DIABETES Dr. Hanin Osama

Diabetes Type I—beta cells destroyed by autoimmune process Type 2—decreased insulin production and decreased sensitivity to insulin

Management 1. Nutritional 2. Exercise 3. Monitoring 4. Pharmacologic 5. Education 6. Management of complications

1. Dietary Management Carbohydrate 45-65% total daily calories Protein-15-20% total daily calories Fats—less than 30% total calories, saturated fats only 10% of total calories Fiber—lowers cholesterol, increase satiety and has slow absorption Diet must be consistent, well-balanced small meals several times per day

2. Exercise Exercise increases uptake of glucose by muscles and improves utilization, alters lipid levels, increases HDL and decreases TAG and total cholestrol If on insulin, eat 15g snack before beginning Check BS before, during and after exercise if the exercise is prolonged

3. Monitoring Glucose monitoring Patients on insulin should check sugars 2-4 times per day before meals and 2 hours after meals Not on insulin, two or three times per week HGB A1C Measures blood levels over 2-3 months Ketones Check in pregnancy During illness If BS >240

4. Pharmacological treatment Insulin therapy used in: Type 1 diabetes Basal bolus insulin and mealtime rapid-acting insulin analog Daily insulin should include intermediate or long acting insulin If poor control—check 2h postprandial Type 2 diabetes When the patient is resistance to oral treatment (evaluate after 3months) or developed ketosis. Insulin is administered IV, IM, S/C (not orally) Types of insulin: Rapid acting—lispro Short acting—Regular, crystalline insulin Intermediate insulins—NPH or Lente. Long acting—Humulin Ultralente.

Oral Hypoglycaemic Medications

5. Education Education is critical Simple pathophysiology Treatment modalities Recognition, treatment and prevention of acute complications When to call the doctor Foot care, eye care, general hygiene, risk factor management

6. Management of Complications Acute Complications of Diabetes 1. Hypoglycemia 2. DKA 3. HHNS Long term complications 1. Macrovascular complications Coronary artery disease Cerebrovascular disease Peripheral arterial disease 2. Microvascular complications Diabetic nephropathy Diabetic retinopathy Diabetic neuropathy

1. Hypoglycemia RBS or less If the patient is conscious give oral sugar, recheck RBS 15 minutes, if still low or the symptoms persist take oral sugar again. If patient is unconscious give IV dextrose D50W (if not available give D10W) followed by infusion of 5% dextrose in water Glucagon 1 mg by subcutaneous, intramuscular, or intravenous route; followed with oral or intravenous carbohydrate Monitor the patient’s response physically and also blood glucose level Continue treatment until blood sugar returns to normal

2. Diabetic Ketoacidosis Hyperglycemia, Dehydration and electrolyte loss and Acidosis Management 1. Fluid therapy and correct electrolytes Rehydrate with NS, then SWITCH to D5W when RBS <250 Initially the patient is hyperkalemic, as patient is rehydrated and given insulin, the potassium move intracellular the patient become hypokalemic. Give K if the initial level ≤ 5 Monitor K levels/4hrs ECG monitoring.

2. Correct hyperglycemia Hourly random blood sugar, IV/IM regular insulin 3. Acidosis Corrected automatically when treating dehydration and hyperglycemia Avoid bicarbonate unless severe acidosis 4. Treat underlying infection if present

3. Hyperglycemic Hyperosmolar Nonketotic Syndrome Characterized by Plasma osmolarity 340 mOsm/l or greater- normal Blood glucose severely elevated, Altered level of consciousness Management Similar treatment as seen in DKA but half the doses are required Admitted to intensive care unit Correct dehydration Potassium is added at a level of 5 mmol/L or less, monitor ECG

Regular insulin: Although immediate treatment with insulin is contraindicated in the initial management of patients with HHS. Begin a continuous insulin infusion of 0.1 U/kg/h after correction of dehydration Treat underlying condition In high risk patients give prophylactic heparin

Macrovascular Complications 1. Management of coronary artery disease Modify/reduce risk factors Smoking cessation Dyslipidemia needs to be addressed—goal of LDL 40 in men and >50 in women, TG 400 Control of blood sugars Control BP ARB or ACE inhibitor Antiplatelet Beta blocker/ CCB Nitrates

2. Management of cerebrovascular disease Life style changes Smoking cessation Control of blood sugar/BP Statin Fibrinolytics if within 3 hrs from presentation Antiplatelet

3. Peripheral vascular disease Life style changes Exercise Smoking cessation Control of blood sugars/BP Statin Surgery in severe cases

Microvascular Complications 1. Retinopathy Diabetic retinopathy-leading cause of blindness in those Need regular eye exams Control BP, control blood sugar and cessation of smoking 2. Nephropathy Medical management: Control BP (ACE or ARB) Treatment of UTIs Avoid nephrotoxic agents, contrast dyes Low sodium diet, Low protein diet Tight glycemic control If developed ESRF need renal replacement therapy (dialysis or renal transplant)

3. Neuropathies Includes peripheral, autonomic Two most common types of peripheral neuropathy are: sensorimotor polyneuropathy and autonomic neuropathy. A. Peripheral neuropathy Pain management: in the form of TCAs, phenytoin, Tegretol, Gabapentin, and Transcutaneous Electrical Nerve Stimulation (TENS). B. Autonomic Neuropathies Monitor BP frequently for s/s orthostatic hypotension Low fat diet, frequent small meals, close blood sugar monitoring and use of prokinetic medications can help in GI symptoms

Diabetic foot Management Teaching patient foot care-inspect feet and shoes daily Examine feet every time goes to doctor See podiatrist at least annually Closed toe shoes Trimming toenails Good foot hygiene

Glycemic control is the key to preventing complications

GOOD LUCK