Essentials of diabetic care

1
Essentials of diabetic care

• By
• Prof. Fathi El-Gamal

2
Diabetic care

• Aims of diabetic care
• Alleviation of symptoms
• quality of life enhancement
• education of the patient and their family
• minimisation of complications
• reduction of early mortality.

3
Presentation

• Asymptomatic
• may be detected on routine screening during well
  man!
• woman checks or
• opportunistic urine screening for glucose.
• A national screening programme is considered.
• Sub-acute
• weight ?,
• polydipsia, polyuria,
• lethargy, irritability,
• infections (candidiasis, skin infection,
  recurrent infections slow to clear),
• genital itching,
• blurred vision,
• tingling in hands/feet.

4
Presentation

• Acute
• ketoacidosis.
• Complications
• neuropathy,
• nephropathy,
• arterial or eye disease.

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Diagnosis

• If an abnormality is foundrepeat.
• Diagnosis is made after 2 abnormal venous blood
  glucose readings sent to a laboratory
• fasting sugar 7.0 mmol / l (126 mg) or
• sugar 2h. after 75g of glucose (350 ml of
  Lucozade) 1l.l mmol / l (200 mg)

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Definitions

• Impaired fasting glycaemia
• Fasting glucose 6.1 and lt7mmol/l. ( 110
  lt126mg).
• Check glucose tolerance test.
• Impaired glucose tolerance
• Fasting sugar lt7.0mmol/l (126mg) and 2h.
  Glucose tolerance test sugar is 7.011.l mmol / l
  (126mg - 200mg).
• Impaired glucose tolerance and impaired fasting
  glucose are both risk factors for DM.
• Follow-up with annual fasting blood sugar.
• 4 / year. develop DM.
• Treat cardiovascular risk factors aggressively.

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Caution

• Blood glucose may be temporarily elevated during
• acute illness,
• after trauma or surgery or
• during short courses of blood glucose raising
  drugs
• If HbA1c gt 7 DM is likely.

8
Diabetes care Organization of care

• GP diabetic clinics can be as effective as
  hospital clinics in achieving diabetic control.

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Features of well-organized care

• Use of a register and structured records (often
  available as part of in-house computer software)
  
• regular review, with follow up of defaulters,
  following a protocol for care
• thorough annual review (see below) with recall
  system
• provision of protected time for the clinic

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Features of well-organized care

• availability of good quality written G
  information for patients
• open access for patients to receive advice
• multidisciplinary team covering all aspects of
  diabetes careGPs, diabetes nurse
  specialists/assistants and educators
• access to dieticians and podiatrists
• quality monitoring through audit and patient
  feedback
• continuing education for professional staff.

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Routine diabetic review

• Ideally occurs every 6 months , or according to
  need.
• Should include
• 1. Problems review
• recent life-events
• new symptoms
• difficulties with management since last visit.

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Routine diabetic review

• 2. Review of -
• self-monitored results (and discussion of their
  meaning)
• dietary behaviours
• physical activity
• smoking
• diabetes education,
• skills and foot care
• blood glucose,
• Lipid and BP therapy and results
• other medical conditions and therapy affecting DM.

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Routine diabetic review

• 3. Management of
• arterial/foot risk factors complications.
• 4. Analysis and planning
• agreement on the main points covered, targets for
  coming months, changes in therapy, interval to
  next consultation.
• 5. Recording
• completion of structured record patient-held
  record.

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Annual Review

• As for routine review plus
• 1. Review of any symptoms of IHD, peripheral
  vascular disease,
• neuropathy or erectile dysfunction.
• 2. Review of foot problems footwear,
  deformity/joint rigidity,
• poor skin condition, ischaemia,
  ulceration, absent pulses,
• sensory impairment.
• 3. Eyes visual acuity and retinal review.
• 4. Kidney damage albumin creatinine ratio or
  dipstick for
• microalbuminuria.

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Annual Review

• 5.Arterial risk blood glucose, BP, blood lipids
  and smoking.
• 6.Review of services the patient is
  receivinghospital diabetic clinic, cardiology,
  podiatry, etc.
• Note
• 710 of patients in long-term residential care
  have DM.
• The care of this group is suboptimal.
• Agree a diabetes care plan for each affected
  resident and ensure at least annual diabetic
  review.

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Diabetes care Education

• Topics to cover
• General knowledge, Knowledge of DM,
• its progressive nature, complications and aims of
  management
• structure of diabetic services and ways to access
  them
• free prescriptions for patients requiring drugs
  or insulin to control their diabetes problems of
  pregnancy (for young women).

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Diabetes care Education

• Diet
• Patients do not need a separate diet from the
  rest of the family or expensive diabetes food
  products.
• A diabetic diet is a healthy diet. 50 of calorie
  intake should be from fibre-rich carbohydrate,
  with a minimum of fat (especially saturated fat),
  refined carbohydrate and alcohol.
• Adjust total calorie intake according to desired
  BMI.
• Recommend at least 5 portions of fresh fruit or
  vegetables/d.
• Spread food intake evenly across the day for
  patients controlled with tablets or diet.
• Ready made meals, processed foods, alcohol are
  often sources of hidden sugar.

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Diabetes care Education

• Immunizations
• Offer influenza vaccine to all diabetics
• and pneumococcal vaccine if gt55y. old.
• Psychological problems
• Education about concerns underlying the diagnosis
  of DM or development of complications.
• Counselling as needed.

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Diabetes care Education

• Exercise
• Review activity at work and in getting to and
  from the workplace,
• hobbies and physical activity in the home
• advise physical activity can ? insulin
  sensitivity, ? BP and improve blood lipid
  control
• if appropriate suggest regular physical activity
  tailored to individual ability (e.g. brisk
  walking for 30min. / day exercise prescription).
  
• Smoking
• Advice on smoking cessation.

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Diabetes care Education

• Employment
• Advise those on insulin that certain jobs are no
  longer possible
• working on scaffolding or with dangerous
  machinery,
• joining the Police or the Armed Services
• or driving a heavy goods or public service
  vehicle.
• Jobs without these hazards should pose no
  problems though the patient might wish to tell
  his/her employer.
• Special advice may be needed for shift work.

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Diabetes care Education

• Travel
• Management of change in time zones, transport of
  insulin and monitoring and injection equipment in
  hand-luggage
• differences in insulin types and concentrations
  between countries
• travel related illness (especially
  gastroenteritis)
• need for immunisation and travel insurance.

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Diabetes care Indices of control

• All patients can achieve good levels of control.
• Poorer control is acceptable in the elderly or
  others with limited life expectancy as long as
  they are symptom free.
• Blood monitoring Essential for all patients using
  insulin and desirable for many on oral
  medication.
• Explain the range of suitable monitoring devices
  available and train in the use of the selected
  method.
• Frequency of self-monitoring varies according to
  need.

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Diabetes care Indices of control

• Set targets for pre-prandial glucose levels.
• Assess skills (and meters if used) yearly or if
  problems with self-monitoring.
• Evaluate reliability of results by comparison
  with HbAlc results and results obtained at
  review.
• Glycosylated haemoglobins (HBA1c)
• Measure at least 2 times / y ear.
• Represent an average of blood sugar control over
  the previous
• 6 8 weeks . (Fructosamine previous 24
  weeks).

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Indices of control

• Measure
  Target
• ____________________________________________
• Fasting blood glucose
  (110mg)
• __________________________________________________
  ________
• Urine
  -ve
• __________________________________________________
  ________
• HbAlc (normal 4.06.0)
  lt7.0
• __________________________________________________
  ________
• Serum cholesterol lt200
• __________________________________________________
  ________
• BMI (kg/m2)
  2530
• __________________________________________________
  ________
• B P
  130/80

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Diabetes care

• Treatment of
• Type 2 diabetes

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Healthy eating and exercise

• Diet is the cornerstone of diabetic treatment.
• In type 2 DM it should always be tried alone
  before medication is considered.
• An adequate trial is normally considered to be 3
  months.
• Increasing physical activity is also beneficial
• (? weight, ? lipids and ? insulin sensitivity)
  though not always possible.

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Oral hypoglycaemic agents

• Sulphonylureas
• Safe and effective.
• 1st line oral treatment for non-obese patients.
• Augment insulin secretioneffective only if there
  is some residual endogenous insulin production.
• All are equally effective.
• They should be taken before meals warn patients
  about possible hypoglycaemia if meals are
  omitted.

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Oral hypoglycaemic agents

• Start at the minimum dose and ? until either
  blood sugar is controlled or the maximum dose is
  reached.
• Wait l mo. between dose adjustments.
• Main side effect is weight gain.
• If one sulphonylurea does not workanother is not
  likely to either.

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Oral hypoglycaemic agents

• Metformin
• Biguanide
• 1st line oral treatment for obese patients
  (BMIgt25).
• Acts by ? gluconeogenesis and ? peripheral
  utilization of glucose.
• Only effective if some endogenous insulin
  production.

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Oral hypoglycaemic agents

• Avoid in very elderly patients, those with
  serious heart disease, liver or renal failure or
  high alcohol intake as they have ? risk of lactic
  acidosis.
• Hypoglycaemia is not a problem.
• Start with the minimum dose and ? monthly until
  control is achieved or maximum dose reached.

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Oral hypoglycaemic agents

• Repaglinide
• Very short acting insulin secretagogues.
• They have rapid onset of action and half-life of
  less than an hour.
• Improves post-prandial glucose profiles only.
• Taken immediately before meals and omitted if the
  patient does not eat.
• In theory causes less hypoglycaemia though yet to
  be proven.
• Particularly useful in patients whose FGL are
  well controlled but have high PPV OR eat few or
  irregular meals
• Generally used in combination with metformin.

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Oral hypoglycaemic agents

• Acarbose (alpha-glucosidase inhibitor)
• ? carbohydrate absorption from the gut decreasing
  post-prandial hyperglycaemia.
• Unacceptable to many patients (causes severe
  flatulence).

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Oral hypoglycaemic agents

• Thiazolidinediones (e.g. pioglitazone)
• Cause ? insulin secretion, ? insulin
  sensitivity and have beneficial effect on blood
  lipid profile.
• Guidance suggests use in combination preferably
  with metformin but if that is not possible, a
  sulphonyurea only if metformin and/or
  sulphonylurea treatment alone and combination
  therapy with metformin and a sulphonylurea have
  been ineffective or impossible to use due to
  contraindications or side effects.
• Do not use in combination with insulin.
• Check liver function tests before starting
  treatment and every 2mo. in the 1st year of
  treatment then 6l2mo. thereafter.

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• Aminoacid derivative
• D-phenyl alanine eg. Nateglinide

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Oral hypoglycaemic agents

• Drug combinations
• Any groups of drugs listed above can be used in
  combination.
• Insulin, sulfonylurea, and meglitinides all
  increase insulin levels. They can be used
  together, but are more efficiently used with
  metformin, a TZD, or an a glucosidase
  inhibitors
• Most (except rosiglitazone) can also be used in
  combination with insulin if diet, exercise, and
  mono-therapy are ineffective.

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Indications for referral to specialist diabetic
services to start insulin

• Continuing weight loss and/or persistent
  symptoms
• Non-obese patients who are on -maximum oral
  therapy but still have poor diabetic control
• Obese patients on maximal oral therapy but with
  poor control may benefit from insulin though
  insulin causes weight gain. A concerted effort to
  lose weight is preferable but not always
  achievable
• Patients planning pregnancy.

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Diabetes care Insulin

• First line treatment for type 1 DM
• and used when diet oral therapy have failed for
  type 2 DM.
• Starting a patient on insulin is usually done by
  a specialist clinic with ongoing care.
• Calculated dose of insulin is 0.5 -1.0 u /Kg/day

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Diabetes care Insulin

• Monitoring
• Ask patients to keep a written diary of blood
  sugar values and time and date they are taken.
• Advise patients to measure their blood sugar
  pre-prandially
• 1 x /d. at different times of the daymore
  often if using multiple injection regimes, after
  dose changes or during inter-current illness.
• Record episodes of hypoglycaemia.
• Target Blood glucose 47mmol/l (80 126mg)
  pre-meals with hypoglycaemic episodes kept to a
  minimum.

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Diabetes care Insulin

• Administration
• Deep sc injection into upper arm, thigh, buttock
  or abdomen.
• Fat hypertrophy and scarring are minimized by
  rotation of injection sites.
• Pen devices and conventional syringe and needle
  are equally effective.
• In all cases prime the needle using an air shot
  (an empty needle ? insulin dose by 2u).
• Rock pens containing pre-mixed insulins to mix
  contents before use.

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Diabetes care Insulin

• Common injection regimes
• Intermediate short-acting insulin od (type 2
  only)
• Short intermediate-acting insulin bd (main and
  pre-evening meal)
• Short intermediate-acting insulin, short-acting
  insulin before evening meal and
  intermediate-acting insulin before bed
• Short-acting insulin tds pre-meals and
  intermediate-acting insulin before bed
• Combinations of oral therapy and od or bd long or
  intermediate-acting insulin.

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Diabetes care Insulin

• Exercise
• ? insulin dose acting at the time of exercise or
  take 12 glucose tablets before exercise then
  check blood glucose afterwards.
• Adjust alterations/glucose dose with experience
  of effects of exercise.
• ? absorption of insulin from a limb site occurs
  if the limb is used in strenuous exercise
  following injection.

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Diabetes care Insulin

• Inter-current illness
• Continue insulin in usual dose.
• Keep a regular check (qds) of blood sugar.
• If gt l3mmol/l (gt 230mg) ? insulin by 2u/d. until
  control is achieved or use top up injections of
  short-acting insulin qds prn.
• Maintain glucose intake even if not eating (with
  Lucozade, milk or similar).
• Admit to hospital if condition warrants
  admission unable to take glucose persistent
  vomiting, dehydration ketotic (check urine if
  blood sugar gtl3mmol/l).

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Diabetes care Insulin

• Poor control
• Exclude inter-current illness.
• Consider diet.
• Check insulin is being used as directed and
  injection sites are not scarred or hypertrophic.
• Consider changing insulin dose
• ask the patient to record a glucose profile
  (blood sugar pre-meals and before bed)
• if using gt1 insulin adjust 1 at a time
• alter by l0 each time
• allow 48h. between dose adjustments
• alter dose of insulin acting at the time the
  blood sugar is most out of control
• if blood sugar is too high, ? insulin dose and
  vice versa.

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Hypoglycaemia

• Emergency management
• Advice for patients
• Check blood sugar before driving and every 2h.
  during a long journey
• carry glucose everywhere and sandwiches on long
  journeys
• if hypoglycaemia occurs stop hazardous activities
  and take evasive action
• wait until fully recovered before resuming.

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Hypoglycaemia

• In case of severe hypoglycaemia
• Supply a responsible member of the family with
  glucose gel (e.g. Hypostop) and glucagon
  injectionteach him/her to use it.
• Response is short-livedgive oral glucose (e.g.
  lucozade, glucose tablets, milk) as soon as the
  patient is conscious.
• Recurrent hypoglycaemia
• If occurs in a regular pattern check pattern of
  meals and activity and alter insulin to match
  needs
• if erratic consider erratic lifestyle, alcohol,
  problems with absorption, errors in
  administration, gastroparesis
• if no obvious cause, consider change in
  underlying insulin sensitivity (e.g. age, renal
  impairment).

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Hypoglycaemia

• Hypoglycaemia unawareness
• Associated with human insulins (but can occur
  with any).
• To restore warning signs adjust insulin and food
  intake to stop glucose levels dropping to lt4
  mmol/l.
• Consider undetected night-time hypoglycaemia
  (HbAlc lt expected from blood sugar diary).
• Driving is not permitted when hypoglycaemic
  awareness has been lost.