1 Diabetes Mellitus Guideline Adopted from: American Diabetes Association. Palestinian Diabetic Guidelines. 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 Ministry of Health Family Practice Residency Training Program
2 Diabetes mellitus Guideline Clinical characteristics of Diabetes mellitus type 1 & type 2……….. 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 Classification of Diabetes Mellitus …....page 3 Contents: Management of complications ………..page 25
3 Clinical characteristics of Diabetes mellitus type 1 & type 2 Classification of Diabetes mellitus Type 1 Diabetes Type 2 Diabetes Gestational Diabetes Other types Characterized by β-cell destruction and absolute insulin deficiency Characterized by insulin resistance and relative insulin deficiency Diabetes Mellitus with onset or first recognition in pregnancy Diabetes caused by other identifiable etiologies.
4 Screening for Type 2 Diabetes Mellitus Diagnostic criteria for Type II DM DiabetesImpaired glucose tolerance NormalBiochemical Index >7mmol/L >126 mg/dl 6.9-6.1 mmol/L 111-125 mg/dl < 6.1mmol/L 110 > mg/dl FBG >11.1mmol/L >200 mg/dl 7.7-11mmol 140-200mg/dL <7.7 mmol/L < 140 mg/dL 2hr OGTT > 11.1mmol/L (>200mg/dl + symptoms)Random PG
5 CHART FOR DIAGNOSIS OF DIABETES MILLETUS Fasting venous plasma glucose (FBG) Random plasma glucose> 11.1mmol/dl+ symptoms or < 6.1mmol/dl6.1- 7mmol/dl > 7 mmol/dl Repeat FBG Within a week Diabetes unlikely Repeat FBG Within a week Diabetes mellitus If FBG 6.1mmol/dl-7mmol/dl If FBG >7mmol/dl Diabetes mellitus Perform 75 gram OGTT Within a week FBG=6.1-7 mmol/dl Impaired fasting glucose 2h-PG=7.7-11.1 mmol/dl Impaired Glucose tolerance test FBG>6.1 mmol/dl Or 2h-pg 11.1mmol/dl Diabetes mellitus FBG<6.1mmol/dl Or 2h-pg <7.7mmol/dl Normal
6 Clinical assessment of Diabetes Mellitus Initial visit page 7 Continuing care page 9 Referral page 12
7 Initial visit History 1. Review patients records for the following: 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 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.
9 Continuing care History Physical examination Self Measurement of Blood Glucose See Appendix 1: Diabetic Sheet
10 Continuing care Laboratory evaluation 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)
16 Exercise Increase energy expenditure with moderate energy exercise Types of exercise: aerobic 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.
18 Initial presentation (based on presentation of the items listed within each box) Mild or no symptoms Negative ketones AND No acute concurrent illness FPG > 200* OR Random > 300* AND Does not meet criteria for mild or severe 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 MNT and Physical Activity Start Oral Anti-hyperglycemic Therapy 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 Initial Visit Management 6-8 weeks
19 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 BMI 30 Monotherapy Start either 1-Glibenclamide 5-10 mg once daily, increasing dose to maximum daily dose 20 mg (two divided doses 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 Monotherapy Start Metformin 850 mg daily, increasing dose over 3-4 weeks( maximum daily dose 850 mg three times daily) 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 Continue regimen & follow every 3 months 2- 4 months Repeat HbA1c Reassess lifestyle change to maximum benefit Is blood glucose controlled YesNo Continue regimen & follow every 3 months Yes 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 Is blood glucose controlled YesNo Continue Regimen Switch to insulin Therapy 1-4 times daily No (non-obese) Yes (obese)
20 Oral Hypoglycemic Agents PrecautionsSide effectsDoseDrug Hypoglycemia in elderly. Patient with hepatic & renal insufficiency Breast feeding Gastrointestinal disturbances headache Initially 5 mg daily (elderly 2.5mg) Max. dose 15 mg daily with breakfast Glibenclamide Daonil Initially 2.5-5 mg daily (elderly 2.5mg) Max. dose 40 mg daily before breakfast in divided doses Glipizide Minidiab Patient with hepatic & renal insufficiency Breast feeding Gastrointestinal disturbances headache Initially 40-80 mg daily (up to 160mg as single dose) Max. dose 320 mg daily in divided doses Gliclazide Diamicron Patient with hepatic & renal insufficiency Anorexia, nausea, vomiting, diarrhea, decrease in vit. B absorption, Lactic acidosis 500 mg every 8 hours or 850 mg /12 hours with or after food. Max. dose 2g daily Metformin Glucophage Patient with hepatic & renal insufficiency Breast feeding Dizziness, Asthenia, Headache, nausea 1-2 mg once daily with breakfast. Max. dose 8 mg daily Glimepiride Amaryl Monitor liver function, risk of heart failure, renal impairment GI disturbances, headache, anemia, fatigue, wt. gain, dizziness 4 mg daily in combination with a sulphnylurea or metformin) increase to 8 mg in 1-2 divided doses after 8 weeks Thiazolidine- diones Rosiglitazone (Avandia) 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
21 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 DURATIONPEAKSONSETTYPE 4-6 hrs2-3 hrs30-60 mintREGULAR (SHORT) 12-18 hrs6-10hrs2-4 hrsNPH (INTERMEDIATE) 16-20 hrs4-12hrs3-4 hrsLENTE (INTERMEDIATE) 20-30 hrsMini peaking6-10 hrsULTRALENATE <5 hrs30-90 mint<15 mintLISPRO(HUMALOG) 18 to 26 hourspeakless 1.5 hoursLantus(Glargine) 18-24hrs2-3 hrs and 8- 12hrs 15-30 mintPremixed(70/30) Human Insulin Activity
22 Action If blood glucose is usually too high 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 Before breakfast reduce delayed PM dose. Before lunch reduce AM short acting. Before evening meal reduce AM delayed dos or pre-lunch short acting. TimeAction If blood glucose is usually too low N.B changes in dose should be by 2U or 10% of the dose at a time. Time Action
23 Sites for insulin injection Preparing for injection 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 dont 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.
24 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.
25 GIVING THE INJECTION 1 2 3 4 Failure of insulin therapy Undetected psychosocial problems. Inter-current illness. Poor injection Tech or sites. Change eating habits. Consider
26 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. 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.
27 Management of Diabetic Nephropathy See attached screening guidelines for nephropathy
28 Diabetic Foot Care Hygiene of the Feet 1.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. 2.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. 3.If the feet become too soft and tender, tub tem with alcohol about once a week. 4.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. 5.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). 6.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)Wear shoes that fit properly and cause no friction or pressure. (2)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. (3)Do not cut corns or calluses. Aids in Treatment of Impaired Circulation (Cold Feet) (1)Never use tobacco in any form. (2)Keep warm. Wear warm stockings and other clothing. (3)Do not wear circular garters, which compress blood vessels and. Reduce blood flow. (4)Do not sit with the legs crossed. (5)Place a pillow under the covers at the foot of the bed. (6)Do not apply any medication to the feet without directions from a physician. (7)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.