Assesment and Monitoring

of
Diabetes and Hypertension
DR CHUA YIK HUANG
P E G AWA I P E R U B ATA N
K L I N I K K E S I H ATA N L A N A N G
OVERVIEW
At diagnosis, a detailed history, full physical examination and
baseline investigations
- to assess the CVD risk factors and complications of diabetes.
Management should be based on the initial assessment and baseline
investigations.
Diabetes management involves lifestyle modification, medications
and patient education to encourage self-care and empowerment.
Diagnostic Values for Diagnosis of T2DM based on Venous
Plasma Glucose

Fasting Random

Venous Plasma Glucose ≥ 7.0 mmol/L ≥ 11.1 mmol/L

In the symptomatic individual, one abnormal glucose value is

diagnostic
In the asymptomatic individual, 2 abnormal glucose values are
required

MODUL LATIHAN PENGENDALIAN PERKHIDMATAN NCD UNTUK PARAMEDIK

Diagnostic Values - OGTT
OGTT Plasma Glucose Values (mmol/L)
Category 0-hour 2-hour
Normal ≤ 6.1 < 7.8
IFG 6.1 – 6.9 -
IGT - 7.8 – 11.0
DM ≥ 7.0 ≥ 11.1
Diagnostic Values for Pre-Diabetes and T2DM
based on HbA1c

Normal Pre-diabetes Diabetes

HbA1c <5.6% 5.6 – 6.2% > 6.3%

(38 mmol/mol) (38-44 mmol/mol) (45 mmol/mol)
HISTORY TAKING
PHYSICAL EXAMINATION
MODUL PENGENDALIAN PERKHIDMATAN NCD UNTUK PARAMEDIKS KKM
INVESTIGATION
Aim of Treatment
Overall aim to improve quality of life, reduce complications and
prevent premature death.
a) Short term:
• Relieve of symptoms and acute complications
b) Long term:
• Achievement of appropriate glycaemic levels
• Reduction of concurrent risk factors
• Identification and treatment of chronic complications
DIABETIC EDUCATION
Effective in improving clinical outcomes and quality of life
Should be advocated to all patients with T2DM regardless of their
treatment mode. Their family members and carers should be
involved as well.
The more the duration of contact time between the educator and
the patient, the better the A1c reduction.
CONTENT OF DIABETES
EDUCATION
Diet  Stop smoking
Food exchanges  Problem solving example
management of hypoglycaemia, sick
Exercise days
Medication  Psycological adaptation to diabetes,
Complications (acute / management of stress related
chronic) diagnosis and progress of diabetes
Self-care / SMBG / Foot
care
RECOMMENDATION
1. All patients should be given diabetes education. [Grade A]

2. The type of education, content, duration and revision frequencies should

depend on the need of the patients and the resources at the health care
centre. [Grade C]

3. All newly diagnosed T2DM need to be reviewed by a medical doctor in

which screening for other cardiovascular risks need to be carried out. [Grade
C]

4. The significance of the legacy effects and metabolic memory should be

emphasised to all newly diagnosed diabetic patients. [Grade A]
TARGET FOR T2DM CONTROL
HbA1c TARGET
MONITORING
 HbA1C
Perform A1c approximately every 3–6 months:
• 3 monthly, if A1c is above target and to allow assessment of effect of
therapeutic adjustment.
• 6 monthly, if A1c target is achieved and stable.

Limitations of A1c
• haemolysis (increased RBC turnover) e.g.haemoglobinopathy and
anaemia
• A1c results do not correlate with glucose levels
• alternatives such as SMBG should be considered.
 SELF MONITORING OF
BLOOD GLUCOSE (SMBG)
 Helps in assessing glycaemic control and prevent
hypoglycaemia.

 Recommended in patients on insulin and is desirable for

those on OAD agents. (Level III)

 Patients should be taught how to use SMBG data to

adjust food intake, exercise, or pharmacological therapy
to achieve pre-defined goals.
Recommendation of SMBG
 TAKE HOME MESSAGES
Pemantauan komplikasi dan ko-mobiditi sekurang-kurangnya
setahun sekali atau lebih kerap jika simptomatik
Ujian pemantauan / asas hendaklah di buat sekurang-kurangnya
setahun sekali
Intervensi non-pharmacology (diet dan aktiviti fizikal) hendaklah
menjadi asas pengendalian diabetes
Pendidikan diabetes sangat penting untuk memastikan pesakit
diabetes diperkasa dan boleh mengendalikan diabetes sendiri
HYPERTENSION
OBJECTIVE
1. To exclude secondary causes of hypertension.
2. To ascertain the presence of target organ damage or
complication.
3. To assess lifestyle and identify other cardiovascular risk
factors or coexisting condition that affect prognosis and
guide treatment.
 SECONDARY HYPERTENSION
• Parenchymal kidney disease • Cushing syndrome
• Renovascular disease
• Phaeochromocytoma
• Sleep apnoea
• Acromegaly
• Primary aldosteronism
• Drug-induced or drug-related
• Thyroid disease
» Oral contraceptives • Parathyroid disease
» Steroids • Coarctation of the aorta
» Non-Steroidal Anti-inflammatory Drugs / COX- • Takayasu Arteritis
2 Inhibitors
» Erythropoeitin
TARGET ORGAN DAMAGE
DIAGNOSIS AND
CLASSIFICATION
HISTORY
 duration and level of elevated BP if known

 symptoms of secondary causes of hypertension

 symptoms of target organ complications (i.e. renal impairment and heart
failure)
 symptoms of cardiovascular disease (e.g. CHD and cerebrovascular disease)
 symptoms of concomitant disease that will affect prognosis or treatment (e.g.
diabetes mellitus, heart failure, renal disease and gout)
family history of hypertension, CHD, stroke, diabetes, renal disease or
dyslipidaemia
• dietary history including salt, caffeine, liquorice and alcohol intake
• drug history of either prescribed or over-the-counter medication (NSAIDs,
nasal decongestants, OCP/HRT)
• exposure to traditional or complementary medicine
• lifestyle and environmental factors including air pollution that will affect
treatment and outcome (e.g. smoking, physical inactivity, substance abuse;
recreational & doping, psychosocial stressors and excessive weight gain)
• presence of snoring and/or day time somnolence which may indicate sleep
apnoea
PHYSICAL EXAMINATION
• General examination including height, weight and waist circumference
• Measure BP appropriately
• Fundus examination
• Examination for carotid bruit, abdominal bruit, presence of peripheral pulses and radio-femoral
delay
• Cardiac examination for cardiomegaly, signs of heart failure and aortic regurgitation
• Abdominal examination for renal masses/bruit and aortic aneurysm
• Neurological examination to look for evidence of stroke
• Signs of endocrine disorders (e.g. Cushing syndrome, acromegaly and thyroid disease)
• Ankle brachial index (if available)
INVESTIGATION
• Full blood count
• Blood glucose
• Renal function tests (creatinine, eGFR, serum electrolytes)
• Lipid profile (total cholesterol, HDL cholesterol, LDL cholesterol and
triglycerides)
• Urinalysis (dip stick: albuminuria/microalbuminuria & microscopic haematuria)
• Electrocardiogram (ECG)
Co-existing Cardiovascular Risk
Factors for Risk Stratification
• Diabetes mellitus
• Dyslipidaemia
• Cigarette smoking
• Microalbuminuria/Proteinuria
• Estimated GFR <60 mL/min/m2
Additional risk factor
- TC>6.5mmol/L, family history of premature
Vascular disease
MONITORING
REFERENCE
1. CPG- Management of Type 2 Diabetes Mellitus, 5th edition (December 2015).
2. CPG- Management of Hypertension, 5th edition (2018).