Professional Documents
Culture Documents
CPG DM
CPG DM
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
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 3
fasting plasma
glucose 126 ./.
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 ./.
=
2 75 (75 g OGTT)
2 h-PG < 140 ./.
=
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
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)
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
27
1-3
180-250 ./.
250-350 ./.
HbA1c >9%
2
>300 ./.
HbA1c >11%
>300 ./.
HbA1c >11%
*
Metformin
Sulfonylurea
:
:
BMI 23 ./. BMI < 23 ./.
acanthosis nigricans
130/85 .
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
Sulfonylurea
1. Metformin
2. Thiazolidinedione
3. DPP-4 inhibitor
4. Basal insulin
Premixed insulin
Premixed insulin analog
metformin
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.
3
RI/NPH 0 RI - NPH
4
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
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.
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 ./.
90-<130 ./.
< 180 ./.
< 7.0%
130 ./.
< 180 ./.
7.0 - 8.0 %
37
1-3 ( 2)
2. 1,2
/
**
(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
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)
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
()
1-2 6
2 3
serum Cr 2 mg/dL
eGFR < 60 ml/min
ACEI
ACEI ARB
microalbuminuria
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 /
( ++)
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
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
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
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
discharge 18 ( 1, ++)
3. 6
osteomyelitis 18 ( 4, +)
4. 2-4
6 osteomyelitis18 ( 1, ++)
70
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
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
5-10
OGTT
(2-hr plasma
glucose 200 ./.)
1.
2.
3.
Biguanide
Sulfonyluea
o
o
1.
2. 1
: 15
74
1. 2 ( 10 )
, ,
plasma
glucose
: 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 ()
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
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)
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
2-3
2
( 1)
1.
1
2
2.00 4.00
(./.)
60-95
<140
<120
>60
proliferative diabetic retinopathy
diabetic nephropathy proteinuria 70
88
(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
diabetic retinopathy
diabetic nephropathy
Myocardial Infarction
Cerebral Infarction
impaired fasting glucose (IFG)
/ /
(..)
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)
(drug interaction) -
- - -/
/
(
)
(non-compliance)
1 ()
1.
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
100
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
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
Biosensor Biosensor
GDH-PQQ GDH-PQQ
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
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
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
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.
*
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
I.V. P.O.
IPDOPD
4-6
I.V. P.O.
IPDOPD
> 3
BONE OR JOINT
No residual infected tissues e.g. post
amputation
Residual soft tissues (not bone)
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)
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
124
125
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
1.
1.1 HCO3 18 mmol/l
1.2
2. 20-30
non-dextrose solutions dehydration
3. (subcutaneous insulin)
3.1
127
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
(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.