 mg/dl)

Acute decompensation of diabetes
(4)



Potassium: check serum K

every 2h



If serum K



5,5 mmol/l (mEq/l) do not

give K



When serum K

falls below 5,5 mmol/l give

20-30 mEq K

(2/3 KCl and 1/3 KPO

) per

each liter of fluid



If K

< 3,3 mmol/l give 40 mEq K

(2/3 KCl

and 1/3 KPO

) per 1h



Keep serum K

at 4-5 mmol/l



Bicarbonate

if pH



7,0

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