2554

1.
2.
3.
4.
5. (eGFR)
6.
7.
8.
9.
10.
11. Diabetic ketoacidosis
12.

1
5
6
11
18
23
32
36
42
52
60
64
72
82
87
92
95
99
100
102
105
108
110
112
116
117
120
123
128

..

(Strength of Recommendation)
++
(cost effective)
+

+/-

- -

(Quality of Evidence)
1
1.1 (systematic review) (randomized-controlled clinical trial)
1.2 - 1 (welldesigned randomized-controlled clinical trial)
2
2.1 (non-randomized
controlled clinical trial)
2.2
(well-designed non-randomized
controlled clinical trial)

2.3 (cohort)
(case control analytic studies)
/
2.4 (multiple time series)


.. 2480

3
3.1 (descriptive studies)
3.2 (fair-designed controlled clinical trial)
4
4.1

(consensus)
4.2
2
(anecdotal report)

1 (screening test)


(high risk screening strategy)
1 2

2


2
1.
(prevalence cross-sectional study)
(prevalent case)
(screening)
3 3 , (body
mass index, BMI)
(risk score)
risk score = (3 x ) + (5 x BMI) + (50 x )
BMI ./.2 0 (
) 1 () score 240
(
) (risk score)
(sensitivity) 96.8 (specificity) 24 positive predictive value negative
predictive value 17.8 97.8
2.
(cohort incidence study) (incident
case) (prevalent case)
incident diabetes

prevalent diabetes


(lifestyle intervention lifestyle modification)
30
6 (incident diabetes) 40-604-6 ( 1,
++) 7
1. 2 8

Diabetes risk score

34 39
40 44
45 49
50

0
0
1
2

23 ./.2
23 27.5 /.2
27.5 ./2

90 . 80 .
90 . , 80 .

( )

0
2
0
3
5
0
2
0
2
0
4

cohort study8
1

(risk score) ( 12
)
( ++)
0-17
2
2. 2

12
5
2

1/20

3-5

5-10

1/12

6-8

11-20

1/7

20

1/3 1/4

-
-

-
- 3
-
-

-
- 1-3
-

-
-
- 1-3
-

-
-
- 1

2
(prevalent case screening)

(incident case screening)

1. (). 4 ..
2551-2552. : / ; 2553.
2. . : ,
(.) 2550.
2550, 1-16
3. Keesukphan P, Chanprasertyothin S, Ongphiphadhanakul B, Puavilai G. The development and validation
of a diabetes risk score for high-risk Thai adults, J Med Assoc Thai 2007; 90: 149-54.
4. Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. Effects of diet and exercise in preventing
NIDDM in people with impaired glucose tolerance: the DaQing IGT and Diabetes Study. Diabetes Care
1997; 20: 537-44.
5. Tumilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, llanne-Parikka P, et al. Prevention of
type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J
Med 2002; 344: 1343-50.
6. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the
incidence of type 2 with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393-403.
7. Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, et al. The long-term effect of lifestyle
interventions to prevent diabetes in China Da Qing Diabetes Prevention Study: a 20-year follow-up study.
Lancet 2008; 371: 1783-9.
8. Aekplakorn W, Cheepudomwit S, Bunnag P, et al. A risk score for predicting incident diabetes in the Thai
population. Diabetes Care 2006; 29: 1872-7.

4
1. 1 (type 1 diabetes mellitus, T1DM)
2. 2 (type 2 diabetes mellitus, T2DM)
3. (other specific type)
4. (gestational diabetes mellitus, GDM)

(provisional diagnosis)
/

1 30

(ketonuria) (ketoacidosis)
- (C-peptide) /
Anti-GAD, ICA, IA-2
2 95
30

2 acanthosis nigrican,
polycystic ovarian syndrome

2 : , ,
. Diabetes Mellitus. 1. : 2548; 1-19.
2American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010; 33 (Suppl 1):
S62-S69.

( 1)
1-5
( 2, ++)
1 ) 35
2) (BMI 25 ./.2 / )

3)
4)
5) 4 6)
impaired glucose tolerance (IGT) impaired fasting glucose
(IFG)
7) (cardiovascular disease)
(waist circumference) 90
80

2 10

7
fasting capillary blood glucose

fasting plasma glucose

fasting plasma glucose

100 ./.

fasting capillary blood glucose

100 ./.

fasting plasma glucose 3

fasting plasma
glucose 126 ./.

Fasting plasma glucose

1

Impaired fasting glucose

1.
2. fasting plasma glucose
1-3

8.
35
9.
*
10.

11.
( 250 ././
(<35./.)
12.
4
13.
IGT IFG
14.
(cardiovascular disease)
* BMI 25./.2 / 90 . 80
.

1. ()

(fasting plasma
glucose, FPG) FPG fasting capillary blood glucose ( ++)
FPG 126 ./. FPG 126 ./.
( 1) FPG 100-125 ./. IFG

FPG 1-3
capillary blood glucose
FPG ( ++) capillary
blood glucose 110 ./. FPG3
capillary blood glucose capillary blood
glucose 110 ./. 3
3 ( 2, ++)

1.

200 ./.
2. 8 (FPG) 126
./.
3. (75 g Oral Glucose Tolerance Test, OGTT)
FPG 126 ./. (
2) 2 200 ./.

1
1.
(FPG)
FPG < 100 ./.
=

FPG 100 125 ./.

=
Impaired fasting glucose (IFG)
FPG 126 ./.
=

2 75 (75 g OGTT)
2 h-PG < 140 ./.
=

2 h-PG 140 199 ./.

=
Impaired glucose tolerance (IGT)
2 h-PG 200 ./.
=

HbA1c
standardization quality control HbA1c

4,5

( 1, ++)


glucocorticoid
()


()
(carotid bruit)
(diabetic retinopathy) (diabetic nephropathy)
(diabetic neuropathy)
1 5
FPG, HbA1c, total cholesterol,
triglyceride, HDL-cholesterol, ( LDL-cholesterol LDL-cholesterol), serum creatinine,
(urinalysis) urinalysis
microalbuminuria
(ECG)

American Diabetes Association. Position statement. Diagnosis and classification of diabetes mellitus. Diabetes
Care 2010; 33 (Suppl 1): S62-S69.
Kahn R, Alperin P, Eddy D, Borch-Johnsen K, Buse J, Feigelman J, et al. Age at initiation and frequency of
screening to detect type 2 diabetes: a cost-effectiveness analysis. Lancet 2010; 375: 1365-74.
.
: "
". , 2553; 17-46.

10

Puavilai G, Kheesukapan P, Chanprasertyotin S, et al. Random capillary plasma measurement in the screening
of diabetes mellitus in high risk subjects in Thailand. Diabetes Res Clin Pract 2001; 51: 125-31.
American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33 (Suppl 1):
S11-S61.
Clinical Guidelines Task Force. Global guideline for type 2 diabetes. International Diabetes Federation 2005.

11

(lifestyle modification)


1

HbA1c 1-2 %2 3-6

(medical nutrition therapy) 1
1.
/
( ++)

5-7 ( ++)

1 ( ++)



(maintenance of weights loss) (
+)

12

( +)

7
(intensity) 150 /

3,4 ( ++)
glycemic index
14 1000

(
++)
50-55

< 130 / ( )

( ++)
glycemic index glycemic load
( +)


( ++)
( ++)
sorbitol, xylitol mannitol
5
50 . 1 . ( ++)

30-35
7 (
++)

13

1
(
++)

300 ./ (
++)
2 / 3 (
++)

15-20
( +)

( ++)
( -)

1 / 2 /
( +) 1
45 . 360 . 120 .6

( +)

( ++)

( -)

( +)

( -)

14

/
1

( +)

( +)

( +)


10-12

( ++)

ketosis
( +)

(
+)

( ++)

( +)

0.8 //
0.6-0.8 //
( ++)

15

( ++)
2000
./ ( ++)

2300 ./
(
++) 1 1160-1420 . 1
960-1420 . 1 492 .
1 2000 .7

(
+)

8,9



/
( ++)
( 2)
2 resistance 3 8-10 /
3 resistance ( ++)
2.

150 / (

50-70% )

75 / 3 /

2 ( ++)10
7

( +)10

16

9

3

9
( ++)
3.

ketosis

ketosis

<100 ./.

proliferative diabetic retinopathy (PDR) severe NPDR

resistance exercise



(peripheral neuropathy)

(nonweight bearing exercise)

17

1. Lifestyle management. In: Global guideline for type 2 diabetes. International Diabetes Federation 2005, p
22-5.
2.American Diabetes Association. Nutrition recommendations and interventions for diabetes 2006: a position
statement of the American Diabetes Association. Annual Review of Diabetes 2007, p 132-49.
3. Diabetes prevention program research group. Reduction of the incidence of type 2 diabetes with lifestyle
intervention or metformin. N Engl J Med 2002: 346: 393-403.
4. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in
lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344: 1343-50.
5. . . : .
, , , , .
2553, 35-55.
6. . :
21-24 2543.

7. .
. 2543; 62-3.
8. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity / exercise and
type 2 diabetes: a consensus statement from the American Diabetes Association. American Diabetes
Association. Annual Review of Diabetes 2007, p 167-72.
9. American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
10. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with
diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes
Association. Circulation 2007; 115: 114-26.

18

1-4
(empowerment)
5,6

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
1

(SMBG) 4

19

(
)

(diabetic
(hyperglycemic
ketoacidosis,DKA)
hyperosmolar non-ketoticsyndrome, HHNS)

1. /

20

21

1.
2.
3.

22

8.

Bodenheimer T, Davis C, Holman H. Helping patients adopt healthier behaviors. Clin Diabetes
2007; 25: 66-70.
9. American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
10.
Gary T, Genkinger J, Guallar E, Peyrot M, Brancati F. Meta-analysis of randomized educational
and behavioral interventions in type 2 diabetes. Diabetes Edu 2003; 29: 488-501.
11.
Steed L, Cooke D, Newman S. A systemic review of psychosocial outcomes following education,
self-management and psychological interventions in diabetes mellitus. Patient Educ Cons 2003; 51: 5-15.
12.
International Diabetes Federation Consultative Section on Diabetes Education. The International
Curriculum for Diabetes Health Professional Education. International Diabetes Federation 2006.
13.
. , ,
, , .
2553.

23

3 GLP-1 Analog 1
2


1-3

3
( 1)
a. (insulin secretagogue)
(sulfonylurea) (non-sulfonylurea glinide)
glucagon like polypeptide-1 (GLP-1) DPP-4 inhibitor
( glipin)
b. biguanide thiazolidinedione glitazone
c. (alpha-glucosidase inhibitor)

() genetic engineering
human insulin human
insulin (insulin analog)
4 ( 10)
1. (short acting regular human insulin, RI)
2. (intermediate acting insulin, NPH)
3. (rapid acting insulin analog, RAA)

4. (long acting insulin analog, LAA)

24

1.

HbA1c
1-2%

Metformin

1-2%

Sulfonylurea

1-2%

Glinide

1-1.5%

Thiazolidinedione 0.5-1.4%

Alpha-glucosidase 0.5-0.8%
Inhibitor (-Gl)
DPP-4 inhibitor
0.8%

/



serum creatinine 1.5 ./.









metformin
2-4
congestive heart failure

metformin thiazolidinedione


GLP-1Analog
1%



Insulin
1.5-3.5%

()
*

25

100 RI, NPH


GLP-1 Analog
GLP-1


exenatide
1,3-7
2
1

4
2.
2.1 HbA1c ()
2.2 ()
2.3
3. 1-4
HbA1c
2-6 3 ( 2,
++)
d.
2 ( 1)

( 2, ++)

4.1 Repaglinide:
(
2, +)

26

4.2 Thiazolidinedione:
metformin
serum creatinine > 1.5 ./. 6
( 2, +)
4.3 Alpha-glucosidase inhibitor: sulfonylurea
metformin ( 2, +)
130 ./.
4.4 DPP-4 inhibitor: sulfonylurea metformin
thiazolidinedione alpha-glucosidase inhibitor
( 2, +)
5. 2 (combination therapy)3,5
2
2
/
250-350 ./. HbA1c >9% 2
( +) 3
3 2
( 1) 2 3
5.1 Repaglinide: 2 3

( +)

5.2 Thiazolidinedione: 2
( 2, +)
3

5.3 Alpha-glucosidase inhibitor: 2 3

( 2,
+)
5.4 DDP-4 inhibitor: 2 3
( 2, +/-) /
thiazolidinedione

27

1-3

< 180 ./. HbA1c < 8%

180-250 ./.

250-350 ./.
HbA1c >9%
2

>300 ./.
HbA1c >11%

>300 ./.
HbA1c >11%

*
Metformin
Sulfonylurea
:
:
BMI 23 ./. BMI < 23 ./.

acanthosis nigricans

130/85 .

Elevated TG, low HDL-C

: Glitazone Repaglinide - GI DPP-4 inhibitor
2

Metformin
1. Sulfonylurea glinide

2. Thiazolidinedione
3. DPP-4 inhibitor
4. Basal insulin
: alpha glucosidase inhibitor

NPH LAA
(21.00 23.00 .)

2
premixed insulin
premixed insulin analog

RAA = Rapid Acting Insulin Analog

RI = Regular Human Insulin
NPH = Neutral Protamine Hagedorn Insulin
LAA = Long Acting Insulin Analog

Sulfonylurea
1. Metformin
2. Thiazolidinedione
3. DPP-4 inhibitor
4. Basal insulin

Premixed insulin
Premixed insulin analog

metformin

RI RI RI NPH or LAA RAA RAA RAA LAA or NPH

LAA () NPH
RI RAA

RI RI RI NPH ---

1. 2 (g metformin )

28

6. 2 basal insulin
( 2, ++)
6.1 basal insulin ( 10)
1. Intermediate acting insulin NPH 21.00-23.00 .
2. Long acting insulin analog (LAA) insulin glargine insulin detemir
insulin glargine
6.2 basal insulin NPH 0.1 - 0.15 unit/kg/day
2-4 3-7


NPH LAA
6.3 RI basal insulin
pre-mixed insulin 1-2

5 2
3 / 3-7
( 2, ++) RI basal insulin
pre-mixed insulin 1-2 1
6 1

( 2) 0.4-0.6 unit/kg/day
NPH basal insulin RI basal insulin 2 -

13.1
< 180 mg/dl 1-2
13.2
> 180 mg/dl 2-4

29
1
*

.
3.

4.
. ( )
.
7.

3
8.

.
0.
1.

RI RI RI NPH or LAA RAA RAA RAA NPH or LAA

(LAA )
RAA RI

3
RI/NPH 0 RI - NPH
4

RAA = Rapid Acting Insulin Analog

RI = Regular Human Insulin
NPH = Neutral Protamine Hegadon Insulin
LAA = Long Acting Insulin Analog
0 = None

2
RI/NPH 0 RI/NPH 0

3 4

1. -
2. 0.4-0.6 / 1 ./
basal insulin 2
1/3
3. >0.8 / 1 .
*1. 1 ( >15 ) 15

2. 5
3.

2. 1

30

1. 1
2. (diabetic ketoacidosis)
(hyperglycemic hypersmolar
nonketotic syndrome)
3. 2

a.

b.
2
c.

(malnutrition)
d.

e.

f.

4.
3.

American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
Clinical Guidelines Task Force. Global Guideline for type 2 diabetes. International Diabetes
Federation 2005.
American College of Endocrinology / American Association of Clinical Endocrinologists Diabetes
Road Map Task Force. Road maps to achieve glycemic control in type 2 diabetes mellitus. Endocr
Pract 2007; 13: 261-8.
Rydn L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer MJ, et al. Guidelines on
diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European
Association for the Study of Diabetes (EASD). Eur Heart J 2007; 28: 88-136.
Nathan Dm, Buse JB, Davidson MB, Ferranni E, Holman RR, Sherwin R, Zinman B. Management
of hyperglycemia in type2 diabetes mellitus: a consensus algorithm for initiation and adjustment of
therapy. Diabetologia 2008; 51: 8-11.

31

Bhattacharyya OK, Estey EA, Cheng AYY. Update on the Canadian Diabetes Association 2008
clinical practice guidelines. Canadian Fam Physicians 2009; 55: 39-43.

National Institute for Health and Clinical Excellence. NICE short clinical guideline 87. Type 2
diabetes: newer agents. London: May 2009. <www.nice.org.uk>

32

(self-monitoring of blood glucose, SMBG)

(empowerment)
SMBG
(capillary blood) (glucose meter)
SMBG SMBG
SMBG

SMBG1-4
1. SMBG
1.1 (pre-gestational
DM) (gestational DM) ( 1,
++)
1.2 1 ( 1, ++)
1.3 (hypoglycemia)
hypoglycemia unawareness ( 2, +)
2. SMBG
2.1 2 ( 1,
++)
3. SMBG
3.1 2 SMBG
/ SMBG

3.2
( 4, +/-)
3.3 SMBG

33

3.4 SMBG

SMBG
SMBG


1. SMBG 1-2 3

2. 3 SMBG 3
SMBG 2 .
2.00-4.00 .
3. 1 insulin pump SMBG 4-6
4. 2 SMBG 2


5. SMBG 4 4 6

6. 2 SMBG
3 / SMBG



6
: ( 3)
(finger prick device) 70%
:
1. 10-15

34

2.
25


(forearm) (thigh)
(palm)
3.
4.
5. ()

6.
7.
: 18-30
( 10-90)
(photometer)

SMBG
SMBG
SMBG

SMBG

SMBG

35

1.
2.

3.
4.

5.
6.

International Diabetes Federation. Guideline: Self-monitoring of blood glucose in non-insulin

treated type 2 diabetes 2009.
Towfigh A, Romanova M , Weinreb JE, Munjas B, et al. Self-monitoring of blood glucose
levels in patients with type 2 diabetes mellitus not taking insulin: A meta-analysis. Am J Manag Care.
2008; 14(7): 468-75.
Boutati EI, Raptis SA. Self-monitoring of blood glucose as part of the integral care of type 2
diabetes. Diabetes Care 2009; 32 (Suppl2): S205-S210.
Diabetes UK. Care recommendations: Self monitoring of blood glucose (SMBG). Accessed on
15 September 2010 from http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/Selfmonitoring_of_blood_glucose/
American Diabetes Association. Standard of medical care in diabetes 2010. Diabetes CARE.
2010; 33 ( Suppl 1): S11-S61.
, , .
. : 1. ,
, . . 2548, 81-106.

36

1,2
1. 1,2
HbA1c
<6.5% ( 1)

2. 3
HbA1c <7.0%
3.
4-6
( ++)
4. (
...)
1. 1-4

70-110 ./.
2 < 140 ./.

Hemoglobin A1c (% of total hemoglobin) < 6.5%

90-<130 ./.
< 180 ./.
< 7.0%

130 ./.
< 180 ./.
7.0 - 8.0 %

37

1-3 ( 2)

2. 1,2
/

< 170 ./.

< 100 ./.
< 150 ./.
40 ./.
50 ./.

**
(systolic BP)
(diastolic BP)

< 130 .
< 80 .

18.5-22.9 ./.
< 90 .
< 80 .

* LDL-C
70 ./.
7,8

** 140 .
110 . 70 .

1-4
3-6
1-3
/ HbA1c ( 1)

38

(
/)
()
HbA1c 1
(lipids profiles) 1

(
3)

HbA1c 3-6
(HbA1c )

HbA1c

1.

HbA1c

39

1,2,9-11
3

3.

HbA1c < 7%

*
*
HbA1c 7.0-7.9%
HbA1c 8%
hypoglycemia 3

**

proteinuria
1. microabuminuria macroproteinuria serum creatinine

serum creatinine = 2./. eGFR

Albumin/creatinine
1.5 ./. 30-59 >7
ratio < 30 /
eGFR 30-59 ml/min/1.73m2
.
<30
eGFR
2
2
ml/min/1.73m
7 ml/min/1.73m
retinopathy
y moderate NPDR severe NPDR
mild NPDR
y VA

PDR
macular edema
VA
hypertension
hypertension
angina pectoris

/ dyslipidemia hypertension
CAD myocardial
dyslipidemia
/ infarction
dyslipidemia CABG

CVA
heart failure
protective sensation peripheral
rest pain

neuropathy

gangrene
previous
peripheral pulse peripheral pulse
amputation

intermittent
claudication
*
**
eGFR12 = estimated glomerular filtration rate; NPDR = non-proliferative diabetic retinopathy; PDR = proliferative

40
diabetic retinopathy; VA = visual acuity; CAD = coronary artery disease; CABG = coronary artery bypass graft; CVA =
cerebrovascular accident

( ++)

1
microalbuminuria urine albumin/creatinine ratio 1 12


1 2 (1 45
. 120 . 360 .)

(
)

American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
Clinical Guidelines Task Force. Global guideline for type 2 diabetes. International Diabetes Federation
2005.
Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between glycemic
control and cardiovascular outcomes in diabetes. A cohort study. Ann Intern Med 2009; 151: 854-60.
Skyler JS, Bergenstal R, Bonow RO, Buse J, Deedwania P, Gale EAM, et al. Intensive Glycemic Control
and the Prevention of Cardiovascular Events: Implications of the ACCORD, ADVANCE, and VA
Diabetes Trials: A position statement of the American Diabetes Association and a scientific statement of

41

5.
6.

7.

8.

9.

the American College of Cardiology Foundation and the American Heart Association. Diabetes Care
2009; 32:18792.
Meier M, Hummel M. Cardiovascular disease and intensive glucose control in type 2 diabetes mellitus:
moving practice toward evidence-based strategies. Vasc Health Risk Management 2009; 5: 85971.
Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA1c in people with type 2 diabetes: a
retrospective cohort study. Lancet 2010; 375: 481-9.
Anderson RJ, Bahn GD, Moritz TE, et al. Blood pressure and cardiovascular disease risk in the Veterans
Affairs Diabetes Trial (VADT). Published online before print November 8, 2010, doi: 10.2337/dc101420, Diabetes Care.
Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular
outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010; 304: 61-8.
Mazze RS, Strock E, Simonson G, Bergenstal R. Macrovascular Diseases. In: Staged Diabetes
Management: a Systemic Approach, 2nd ed. International Diabetes Center. West Sussex, England. John
Wiley & Sons, Ltd 2004: 299-321.
.
( ). . - () ,
2553.
Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with
diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes
Association. Circulation 2007; 115: 114-26.
.. 2552.
2552

42

1,2

1.

2.

3.

3 (Whipple triad)
<70 ./.,

<70 ./.
<50 ./. <70 ./.
(glucose counter-regulatory
system)

2 (autonomic
symptom) (neuroglycopenic symptom)
4.

5.
cognitive
(hemiparesis)
(stroke),
1 2

43

(hypoglycemia
unawareness) 1,3,4,

4 1,2
1. Documented symptomatic hypoglycemia
<70
./.
2. Asymptomatic hypoglycemia
<70 ./.
3. Probable symptomatic hypoglycemia

4. Relative hypoglycemia
>70 ./.

3
1,5
1. (mild hypoglycemia)

2. (moderate hypoglycemia)

3. (severe hypoglycemia)

44

6-10 ( 4)

(insulin secretagogue) sulfonylurea glinide1,5
metformin, thiazolidinedione, dipeptidyl peptidase-IV inhibitor
glucagon-like peptide-1 receptor agonist (monotherapy)
-glucosidase inhibitor
(combination therapy)
1,5
1
4.
5.

6.
7. (endogenous hepatic glucose production)

8. (insulin sensitivity)
9. /
10.
11. HbA1c /

12.
13.

2
11 2

11

45

1,12



1.
15
30 11
15 3 180 . 180 . 3
1 240 . 2 1
15-20
2.
() 15-20

3.
15 <70 ./.
4.
>80 ./.
1
(snack) 15

5.

6.

( )

(complex
carbohydrate)

1. 1 .
2.

46

1. 1 .
2.

10-15
15
50%

50% ( 1)
1. 20 1
2. 10 .

( )
3.
4. 1 2 2
50% 50 . ( 25 )
10-20 .
5. 50% 10-20 .
50% 30-40 .
50% 50 .

6. 50%
50%
7.
50% 50 .
10%
(10%D) 2 ./ 1 ./ ( 60 ./
50 .) 80 ./
. 120 ./.

47

sulfonylurea

6
8.
10% (10%D) 2 ./ 1 ./
60 ./ 50 .
9. 10%D
10. 10%D
15-30
11. 10%D
10%D (
osmotic diarrhea )
sulfonylurea
octreotide 50-100 8-12
, diazoxide 100 . 8
dexamethasone 5 . 6

12.
10%D

13. 10%D
10%D (
10%D 5%D )
14.

15. 15-30
>80 ./. 3
(posthypoglycemic brain edema)


dexamethasone 5 .
6 / 20% mannitol 300 .

48

<70 ./.

, ,
, , , , ,
,
, ,
, cognitive ,
, , , , ,
, , , ,

(
)

-
15
3 , 180 ., 180
., 3 ., 1 , 1
,
15
15
<70 ./.

>80 ./.

:
() 0.5 . ( <5 ) 1 . ( >5
)
: ,
,
50% 10-20 . bolus
heparin saline lock
5-10%

15

>80
./.

1.

49

<70 ./. ( 2,
+)1
sulfonylurea
( 1,
++)1

(microvascular complication)
( 1, ++)1

(
2, ++)1
(diabetes care team)

(
1, ++)1
1 ( 1,
++)
1.
(regimen)
sulfonylurea glinide
2.
3. (self-monitoring of blood glucose, SMBG)
4. (diabetes self-management)

5.

50

6.
2-3 12
( 1, +)1

( 1, ++)1
15 38 ./. 20
20 65 ./. 45
30 5
15-30

1.

( 1, ++)
2.
2
50% ( 1,
++) 50%

( 1, +)

a. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ. Evaluation and
management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin
Endocrinol Metab 2009; 94: 70928.
b. American Diabetes Association Workgroup on Hypoglycemia. Defining and reporting hypoglycemia in
diabetes: a report from the American Diabetes Association Workgroup on Hypoglycemia. Diabetes Care
2005; 28: 1245-9.
c. Dagogo-Jack SE, Craft S, Cryer PE. Hypoglycemia-associated autonomic failure in insulin-dependent
diabetes mellitus. Recent antecedent hypoglycemia reduces autonomic responses to, symptoms of, and
defense against subsequent hypoglycemia. J Clin Invest 1993; 91: 81928.
d. Segel SA, Paramore DS, Cryer PE. Hypoglycemia-associated autonomic failure in advanced type 2
diabetes. Diabetes 2002; 51: 72433.

51

e. Yale JF, Begg I, Gerstein H, Houlden R, Jones H, Meheux P, Pacaud D. 2001 Canadian Diabetes
Association Clinical Practice Guidelines for the prevention and management of hypoglycemia in diabetes.
Can J Diabetes 2001; 26: 22-35.
f. Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest 2007; 117: 868870.
g. Laing SP, Swerdlow AJ, Slater SD, Botha JL, Burden AC, Waugh NR, et al. The British Diabetic
Association Cohort Study, II: cause-specific mortality in patients with insulin-treated diabetes mellitus.
Diabet Med 1999; 16: 46671.
h. Gerstein HC, Miller ME, Byington RP, Goff Jr DC, Bigger JT, Buse JB, et al. Effects of intensive
glucose lowering in type 2 diabetes. The Action to Control Cardiovascular Risk in Diabetes Study Group.
N Engl J Med 2008; 358: 254559.
i. Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, Woodward M, et al. for the ADVANCE
Collaborative Group. Severe hypoglycemia and risks of vascular events and death. N Engl J Med 2010;
363: 1410-8.
j. Desouza CV, Bolli GB, Fonseca V. Hypoglycemia, diabetes, and cardiovascular events. Diabetes Care.
2010; 33: 1389-94.
k. UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment
modalities and their duration. Diabetologia 2007; 50: 11407.
l. Fanelli CG, Epifano L, Rambotti AM, Pampanelli S, Di Vincenzo A, Modarelli F, et al. Meticulous
prevention of hypoglycemia normalizes the glycemic thresholds and magnitude of most of
neuroendocrine responses to, symptoms of, and cognitive function during hypoglycemia in intensively
treated patients with short-term IDDM. Diabetes 1993; 42: 16839.

52

/
(diabetic retinopathy) (diabetic nephropathy) 1-4

(diabetic retinopathy)

1. Non-proliferative diabetic retinopathy (NPDR) 3 (mild)

(moderate) (severe)
2. Proliferative diabetic retinopathy, (PDR)

3. Diabetic macula edema

NPDR


HbA1c PDR macula edema

5,6
( 1)

visual acuity
( 2, ++)
digital camera
( 4, ++)
1 5 12
1 ( ++)

53

2
( ++)

126 ./.

5
12

No DR

Mild NPDR

Moderate NPDR

3-6

Severe NPDR

PDR

1.

Macula edema

54

HbA1c 7%
( 1, ++) HbA1c 6.5%

(
++)
130/80
1,5,6
( ++)

1,7,8
( +)
severe NPDR PDR Macula edema
( ++)

( ++)

(
++)

( ++)


( ++)

( +)

55

3

( ++)
(diabetic nephropathy)
diabetic nephropathy
8-10 ( 1)
30-299
microalbuminuria
300
macroproteinuria (overt diabetic nephropathy)
11-12
( 2)
1 5
2
( 2,
++)
urine protein albuminuria
dipstick
macroalbuminuria macroproteinuria

dipstick urinary albumin
creatinine ratio (Alb/Cr) Alb/Cr 30-299 ./ dipstick
microalbuminuria microalbuminuria 20 ./
1-2 6 microalbuminuria 2
3
1. (estimated GFR, eGFR)12
serum creatinine ( 2, ++)
serum creatinine 5

56

12
urine protein
()

microalbuminuria albumin/creatinine ratio (Alb/Cr)

dipstick specific microalbumin

Alb/Cr 30-299 mg/g

microalbumin
dipstick > 20 mg/l

Alb/Cr < 30 mg/g

microalbumin
dipstick < 20 mg/l

Alb/Cr 300 mg/g

microalbumin
dipstick > 100 mg/l

1-2 6
2 3

serum Cr 2 mg/dL
eGFR < 60 ml/min

ACEI
ACEI ARB

microalbuminuria

2. (Alb/Cr = albumin creatinine ratio)

57

11,12
2. microalbuminuria
o

( ++)
o 130/80
( ++)
3. microalbuminuria (incipient nephropathy)
o

microalbuminuria (chronic kidney
disease, CKD) ( ++)
o 130/80
( ++)
angiotensin converting enzyme inhibitor (ACEI) angiotensin II receptor blocker
(ARB) ( ++)
o 0.8 (
++)
o
aminoglycoside
o

o diabetic retinopathy
4. macroalbuminuria (clinical or overt diabetic nephropathy)
o

130/80
( ++)
o

ACEI ARB
( ++)
o
diabetic retinopathy

58

o 60 //1.73 .2
serum creatinine 2 ./.
( ++)
5. (end stage renal disease)
o 30 /
( ++)

1. Chetthakul T, Deerochanawong S, Suwanwalaikorn S, et al. Thailand Diabetes Registry Project:

Prevalence of diabetic retinopathy and associated factors in type 2 diabetes mellitus. J Med Assoc Thai
2006; 89 (Suppl 1): S27-S36.
2. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications
Research Group. Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of
intensive therapy. N Engl J Med 2000; 342: 381-9.
3. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW. 10-Year Follow-up of intensive glucose
control in type 2 diabetes. N Engl J Med 2008; 359: 1577-89.
4. American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
5. .
( ). . - (),
2553.
6. Holman RR, Paul SK, Bethel MA, Neil HAW, Matthews DR. Long-term follow-up after tight control of
blood pressure in type 2 diabetes. N Engl J Med 2008; 359: 1565-76.
7. Keech A, Mitchell P, Summanen P, et al. Effect of fenofibrate on the need for laser treatment for diabetic
retinopathy (FIELD study): a randomized controlled trial. Lancet 2007; 370: 1687-97.
8. Ngarmukos C, Bunnag P, Kosachunhanun N, et al. Thailand Diabetes Registry Project: Prevalence
characteristics and treatment of patients with diabetic nephropathy. J Med Assoc Thai 2006; 89 (Suppl 1):
S37-S42.
9. National Kidney Foundation: K/DOQI Clinical practice guidelines for chronic kidney disease: evaluation,
classification and stratification. Am J Kidney Dis 2002; 39 (Suppl 1): S1-S266

59

10. Eknoyan G, Hostetter T, Bakris G, et al. Proteinuria and other markers of chronic kidney disease: a
position statement of the National Kidney Foundation (NKF) and the National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK). Am J Kidney Dis 2003; 42: 617-22
11. Kramer H, Molitch M. Screening for kidney disease in adults with diabetes. Diabetes Care 2005; 28:
1813-6
12. .. 2552.
2552

60

1,2

2 3

4 ( 1, ++)




peripheral arterial disease
albuminuria microalbuminuria macroalbuminuria
(Primary prevention)

130/80 . ( 2,
++)
120 .
140 .5

61

2,6

a. Angiotensin converting enzyme inhibitor (ACEI)

b. Angiotensin II receptor blocker (ARB)
c. Diuretics (low dose) hydrochlorothiazide 12.5-25 ./
d. Calcium-channel blocker
e. Beta-blocker
ACEI diabetic nephropathy ARB ACEI
ACEI ARB serum potassium serum creatinine
( 1, ++)
ACEI ARB ARB
ACEI
Beta-blocker tachyarrhythmias
Calcium-channel blocker

LDL-C4,6,7
100 ./.
LDL-C statin2,7,8
( 1, ++)
40 LDL-C 100-129 ./.

HDL-C triglyceride7

triglyceride 200-499 ./. non-HDL-C
2 LDL-C non-HDL-C 130 ./. (non-HDL-C
HDL-C )
non-HDL-C statin
fibrate niacin
triglyceride 500 ./. fibrate
niacin statin ( 2, ++)
8,9 ( 2, ++)

62

HbA1c 6.5% 7.0%

HbA1c 7% 8%
o

o
(short life expectancy)

( 1, ++)
antiplatelet
antiplatelet 50
60 4,7

albuminuria
antiplatelet aspirin 60-162 ./ ( 1,
++)
(Secondary prevention)

2,8,9
2 ( 1, ++)
<130/80 .
110 .10 70 .11
beta-blocker

LDL-C 70 ./.

statin ( 1, ++)

HDL-C triglyceride (
2, ++)
antiplatelet

63

o antiplatelet aspirin 60-162 ./

o aspirin antiplatelet clopidogrel (
2, ++)

Gaede P, Lund-Anderseo H, parving HH, Pedersen O. Effect of a multifactorial intervention on mortality

in type 2 diabetes. New Engl J Med 2008; 358: 580-91.
Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and
control diabetes mellitus: a systematic review. Diabetes Care 2010; 33: 1872-94.
Wackers FJ, Young LH, lnzucchi SE, et al. Detection of silent myocardial ischemia in asymptomatic
diabetic subjects: the DIAD study. Diabetes Care 2004; 27: 1954-61.
American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
2. The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. New
Engl J Med 2010; 362: 1575-85.
.. 2551
. Thai Hypertension Society: Guidelines in the treatment of hypertension 2008.
Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with cardiometabolic
risk: Consensus conference report from the American Diabetes Association and the American College of
Cardiology Foundation. J Am Coll Cardiol 2008; 51: 1512-24.
Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycemic control and the prevention of
cardiovascular events: Implications of the ACCORD, ADVANCE and VA Diabetes Trials. A position
statement of the American Diabetes Association and the scientific statement of the American College of
Cardiology Foundation and the American Heart Association. Circulation 2009; 119: 351-7.
3. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between glycemic
control and cardiovascular outcomes in diabetes. A cohort study. Ann Intern Med 2009; 151: 854-60.
4. Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular
outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010; 304: 61-8.
5. Anderson RJ, Bahn GD, Moritz TE, et al. Blood pressure and cardiovascular disease risk in the Veterans
Affairs Diabetes Trial (VADT). Published online before print November 8, 2010, doi: 10.2337/dc101420, Diabetes Care.

64

(lower limb amputation)

1-3

2,4

( 1,
++)5
(foot examination) 1
(risk category) 6 ( 1,
++) (foot inspection)

6 ( 1, ++)



7-9 ( 1, ++) (

3)
(peripheral vascular disease)
2,4 (arterial bypass
surgery) ( 4, +)
1-4,10,11

( 1)
( 1)
( 1)
( 1)

65

(foot deformities) ( 2)
(callus) ( 2)
( 2)
( 2)
( 2)
10 ( 2)
( 2)
HbA1c ( 2)
( 2)
( 2)
( 2)
( 2)

2
( 1)

( ++)

66

(self foot-care)
( ++) (
3)
( ++)

( ++)
1

-
/



ABI 0.9

-
/

-
/



ABI < 0.9

6-12

67

1.

1 ( ++)
( ++)

( ++)
6-12 ( ++)
( ++)
( ++)

( ++)

6 ( ++)

( ++)
/

( ++)
/

12 (
1, +)

( ) (

++)
( ) ( gangrene)
(callus) ( ++)
(ingrown toenail)
( ) (
++)

68
(deformity) neuropathy

hallux
valgus, hallux varus, claw toe, hammer toe, (bony prominence) Charcot
foot (gait)
(mobility) ( ++)
neuropathy (
++) ankle reflex ( ++) 128
( ++) Semmes-Weinstein monofilament 5.07
10 ( ++) monofilament
1,13-15
( 1)( 4)
(claudication)
femoral, dorsalis pedis posterior tibial 2 (
++) ankle-brachial index (ABI)
/
( +) ABI 0.9
( ++) (
5)

(neuropathic ulcer)
(ischemic ulcer) (acute ulcer)
( ++) (
6)
()
Wagner Meggitt16 ( ++) ( 6)
(sterile normal saline) 2 alcohol,
betadine , Dakin, hydrogen peroxide
( ++)

69

alginate, cream, debriding agent, foam, film, gauze, hydrocolloid

hydrogel
2 ( 4, +/-)
( ++)
( ++)

(Wagner grade 1 < 2 . 0.5 .

< 2 .)
2,17 ( 4, ++)
1-2 18 (
1, ++) ( )
18
( 4, ++)
(local antibiotic)
18 ( 2, +/-)
2
( ++)

1. ( >2 . > 0.5 . >2

. Wagner grade 2 )
2,17 ( 4, ++)
2. (biopsy) (curettage)

discharge 18 ( 1, ++)
3. 6
osteomyelitis 18 ( 4, +)
4. 2-4
6 osteomyelitis18 ( 1, ++)

70

5. vascular insufficiency bypass surgery ( +)

debridement

6. ( ++)
contact cast (shoe modification) (custom molded shoes)
2 ( 2, +/-)
7. hyperbaric oxygen, granulocyte-colony stimulating factor, growth
factor, electrical stimulation
2 ( 2, -)

- Crawford F, lnkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: a systematic
review and meta-analysis. QJM 2007; 100: 65-86.
- Mclntosch A, Peters JR, Young RJ, et al. Prevention and management of foot problems in type 2 diabetes:
Clinical guidelines and evidence 2003. (full NICE guideline). Sheffield: University of Sheffield.
www.nice.org.uk
- Sriussadaporn S, Mekanandha P, Vannasaeng S, et al. Factors associated with diabetic foot ulceration in
Thailand: a case-control study. Diabet Med 1997; 14: 50-6.
- American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
- Donohoe ME, Fletton JA, Hook A, et al. Improving foot care for people with diabetes mellitus-a
randomized controlled trial of an integrated care approach. Diabet Med 2000; 17: 581-7.
- McCabe CJ, Stevenson RC, Dolan AM. Evaluation of a diabetic foot screening and protection
programme. Diabet Med 1998; 15: 80-4.
- Valk GD, Kriegsman DM, Assendelft WJ. Patient education for preventing diabetic foot ulceration. A
systematic review. Endocrinol Metab Clin North Am 2002; 31: 633-58.
- Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities
in patients with non-insulin dependent diabetes. Ann lntern Med 1993; 119: 36-41.
- Barth R, Campbell LV, Allen S, Jupp JJ, Chisholm DJ. Intensive education improves knowledge,
compliance and foot problems in type 2 diabetes. Diabet Med 1991; 8: 111-7.
- Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes
(Technical Review). Diabetes Care 1998; 21: 2161-77.

71

- Sriussadaporn S, Ploybutr S, Nitiyanant W, Vannasaeng S, Vichayanrat A. Behavior in self-care of the

foot and foot ulcers in Thai non-insulin dependent diabetes mellitus. J Med Assoc Thai 1998; 81: 29-36.
- Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot re-ulceration in patients
with diabetes. A randomized controlled trial. JAMA 2002; 287: 2552-9.
- Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at high risk for lower-extremity
amputation in a primary health care setting. A prospective evaluation of simple screening criteria.
Diabetes Care 1992; 15: 1386-9.
- Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify
people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care 2000; 23:
606-11.
- Pacaud D, Singer D, McConnell B, Yale J-F. Assessment of screening practices for peripheral neuropathy
in people with diabetes. Can J Diab Care 1999; 23: 21-5.
- , . . :
, , . Diabetes Mellitus. 1.
: 2548; 583-608.
- Klein R, Levin M, Pfeifer M Rith-Najarian SJ. Detection and treatment of foot complications. In: Mazze
RS, Strock ES, Simonson GD, Bergenstal RM, eds. Staged Diabetes Management a Systematic Approach,
2nd ed. West Sussex: John wiley & Sons; 2004; 353-65.
- Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. IDSA
guidelines. Clinical Infectious Diseases 2004; 39: 885-910.

72

1 2
10 2 3
1.
2. (BP 130/85 .)
3. acanthosis nigricans
( ++) 1
1
2 200 ./.
(diabetic ketoacidosis, DKA)

OGTT
( 2) (
5)

(
10)

73

10
1. ( 120)
2. 2 3
2.1
2.2 (BP 130/85 .)
2.3 acanthosis nigricans

Capillary blood glucose

110 ./.

5-10

Fasting plasma glucose

126 ./. 2

(2-hr plasma glucose < 140 ./.)

OGTT

(2-hr plasma
glucose 200 ./.)

1.

2.

3.

Biguanide

Sulfonyluea

IGT (2-hr plasma

glucose 140-199
./.)

o
o

1.

2. 1

: 15

74

1. 2 ( 10 )

, ,

Random capillary blood glucose (RCBG)

RCBG <110 ./.

RCBG 200 ./.

plasma glucose 200 ./.

RCBG 110-199 ./.

plasma
glucose

plasma glucose <200 ./.

Fasting plasma glucose

126 ./. 2

: 15

DKA
11

DKA
1.
2.

75

2. 1
1. 1 ( 2)
1.1
(WWW.)
1.2
( 12
)
1.3
- (prepubertal age) = 0.7-1.0 /./
- (pubertal age) = 1-1.5 /./
2
- 2 / (conventional method)
(NPH) (regular insulin, RI)
(biphasic insulin analogue)
- 3-4 / (intensive method)
3 /
,

2/3
1/3
4 / basal-bolus insulin
basal insulin 1-2
(bolus insulin)
30-50
basal insulin 50-70 bolus insulin
HbA1c
( 2)

76

1.4
( 1)
50-60 25-30 15-20 70

5
1.2 : 1
( ++)
1.
()
()
0-12
12-15 ()
12-15 ()

1,000 + [100 x ()]

1,500 2,000 + [100 x () 12 ]
2,000 2,500 + [200 x () 12 ]

15-20 ()
15-20 ()
* DBW: Desired body weight

[29-33] x DBW* ()
[33-40] x DBW* ()

5-10
0.25-0.5 ./ 250500 /

conventional method 3 2-3
intensive method basal-bolus insulin 3-4

1.5 (diabetic education and skills for self-care)

7-10
- 1
-
-

77

- 3-4
250 ./.
-

-
-
-
-

1.6
(psycho-social adjustment and family support)

1.7 1
3
3 -6
2 ( ++)
2. 2 ( 1)
2.1 4
2.2 biguanide
sulfonylurea 200 ./. HbA1c >8 7.5 %
1-3

78

2.3

2.4 (diabetes education and skills for self care)

7-10
2

2.5
(psycho-social adjustment and family support)
1

HbA1c
2
2.

0-6

(HbA1c)
6-12

(HbA1c)
13

(HbA1c)

100 - 180 ./.

110 - 200 ./.
7.5 - 8.5%
90 - 180 ./.
100 - 180 ./.
< 8%
90 - 130 ./.
90 - 150 ./.
< 7.5%

79

3
3.

3-6 1

HbA1c
*
(microalbuminuria)

**
freeT4 TSH

10
1 5
1
10
5
2

* 2
**
- 2 >10
-

3 6-12
1. (medical outcome)
- HbA1c
-
-
-

80

HbA1c DKA
2
2. (psychosocial)
-
-
-
-
3. (behavioral)
- (self monitoring of blood glucose)
-
-

1. HbA1c 8.5% 1 7% 2
2. DKA 6
3. hypoglycemia hypoglycemia unawareness

1. American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
2. International Society for Pediatric and Adolescent Diabetes. Consensus Guideline 2000: ISPAD
Consensus guidelines for the management of type 1 diabetes mellitus in children and adolescent. Medical
Forum International. Zeist Netherlands 2000; 11-19R.
3. Likitmaskul S, Wekawanich J, Wongarn R, Chaichanwatanakul K, Kiattisakthavee P, Nimkarn S, et al.
Intensive diabetes education program and multidisciplinary team approach in management of newly
diagnosed type 1 diabetes mellitus: a greater patient benefit, experience at Siriraj Hospital. J Med Assoc
Thai 2002; 85 (Suppl 2): S488-95.

81

4. National Collaborating Center for Womans and Childrens Health. Type 1 diabetes diagnosis and
management of type 1 diabetes in children and young people: clinical guideline 2004. RCOG Press
London.
5. Bangstad HJ, Danne T, Deeb LC, Jaroz-Chabot P, Urakami T, Hanas R. Insulin treatment in children and
adolescents with diabetes. Pediatric Diabetes 2009:10 Suppl 12:82-99.
6. Bode BW, Davidson PC, Steed RD, Robertson DG, Skyler JS, editors. How to control and manage
diabetes mellitus. Alexandria: American Diabetes Association; 2001.
7. Garg A, Barnett JP. Nutritional management of the person with diabetes. In: Porte D Jr, Sherwin RS,
Baron A, editors. Ellenberg & Rifkins diabetes mellitus. 6th ed. New York: McGraw-Hill; 2003. p.437-52
8. Likitmaskul S, Santipraphob J, Nakavachara P, Sriussadaporn P, Parkpreaw C, Kolatat T and 31
members. A holistic care and self management education programe for children and adolescents with
diabetes at Siriraj Hospital. Abstract presented in International Conference on Health Promotion and
Quality in Health Services. 19-21 November 2008, Bangkok, Thailand. p 253-55.

82

(hypoglycemia)
(moderate hyperglycemia) (diabetic
ketoacidosis, DKA)

(hypoglycemia)

I. 1,2

( 41

(autonomic symptom) (neuroglycopenic symptom)










II.
1 2
2
/ 1,2

83

1
1. (mild hypoglycemia)
1.1 70 ./.
o ( )

o 20 -30
1.2 70 ./.
2.
20-30 5-10

10-15
3.
10
- soft drink 90
- 3-4
- 1
- 20-30
4.
15 (1 )
- 1 (200 )
- 1
- 200
- 1
o 30-60 80 ./.
o
o (moderate hypoglycemia) <70
./.
o 10
- soft drink 90
- 3-4
- 1
- 20-30
1. 15 (1 )
- 1 (250 )
- 1
- 200
- 1
2. 30-60 80 ./.

3.
4.
3. (severe hypoglycemia)

84

3.1 ()
0.5 < 5 1 > 5

3.2
() 0.5 < 5 1 > 5
50% 50% 1-2
./ 1 . 10% (10%D) 2-3 ././
. 90-120 ./.
6-12

10%D 2-3
././. 6-12
2
1


III.




(hyperglycemia) diabetic ketoacidosis (DKA)3-5
DKA 1
250 ./. (ketone)

1.
1.1
-
-

85

- 250 ./.

5 -10
1.2
- /
- 2-4 2
-
10-20
- 4-6
180 ./.
- 8

2.
2.1
o 4-6
o
o 1

2.2

DKA
/
2-4 2
regular insulin 0.1-0.25 unit/kg/dose 4-6
NPH regular insulin
2-4

4-6
8- 24 24

86

DKA
acetone

( 11 Diabetic ketoacidosis )

o Silink M, et al. hypoglycemia. In: Silink M, ed. APEG Handbook on Childhood and Adolescent Diabetes; the
management of insulin dependent diabetes mellitus (IDDM). 1st ed. Australia: Parramatta NSW; 1996: 61-8.
o Clarke W, Jones T, Rewers A, Dunger D, Klingensmith GJ. Assessment and management of hypoglycemia in
children and adolescents with diabetes: ISPAD Clinical Practice Consensus Guideline 2009. Pediatric Diabetes
2009:10 (Suppl 12): 134-45.
o American Diabetes Association. Standards of Medical care in Diabetes. Diabetes Care 2010; 33 (1): S11- S61.
o Wolfsdort J, Craig ME, Daneman D, et al. Diabetes ketoacidosis in children and adolescents with diabetes: ISPAD
Clinical Practice Consensus Guideline 2009. Pediatric Diabetes 2009:10 (Suppl 12): 118-33.
o . (Management for diabetic
ketoacidosis). 2545: 41 (1): 115-22.

87

2 (pregestational diabetes) (gestational diabetes)1,2

(team approach)

(tight control)
( 9)
(conception) 2-3 2 (
1, ++)

2-3

2

( 1)
1.

1
2
2.00 4.00

(./.)
60-95
<140
<120
>60

proliferative diabetic retinopathy

diabetic nephropathy proteinuria 70

88

(creatinine clearance) proteinuria

serum creatinine 3 ./
.

(simple sugar) 32
(ideal body weight) 38
2 3 50-55 20 25-30
200 2
accelerated starvation ketosis

( 1, ++)


1 2
3
( 1, ++)
(rapid acting insulin analogue) lispro insulin, aspart insulin
(regular human insulin) glargine insulin long acting
insulin analogue IGF-1 receptor

insulin detemir
2

( 2, ++)

89

10-12

8 ( 2, ++)

HbA1c HbA1c
(organogenesis)
HbA1c

fructosamine HbA1c 2
( 2, +)

1

180 ./. ( 2, +)

70-120 ./.
ketosis
5% 100-125 ./
1-2
(normal saline) 1-2 /
(caesarian section)
5%
100-125 ./ 1-2 5%
70-120 ./.
(normal saline) 1-2 /

90

2
4-6
400

(Gestational diabetes)


(glucose intolerance)
1-14 ( 1)
( 12)

25

24-28
50 (50 g glucose challenge test) 1
140 ./.
oral glucose tolerance test (OGTT)
( 2) National Diabetes Data Group (NDDG)
American College of Obstetricians and Gynecologist

pregestational diabetes
1

91

105 ./.
95 ./. 1 . 2 . 140 120
./. 1-2
( 1,
++)
glibencamide metformin
metformin ( 3,
+)

7.4 5
6
75 (75 g oral glucose tolerance test, OGTT) 1

( 1, ++)

5. . . : 2550.
, , , . .
2550
6. IDF Clinical Guidelines Task Force. Global Guideline on Pregnancy and Diabetes. International Diabetes
Federation. Brussels, 2009.
7. Deerochanawong C, Putiyanun C, Wongsuryrat M, Jinayon P. Comparison of NDDG and WHO criteria
for detecting gestational diabetes. Diabetologia 1996; 39: 1070-3.
8. The HAPO study cooperative research group. Hyperglycemia and adverse pregnancy outcomes. New
Engl J Med 2008; 358: 1991-202.
9. Bellamy L, Casas JP, Hingoranai AB, Williams D. Type 2 diabetes mellitus after gestational
diabetes: a systemic review and meta-analysis. Lancet 2009; 373: 1273-9.

92

Wagners Chronic Care Model (CCM) WHOs Chronic Care Model1,2





3,4

()

(

)

93

1.

/


5
(Prevalence)(Incidence)
fasting plasma glucose (FPG = 70 - < 130 ./.)
HbA1c
HbA1c 7%

lipid profile
LDL-C 100 ./.
130/80 .
microalbuminuria

94

microalbuminuria ACE inhibitor ARB

diabetic retinopathy
diabetic nephropathy
Myocardial Infarction
Cerebral Infarction
impaired fasting glucose (IFG)
/ /
(..)

1. King H, Gruber W, Lander T. lmplementing national diabetes programmes. Report of a WHO

Meeting. World Heath Organization. Division of Non-communicable Diseases, Geneva 1995.
2. Wagner EH. Chronic Disease Management: What will it take to improve care for chronic illness?
Effective Clinical Practice 1998; 1: 2-4.
http://www.improvingchroniccare.org/change/model/ components.html >>verified 2/5/2007
3. U.S. Department of Health and Human Service, 2006 National Healthcare Quality Report AHRQ.
Publication No 07-0013, December 2006.
4. American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33
(Suppl 1): S11-S61.
5. TCEN - .
2552.

95

1-3

1.
2.
3.

(
) (capillary blood glucose,
CBG) glucose meter point-of-care-device (

6)

1

70-130 ./. 6 (
1)
()

96

2. CBG < 70 ./.
3. hypoglycemia
4. CBG > 200 ./. 2
5. CBG > 300 ./.
6.
7.
8.
9. tachycardia ( > 100 /) / orthostatic hypotension
10. /
11. 180/110 .
systolic BP > 130 . / diastolic BP > 80 .
3
12.

13.
14.
15. hyperglycemia
hypoglycemia
16.




16.

97

5
CBG > 130 ./. 3

1.
2.
3.

(medication error)

CBG 130 ./.

3

(drug interaction) -
- - -/

/
(
)

(non-compliance)

1 ()

1.

(CBG < 130 ./.)

98

1) (non-compliance)


2)

3)

1. Katherine K, Max, R, Anandi L, et al. The role of community pharmacies in diabetes care: eight case
studies.
California
Healthcare
Foundation
2005.
Available
at:
http://www.chcf.org/topics/chronicdsease/index.cfm?itemID=112672. Accessed November 11, 2006
2. Stacy AM, Kim RK, Warren AN. Identifying at-risk patient through community pharmacy-based
hypertension and stroke prevention screening projects. J AM Pharm Assoc 2003; 43: 50-5
3. World
Health
Organization.
Diabetes
Mellitus
Available
at:
http://www.who.int/topics/diabetes_mellitus/en./. Accessed November 11, 2006

99

1.

- 1 (type 1 diabetes mellitus, T1DM)
a. Immune mediated
b. Idiopathic
2. 2 (type 2 diabetes mellitus, T2DM)
o Predominant insulin resistance
o Predominant insulin secretory deficiency
(other specific type)
2.1
Maturity onset diabetes in the young (MODY)
Mitochondrial DNA
1. MODY 3 Chromosome 12 HNF-1
2. MODY 2 Chromosome 7 glucokinase
3. MODY 1 Chromosome 20 HNF-4
o
Type A insulin resisitance, Leprechaunism, Lipoatrophic diabetes
o Hemochromatosis

o Acromegaly, Cushing syndrome,

Pheochromocytoma, Hyperthyroidism
o Pentamidine, Steroid, Dilantin,
-interferon, Vacor
o Congenital rubella, Cytomegalovirus
o Anti-insulin receptor
antibodies, Stiff-man syndrome
o Down syndrome, Turner syndrome,
Klinefelter syndrome, Prader-Willi syndrome, Friedrichs ataxia, Huntingtons
chorea, Myotonic dystrophy
(gestational diabetes mellitus, GDM)

100

2. (Oral Glucose Tolerance Test)

()
1)
150 3

2) ,

3) 10-16
10 FPG 16

4) (fasting venous blood sample)
75 250-300 . 5
2 30
5) 6 .
1.,

1.75 / 1 75
(gestational diabetes mellitus)
GDM oral glucose tolerance test
National Diabetes Data Group (NDDG) 3 hour oral
glucose tolerance test 8 100
250-300 . 1, 2 3
2 1, 2
3 105, 190, 165 145 ./.
IADPSG (International Association Diabetes Pregnancy Study Group)
75 OGTT

101

92, 180 153 ./.

1 2
.
(./.) () GDM

1
2
3
NDDG
100
105
190
165
145
2
Carpenter & Couston
100
95
180
155
140
2
ADA
75
95
180
155
2
WHO
75
< 126
140
2
IADPSG
75
92
180
153

NDDG = National Diabetes Data Group; ADA = American Diabetes Association, IADPSG = International Association of
Diabetes Pregnancy Study Group

102

3.
SMBG
SMBG
1 2
SMBG
SMBG1 meta-analysis stratified SMBG
SMBG
1. SMBG (HbA1c)
2. SMBG (real time)

3.

4. 2 SMBG

HbA1c
/
( )

103

SMBG2
4.
o

5.
-
-

-
6.
-

2
1

7.
o

()
o

o
(PaO2) PaO2 150 .
biosensor (glucose oxidase)

1. Towfigh A, Romanova M, Weinreb JE, Munjas B, et al. Self-monitoring of blood glucose levels in
patients with type 2 diabetes mellitus not taking insulin: A meta-analysis. Am J Manag Care 2008; 14(7):
468-75.
2. , , .
: 1. , ,
. . 2548, 81-106.

104

Accu-chek Accu-chek Accu-chek Medisafe

Performa Advantage II Active
Mini
Roche
Roche
Roche
Terumo

Biosensor Biosensor

GDH-PQQ GDH-PQQ

Whole blood Whole blood

Plasma Whole blood

0.6
4
()
Forearm
5
26
()
10-600
10-600

(./.)
0.992
0.96-1.03

C, V, A, N C, V, A, N

Precision Medisense
Optium
QID
Abbott
Abbott

One-Touch Surestep One-Touch

Ultra
Horizon
Johnson & Johnson & Johnson &
Johnson
Johnson
Johnson
Photometry Photometry Biosensor Biosensor Biosensor

Biosensor

Biosensor

GDH-PQQ GO

GO

GDHNAD

GO

GO

GO

Whole blood Whole blood Whole blood Whole blood Whole blood Whole blood Whole blood
Plasma

Plasma

Plasma

Plasma

Plasma

Plasma

Plasma

1-2

2.5

3.5

2.5

10

30

forearm,
palm
15

5- 10

forearm,
palm
5

20

20

10-600

20-600

20-600

0-500

20-600

20-600

20-500

0.987

C, V, A, N C, V, A, N

0.969

C, V

0.984

code Autocoding Autocoding Autocoding Calibration Calibration Calibration

code (button) code (button) code (button)

10-70
20-55 (
20-55
20-60
30-55
26-60
30-55
30-60
30-60

>200
(%)
./.)

GDH-PQQ = glucose dehydrogenase pyrroloquinoline quinone;GDH NAD = glucose dehydrogenase-nicotine adenine dinucleotide; GO =
glucose oxidase; C = capillary; V = vein; A = artery ; N = neonate relative humidity

105

4.

1.
1 2-5
2. 6
7
(hypoglycemia unawareness)8,9
3.
6
4.

10

1)

(plasma glucose) 6,11
(venous blood)
(anticoagulant) (plasma)
(laboratory-based glucose measurement) glucose
oxidase hexokinase
2)
(hypoglycemic agent)
(capillary blood glucose)
()
(validated portable glucose meter) (monitor-based
glucose measurement) (self monitoring of blood glucose,
SMBG) (point-of-care testing of blood glucose)

12

106

3)

4)

5)

(plasma glucose)
(whole blood glucose)


(International Federation of Clinical Chemistry IFCC)



(adjusted plasma glucose) 11
correction factor 1.11
adjusted plasma glucose = capillary whole blood glucose x 1.11

(falsely low)
( 3)

(HbA1c)

13,14
12

1) Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest 2007; 117: 868870.
2) Laing SP, Swerdlow AJ, Slater SD, Botha JL, Burden AC, Waugh NR, et al. The British Diabetic
Association Cohort Study, II: cause-specific mortality in patients with insulin-treated diabetes mellitus.
Diabet Med 1999; 16: 46671.
3) Gerstein HC, Miller ME, Byington RP, Goff Jr DC, Bigger JT, Buse JB, et al. Effects of intensive
glucose lowering in type 2 diabetes. The Action to Control Cardiovascular Risk in Diabetes Study Group.
N Engl J Med 2008; 358: 254559.

107

4) Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, Woodward M, et al. for the ADVANCE
Collaborative Group. Severe hypoglycemia and risks of vascular events and death. N Engl J Med 2010;
363:1410-8.
5) Desouza CV, Bolli GB, Fonseca V. Hypoglycemia, diabetes, and cardiovascular events. Diabetes Care.
2010;33:1389-94.
6) Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ. Evaluation and
management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin
Endocrinol Metab 2009; 94: 70928.
7) Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes
with impaired awareness of hypoglycemia. Diabetes Care 1994; 17: 697703.
8) Dagogo-Jack SE, Craft S, Cryer PE. 1993 Hypoglycemia-associated autonomic failure in insulindependent diabetes mellitus. Recent antecedent hypoglycemia reduces autonomic responses to, symptoms
of, and defense against subsequent hypoglycemia. J Clin Invest 1993; 91: 81928.
9) Segel SA, Paramore DS, Cryer PE. Hypoglycemia-associated autonomic failure in advanced type 2
diabetes. Diabetes 2002; 51: 72433.
10) Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of type I and type II
diabetes. Diabetologia 2002; 45: 93748.
11) DOrazio P, Burnett RW, Fogh-Andersen N, Jacobs E, Kuwa K, Wolf R. Klpmann KK, et al. The
International Federation of Clinical Chemistry Scientific Division Working Group on selective electrodes
and point of care testing. Approved IFCC Recommendation on reporting results for blood glucose
(Abbreviated). Clinical Chemistry 2005; 51: 9: 15736.
12) American Diabetes Association Workgroup on Hypoglycemia. Defining and reporting hypoglycemia in
diabetes: a report from the American Diabetes Association Workgroup on Hypoglycemia. Diabetes Care
2005; 28: 1245-9.
13) The effect of intensive treatment of diabetes on the development and progression of long-term
complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial
Research Group. N Engl J Med 1993; 329: 97786.
14) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and
risk of complications in patients with type 2 diabetes (UKPDS33). UK Prospective Diabetes Study
(UKPDS) Group. Lancet 1998; 352: 83753.

108

5. (eGFR)
(eGFR) MDRD

(./.)
0.6
0.7
0.8
0.9
1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
4.0
4.1
4.2

()
20
>90
>90
>90
85
75
67
61
56
51
47
44
41
38
36
34
32
30
29
27
26
25
24
23
22
21
20
20
19
18
18
17
17
16
16
15
15
14

30
>90
>90
90
78
69
62
56
51
47
43
40
38
35
33
31
29
28
26
25
24
23
22
21
20
19
19
18
17
17
16
16
15
15
14
14
14
13

40
>90
>90
84
74
65
58
53
48
44
41
38
35
33
31
29
28
26
25
24
23
22
21
20
19
18
18
17
16
16
15
15
14
14
14
13
13
12

ml/min/1.73 m2

50
>90
>90
81
70
62
56
51
46
42
39
36
34
32
30
28
26
25
24
23
22
21
20
19
18
18
17
16
16
15
15
14
14
13
13
13
12
12

60
>90
>90
78
68
60
54
49
44
41
38
35
33
31
29
27
26
24
23
22
21
20
19
18
18
17
16
16
15
15
14
14
13
13
12
12
12
11

70
>90
88
75
66
58
52
47
43
40
36
34
32
30
28
26
25
23
22
21
20
19
19
18
17
16
16
15
15
14
14
13
13
12
12
12
11
11

80
>90
86
73
64
57
51
46
42
38
35
33
31
29
27
25
24
23
22
21
20
19
18
17
16
16
15
15
14
14
13
13
13
12
12
11
11
11

109

(eGFR) MDRD

(./.)
0.8
0.9
1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
4.0
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
5.0
5.1
5.2
5.3
5.4
5.5
5.6

()
20
>90
>90
>90
>90
82
75
69
63
59
55
51
48
46
43
41
39
37
35
34
32
31
30
28
27
26
26
25
24
23
22
22
21
20
20
19
19
18
18
17
17
17
16
16
15
15
15
14
14
14

30
>90
>90
>90
84
76
69
63
58
54
51
47
44
42
40
38
36
34
32
31
30
28
27
26
25
24
24
23
22
21
21
20
19
19
18
18
17
17
16
16
16
15
15
15
14
14
14
13
13
13

40
>90
>90
88
79
71
65
60
55
51
48
45
42
40
37
35
34
32
31
29
28
27
26
25
24
23
22
21
21
20
19
19
18
18
17
17
16
16
16
15
15
14
14
14
13
13
13
12
12
12

50
>90
> 90
84
75
68
62
57
53
49
46
43
40
38
36
34
32
31
29
28
27
26
25
24
23
22
21
20
20
19
19
18
17
17
16
16
16
15
15
14
14
14
13
13
13
13
12
12
12
12

60
>90
>90
81
73
66
60
55
51
47
44
41
39
36
34
33
31
29
28
27
26
25
24
23
22
21
20
20
19
18
18
17
17
16
16
15
15
15
14
14
14
13
13
13
12
12
12
11
11
11

70
>90
89
79
70
64
58
53
49
46
43
40
37
35
33
32
30
29
27
26
25
24
23
22
21
21
20
19
18
18
17
17
16
16
15
15
15
14
14
13
13
13
13
12
12
12
11
11
11
11

80
>90
86
76
68
62
56
52
48
44
41
39
36
34
32
31
29
28
27
25
24
23
22
22
21
20
19
19
18
17
17
16
16
15
15
15
14
14
13
13
13
13
12
12
12
11
11
11
11
10

110

6.

*
1) 2

2) , , ,

3)
4)

5) ( )

6)



7)
8) (
)
velcro

9)

10)
11)

12)
1

111

13) (
)

14)

15)

16)
17) (
)
18)
19)
20)
21)
22)

* , . : ,
, . Diabetes Mellitus. 1. : ; 2548:583-608.

112

7.
Semmes-Weinstein monofilament ( 5.07 10 )
Semmes-Weinstein monofilament
light touch deep pressure. Semmes-Weinstein monofilament
() monofilament
monofilament monofilament
monofilament monofilament 5.07 10

(protective sensation)
(reproducebility) *
monofilament
monofilament 2 (reusable)
(disposable) monofilament
monofilament

monofilament

* Klenerman L, McCabe C, Cogley D, Crerand S, Laing P, White M. Screening for patients at risk of diabetic foot ulceration
in a general diabetic outpatient clinic. Diabet Med 1996; 13: 561-3

113

monofilament monofilament 2
monofilament
monofilament 10 ( 1
10 ) 100 monofilament
24 monofilament
monofilament
4 metatarsalhead 1, 3
5

callus
monofilament 5.07 10 The
American College of physicians 2007


monofilament (forearm)
monofilament 1-1.5

monofilament
monofilament 1-1.5 ()

114

monofilament monofilament
monofilament

3 (real application
monofilament ) 2 (sham application
monofilament monofilament ?) 1

2 3 ( 1
5) protective sense

1 3 (
1 5) 5

1 3

4 2
2

protective sensation (insensate foot)
1

115

The American College of Physicians 2007

128





distal interphalangeal joint 2

?

1 2

7 1 2
4
2 1
7-9 1 2 2
8
5
peripheral neuropathy

116

8.
*

metatarsophalangeal 1
(
) 3/8 1
(forefoot) metatarsophalangeal joints
(claw hammer toe)

velcro

* , . : ,
, . Diabetes Mellitus. 1. : ; 2548:583608

117

9.

*
1)

2)
/
3)
(hemorrhagic callus)

4) (
)

(Wagner grade) *
Grade 0 Pre-ulcerative lesions (healed ulcer, presence of bony deformity)
Grade 1 Superficial ulcer without subcutaneous tissue involvement
Grade 2 Penetration through the subcutaneous tissue (may expose bone, tendon, ligament or joint
capsule)
Grade 3 Osteitis, abscess or osteomyelitis
Grade 4 Gangrene of digit
Grade 5 Gangrene of the foot requiring disarticulation

* , . : ,
, . Diabetes Mellitus. 1. : ; 2548:583608

118

**
-
callus granulation


(claw hammer toe)
-


(intermittent claudication)
(rest pain)

dorsalis pedis posterior tibial
-


( )

** . : , , .
Diabetes Mellitus. 1. : 2548: 563-82

119

*
SEVERITY OF INFECTION
ROUTES OF ADMINISTRATION
Dicloxacillin or Clindamycin or Catexin
Amoxycillin / Clavulanate or Co-trimoxazole
Levofloxacin
Ceftriaxone or Cefoxitin
Ampicillin / Sulbactam
Cefuroxime with or without metronidazole
Ticarcillin / Clavulaniate
Piperacillin / Tazobactam
Ciprofloxacin or Levofloxacin + Clindamycin
Imipenem / Cilastatin
Vancomycin + Ceftazidime + metronidazole

MILD
P.O.

MODERATE SEVERE
P.O.
I.V.

* Infectious Disease Society of America Guideline 2004

P.O. = I.V. = =

*
SITE AND EXTENT

ROUTE

SETTING

DURATION

OF INFECTIONS

OF Rx

OF Rx

OF Rx

Mild

T.C. / P.O.

OPD

1-4

Moderate

I.V. P.O.

IPD/OPD

2-4

Severe

I.V. P.O.

IPDOPD

2-4

I.V. / P.O.

IPDOPD

2-5

I.V. / P.O.

IPDOPD

2-4

Residual infected viable bone

I.V. P.O.

IPDOPD

4-6

Residual dead bone / No surgery

I.V. P.O.

IPDOPD

> 3

SOFT TISSUE ONLY

BONE OR JOINT
No residual infected tissues e.g. post
amputation
Residual soft tissues (not bone)

* Infectious Disease Society of America Guideline 2004

T.C. = , P.O. = , I.V. = , IPD = inpatient department,
OPD = outpatient department

120

10.
1.
2. ()
3.
( ++)
-

- 4 /
1 2
- G 32 0.5 .
1.0 . 2
4
-
( ++)



/

-
-
-
- ,
-

-
-
-
-

121

-
-

-
-
-
-

-
-
/
-
-

-



( ++)
-
- (networking)
a. (PCU)

b. call
center hotline
c.

122

- 1-3 12

()
(regular insulin, RI)

(Actrapid HM, Humulin R, Gensulin R,

Insugen R)
(Insulin Isophane
Suspension, NPH)

(Insulatard HM, Humulin N, Gensulin N,

Insugen N)

Pre-mixed 30% RI + 70% NPH (Mixtard 30

HM, Humulin 70/30, Gensulin M30, Insugen 30/70)

Pre-mixed 50% RI + 50% NPH (Gensulin

M50)

Insulin Lispro (Humalog)

Insulin aspart (NovoRapid)

Insulin glargine (Lantus)

Insulin detemir (Levemir)

(Biphasic insulin
analogue)

Premixed 30% insulin aspart + 70% insulin

aspart protamine suspension (NovoMix 30)

Premixed 25% insulin lispro + 75% insulin

lispro protamine suspension (Humalog Mix 25)

30-45

2-3

4-8

2-4

4-8

10-16

30-60

2 8

12-20

30-60

2 8

12-20

5-15
10-20

1-2
1-2

3-4
3-4

2
2

24
18-24

10-20

1 8

12-20

10-20

1 8

12-20

123

11. diabetic ketoacidosis (DKA)

1-4
I.
1. DKA (Kussmaul
breathing metabolic acidosis) acetone
(dehydration)
2.
- >250 ./.
- (acidosis): serum bicarbonate (HCO3) <18 / arterial
pH <7.30 venous pH <7.25
- ketone
3. DKA 2
- Mild DKA:
arterial pH 7.25-7.30 HCO3 15-18 /
- Moderate DKA: arterial pH 7.00-7.24 HCO3 10-14 /
- Severe DKA: arterial pH <7.00
HCO3 <10 /
4. lactic acidosis alcoholic
ketoacidosis, ingestion of drugs salicylate, methanol, ethylene glycol, paraldehyde chronic renal
failure
II.
1
1.
-
- diabetic ketoacidosis

2.
- glucose ketone
- serum electrolytes, BUN, Cr, Ca, PO4, CBC
- blood gas urine ketone
- monitor EKG lead II serum potassium

124

3. DKA flow sheet

- body surface area
electrolytes
- 2-4
4.
4.1 degree of dehydration1,2
- 7% dehydration: <7%, HCO3 >17 mmol/l
- 7-10% dehydration: 7-10% decreased skin turgor, pH >7.2,
HCO3 >10 mmol/l
- 10-15% dehydration: 10-15%, capillary refill >4 , pH <7.2, HCO3<10
mmol/l shock
4.2 degree of dehydration
4.2.1 7 % dehydration
- 0.45% NaCl 3000 ml/m2/24 hr.
- potassium (K): 40 mmol/l serum K 3.5 mmol/l
K 60 mmol/l ( monitor EKG K 0.3
mmol/kg/hr) K K 6 mmol/l
4.2.2 7% dehydration
- 0.9% NaCl 10 ml/kg 1/2
4.2.1
- shock bolus 0.9% NaCl
5. DKA
5.1 Intracranial complication
disorientation cerebral edema 24
cerebral edema mannitol 0.5-1 g/kg
20-30 cerebral edema water deficit
48 4000 ml/m2/24 hr
hypotonic solution hypernatremia
5.2 HCO31,2 HCO3 DKA severe acidosis (HCO3
8 mmol/l pH 7.0) hypovolemic shock
0.9% NaCl bolus HCO3
HCO3

125

HCO3 (mmol) = 0.3 x BW (kg) x (10- HCO3)

HCO3 10 mmol/l 2-4
HCO3 DKA
- serum osmolarity
- overshoot alkalosis
- K hypokalemia
- cerebral edema, coma death
- hypoxia shift oxyhemoglobin dissociation curve
5.3 Hypernatremic dehydration (corrected serum sodium >150 mmol/l) hyperglycemia
serum sodium (Na) corrected Na
Corrected Na = Na (/) +

blood glucose (./.) 100

x 1.6
100

corrected Na >150 mmol/l hypernatremia hyperosmolarity

Na cerebral edema
water deficit ( 72 ) 24
200-300 mg/dl Na
0.9% NaCl 2000 ml/m2/24 hr
Na hypernatremia
Na 10-15 mmol /l/24 hr
2-48

1.
0.45% NaCl + 40 mmol/l of potassium (20 mmol/l of KCl + 20 mmol/l of 2HPO4)
3000 ml/m2/24 hr ( hypernatremia)
2. (regular insulin)
2.1 regular insulin 100 units 0.9% NaCl 100 ml 1 ml = 1 unit
2.2 flush IV 30 ml
2.3 infusion pump pediatric set

126

2.4 0.1 unit/kg/hr continuous infusion

2.5 100 mg/dl/hr
3. Glucose infusion dextrose 300 mg/dl
100 mg/dl/hr alteration of consciousness 5%
10% Dextrose solutions 150-250 mg/dl
4.
4.1 glucose meter 1

4.2 serum electrolytes, Ca, PO4 2 4-6

acidosis
5.
5.1 flow sheet
5.2 vital signs, fundi cerebral edema
electrolytes
5.3

1.
1.1 HCO3 18 mmol/l
1.2
2. 20-30
non-dextrose solutions dehydration
3. (subcutaneous insulin)
3.1

3.2 regular insulin 0.25-0.5 unit/kg/dose

4-6 24 regular insulin
(NPH) 0.7-1 unit /kg/day 1-1.5 unit/kg/day 2 3
( NPH : regular insulin 2:1 ) 1 3
( NPH : regular insulin 1:1)

127

o . (Management for diabetic

ketoacidosis). 2545: 41 (1): 115-22.
o Wolfsdort J, Craig ME, Daneman D, et al. Diabetes ketoacidosis in children and adolescents with
diabetes: ISPAD clinical practice consensus guideline 2009. Pediatric Diabetes 2009:10 (Suppl 12): 11833.
o Sperling MA, Weinzimer SA, Tamborlane WV. Diabetes mellitus. In: Sperling MA, ed. Pediatric
Endocrinology, 3rd edition. Philadelphia: Saunders Elsevier 2008; 374-421.
o Clinical Practice Guideline: Diabetic Ketoacidosis.
. Available from
http://www.ped.si.mahidol.ac.th/mdbtemplate/mytemplate/template.php?component=menu&qid=9

128

12.
(Pre-gestational diabetes)

1.

2 human chorionic somatomammotropin (post-prandial
hyperglycemia)
2. diabetic retinopathy
(tight control)

diabetic retinopathy proliferative
diabetic retinopathy diabetic retinopathy

3. diabetic nephropathy proteinuria

70
diabetic nephropathy proteinuria (creatinine
clearance) proteinuria
serum creatinine 3 ./

(toxemia of pregnancy) (pyelonephritis) (polyhydramnios)
(caesarian section)

(spontaneous abortion) (congenital malformation)
9 HbA1c
9 macrosomia

129

hyperinsulinemia
intrauterine growth retardation (IUGR)
(microangiopathy)
uteroplacental insufficiency (intrauterine fetal death)

lactate
metabolic acidosis
respiratory distress syndrome
hyperinsulinemia

(hypocalcemia hypomagnesemia).
(Gestational diabetes mellitus)
perinatal loss
(macrosomia, 4
) hypoglycemia, hypocalcemia, polycythemia hyperbilirubinemia macrosomia
(obesity)


(organogenesis)

1. The HAPO study cooperative research group. Hyperglycemia and adverse pregnancy outcomes. New
Engl J Med 2008; 358: 1991-202.
2. Bellamy L, Casas JP, Hingoranai AB, Williams D. Type 2 diabetes mellitus after gestational
diabetes: a systemic review and meta-analysis. Lancet 2009; 373: 1273-9.