DIABETES MELLITUS - MANAGEMENT

SANDRA A P
39th BATCH
COMPLICATIONS OF DIABETES MELLITUS

ACUTE COMPLICATIONS:-
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Diabetic ketoacidosis (DKA) (type 1 DM) and
hyperglycemic hyperosmolar state (type 2 DM)
CHRONIC COMPLICATIONS:-
1)Microvascular complications (diabetic retinopathy,diabetic
nephropathy,diabetic neuropathy)
2)Macrovascular complications(coronary,cerebral,peripheral
circulation)
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Ophthalmologic: nonproliferative or proliferative diabetic retinopathy, macular edema, rubeosis of
iris, glaucoma, cataracts
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Renal: proteinuria, end-stage renal disease (ESRD), type IV renal tubular acidosis
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Neurologic: distal symmetric polyneuropathy, polyradiculopathy, mononeuropathy, autonomic
neuropathy
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Gastrointestinal: gastroparesis, diarrhea, constipation
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Genitourinary: cystopathy, erectile dysfunction, female sexual dysfunction, vaginal candidiasis
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Cardiovascular: coronary artery disease, congestive heart failure, peripheral vascular disease,
stroke
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Lower extremity: foot deformity (hammer toe, claw toe, Charcot foot), ulceration, amputation
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Dermatologic: Infections (folliculitis, furunculosis, cellulitis), necrobiosis, poor healing, ulcers,
gangrene
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Dental: Periodontal disease
MANAGEMENT
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Optimal treatment of DM requires more than plasma glucose management -
comprehensive diabetes care - also detect and manage DM-specific
complications and modify risk factors for DM-associated diseases.
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The patient with type 1 or type 2 DM should receive education about nutrition,
exercise, care of diabetes during illness, and medications to lower the plasma
glucose.
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In general,
1) the target HbA1c level should be <7.0%,
2) goal preprandial capillary plasma glucose levels should be 3.9–7.2 mmol/L (70–
130 mg/dL) , and
3) postprandial levels should be <10.0 mmol/L (<180 mg/dL) 1–2 h after a meal.
MANAGEMENT OF TYPE 1 DM
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Patients with type 1 DM require 0.5–1.0 U/kg per day of
insulin divided into multiple doses.
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Preferred regimens include injection of glargine at bedtime
with preprandial lispro, glulisine, or insulin aspart or
continuous SC insulin using an infusion device.
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Pramlintide, an injectable amylin analogue, can be used
as adjunct therapy to control postprandial glucose
excursions.
MANAGEMENT OF TYPE 2 DM
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Managed with diet and exercise alone or in conjunction with oral glucose-lowering
agents, insulin, or a combination of oral agents and insulin.
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A reasonable treatment algorithm for initial therapy proposes metformin as initial
therapy because of its efficacy (1–2% decrease in HbA1c), known side-effect
profile, and relatively low cost.
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Advantages of metformin:-promotes mild weight loss, lowers insulin levels,
improves the lipid profile slightly, lowers cancer risk, and does not cause
hypoglycemia when used as monotherapy.
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Metformin is contraindicated in renal insufficiency, congestive heart failure, any
form of acidosis, liver disease, or severe hypoxia, and should be temporarily
discontinued in pts who are seriously ill or receiving radiographic contrast material.
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A routine urinalysis may be performed as an initial screen for
diabetic nephropathy. If it is positive for protein, quantification
of protein on a 24-h urine collection should be performed.
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If the urinalysis is negative for protein, a spot collection for
microalbuminuria should be performed (present if 30–300
μg/mg creatinine on two of three tests within a 3- to 6-month
period).
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A resting ECG should be performed in adults, with more
extensive cardiac testing for high-risk pts.
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Therapeutic goals to prevent complications of DM :-
1) Management of proteinuria with ACE inhibitor or angiotensin receptor
blocker therapy
2) BP control (<130/80 mmHg if no proteinuria, <125/75 if proteinuria),
3) Dyslipidemia management [LDL <2.6 mmol/L (<100 mg/dL)
4) HDL > 1.1mmol/L (>40 mg/dL) in men and >1.38 mmol/L (50 mg/dL) in
women, triglycerides <1.7 mmol/L (<150 mg/dL)]. In addition, any diabetic
pt >40 years should take a statin, regardless of the LDL cholesterol, and
in those with existing cardiovascular disease, the LDL target should be
<1.8 mmol/L (70 mg/dL).
GUIDELINES FOR ONGOING MEDICAL
CARE FOR PATIENTS WITH DIABETES
MANAGEMENT OF THE HOSPITALIZED
PATIENT
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Goals :- To achieve near-normal glycemic control, avoidance of hypoglycemia, and transition
back to the outpatient diabetes treatment regimen.
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Patients with type 1 DM undergoing general anesthesia and surgery, or with serious illness,
should receive continuous insulin, either through an IV insulin infusion or by SC
administration of a reduced dose of long-acting insulin(Short-acting insulin alone is
insufficient to prevent the onset of diabetic ketoacidosis.)
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Oral hypoglycemic agents should be discontinued in patients with type 2 DM at the time of
hospitalization.
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Either regular insulin infusion (0.05–0.15 U/kg per hour) or a reduced dose (by 30–50%) of
long-acting insulin and short-acting insulin (held, or reduced by 30–50%), with infusion of a
solution of 5% dextrose, should be administered when pts are NPO for a procedure.
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A regimen of long-and short-acting SC insulin should be used in type 2 patients who are
eating.
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The glycemic goal for hospitalized patients with DM should
be a preprandial glucose of <7.8 mmol/L (<140 mg/dL) and
<10 mmol/L (<180 mg/dL) at post-meal times.
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For critically ill pts, glucose levels of 7.8–10.0 mmol/L (140–
180 mg/dL) is recommended
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Those with DM undergoing radiographic procedures with
contrast dye should be well hydrated before and after dye
exposure, and the serum creatinine should be monitored
after the procedure.