Diabetes Mellitus

• General measures: 1)all patients need lifestyle modification. 2)obese people need to loose some weight. 3)moderate no alcoholo intake. 4)smoking cessation. 5)increase physical activity,aim for 30min/daily ,5 times a week. 6)educate patient about foot care. 7)manage comorbid depression.
• diagnose Diabetes if patient has hyperglycaemia and one of the following: 1)random plasma glucose 11,1 mmol/L or greater. 2)fasting plasma glucose is 7mmol/L or greater 3)2-hour plasma glucose in a 75g oral glucose tolerance 11,1 mmol/L or greater
• if the patient do not have hyperglycaemia and they are asymptomatic, to diagnose diabetes repeat test on separate day within 2 weeks, and to confirm diagnose when: 1)fasting plasma glucose is still 7mmol/L or more for second time. 2)2-hour plasma glucose in a 75g oral glucose tolerance test is 11,1 mmol/L or more
• for monitoring Diabetes,at every visit do: 1)finger-prick blood glucose. 2)take weight and calc. BMI 3)measure waist circumference. 4)take Bp
• Baseline monitoring include: 1)checking serum creatinine concentration-and calc eGFR. 2)if patient is taking ACE inhibitors-risk of hyperkalemia or eGFR is <30mL/min then check serum potassium concentration. 3)Check urine protein by dipstick-if dipstick negative, request for albumin-to-creatinine ratio(ACR),but not if they are on ACE inhibitors-because it reduces urine protein. -if dipstick positive(1+ or more),repeat dipstick on another day,if there is still protein elevated in the urine, do spot-urine-protein-creatinine-ratio (>0,1g/mmol confirm DM)
• baseline monitor: 4)check blood lipids-fasting total cholesterpl,tryglycerides,HDL and LDL cholesterol. 5)do foot exam 6)eye exam-for retinopathy 7)do waist circumference
• measure HbA1c every 6 months in patients that the treatment is effective and measure every 3months if is not effective or we have changed therapy
• Targets fo DM control in glycaemic patients include: 1) for young,low riskor newly diagnosed,HbA1c target is <6.5%-target FPG 4-7mmol/L-target PPG 4.4-7.8mmol/L
• Targets fo DM control in glycaemic patients include: for majority of people,target HbA1c <7%, target FPG 4-7mmol/L, target PPG 5-10mmol/L
• Targets fo DM control in glycaemic patients include: for elderly,high risk, hypoglycaemic,target HbA1c <7.5% ,target FPG 4-7mmol/L and target PPG <12mmol/L
• Targets fo DM control in non-glycaemic patients include: targets BMI <25kg/m2 and Bp <140/90 and >120/70
• type 2 diabetes mellitus management include treatment of hyperglycaemia,hypertention,dyslipidemia, microvascular and macrovascular complication ttreatment and prevention
• treatment of type 2 diabetes is metformin, if it fails to lower HbA1c then add sulphonylurea, if fails add basal insulin. if the three fails give pre-mixed insulin or basal bolus therapy and dicontinue sulphonylurea
• type 2 DM treatment include: Metformin,oral,500mg 2 times a day with meals. adjust dose based on the control of glucose, max dose is 850 mg,8 hourly and frequently check renal function
• for renal impairment with eGFR <30mL/min we have to stop metformin
• metformin contraindications include: 1)renal impairement-<30ml/min GFR. 2)uncontrolled CHF 3)severe liver disease. 4) patients with respiratory compromise-SOB. 5)Peri-operative-around time of surgery
• type 2 DM treatment include: Sulphonylurea-glimepiride,oral,1mg daily. adjust dose(according to how patients respond) and increase by 1mg weekly up to 6mg. usual dose is 4mg and max dose glimepiride is 8mg daily
• type 2 DM treatment include: Sulphonylurea-glibenclamide,oral,2.5mg daily 30min before breakfast. max dose is 15 mg daily
• do not give glibenclamide to patients with renal impairment (eGFR <60mL/min)
• indications for insulin therapy for type 2 diabetes include: 1)inability to control blood glucose pharmacologically. 2)pregnancy. 3)in severe kidney or liver disease 4)if we going to use it temporarily incase of medical illness or surgery
• insulin therapy type include: 1)intermediate to long-acting insulin. 2)substitution therapy-biphasic insulin{30/70 mix}. 3)basal bolus insulin therapy
• intermediate to long-acting insulin: Starting dose is 10 units{or 0.3 units/kg/day} in the evening before bed but not after 22:00. if not effective, increase dose by 2-4 units every 3-7 days until patient reach fasting plasma glucose target.
• biphasic therapy mix: starting dose is 0.3 units/kg/day divide between morning 30min before breakfast(2/3 of 0.3) and 30min before supper(1/3 of 0.3). if the starting dose is not effective increase by 4 units weekly
• basal bolus therapy: starting dose is 0.4-0.6 units/kg and divide this into 50/50. so 50% for basal-long acting insulin and 50 % bolus-short acting. basal insulin is adjusted based on fast glucose response and bolus insulin is adjusted based on pre and post prandial glucose
• reduce cardiovascular risk with lipid lowering therapy: give statins-Simvastatin,oral,10mg at night
• the following patients need lipid lowering therapy to reduce cardiovascular risk: 1)type 2 diabetics >40years. 2)type 1 diabetes with microalbuminuria. 3)diabetes with chronic kidney disease (eGFR <60 mL/min)
• aspirin therapy is given in diabetic patients with history of cardiovascular disease. Aspirin,oral,150mg daily
• for patients with renal impairment(meaning urine ACR >2.5mg/mmol-men and >3.5mg/mmol -women) give low dose of ACE-inhibitors. enalapril,oral,5 mg 12 hourly. max dose is 20mg 12 hourly
• if ACE-inhibitor is not tolerated,give Losartan,oral,50mg daily. max dose is 100mg daily if tolerated