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DM Yumitra
DM Yumitra
DIABETES MELLITUS
2
Lethargy
Diagnostics
► Oral glucose tolerance test (OGTT)
► Fasting blood glucose
► HBA1C
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Cardiovascular Risk Estimation
ASSESSMENT UPON DIAGNOSIS 11
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Physical examination of newly diagnosed 14
patient with T2DM
BASELINE 15
INVESTIGATIO
N
► Fasting plasma glucose (FPG)
► HbA1c
► Renal profile
► Lipid profile
► Liver function test
► Urinalysis for albumin, microalbuminuria if
albuminuria is absent
► ECG
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Tobacco cessation
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MEDICATIONS
OHA
Biguanides
Sulphonylurea
s Meglitinides
Alpha glucosidase inhibitor
Thiazolidinediones
Dipeptidyl peptidase 4 inhibitor
Sodium glucose
cotransporter 2 inhibitor
Biguanides (metformin) 19
BASAL INSULIN
PRANDIAL INSULIN administered once or twice daily. The
administered pre-meal because of its intermediate or long
short or rapid acting pharmacokinetic profile
onset of action in controlling covers the basal insulin requirements
postprandial glucose excursion. in between meals and through the
night.
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How to Initiate Insulin? 26
► An ideal insulin regimen should mimic the physiological insulin response
to meals and endogenous hepatic glucose production.
► Option for initiation include:
1. basal insulin
- can be initiated at 10U a day or 0.1-0.2 U/kg/day,
- set FPG target and choose evidence-based titration algorithm e.g.
- increase by 2 U every 3 days to reach target FPG without
hypoglycaemia; OR
- Adjust 2 U every week based on 3 days’ glucose
readings.
MANAGEMENT OF
CHRONIC
COMPLICATIONS
DIABETIC 32
► SCREENING
R ETIN O PATHY ▪ visual acuity assessment – Snellen chart
▪ fundus camera photography
► EYE EXAMINATION
▪ Referral to ophthalmologist at the time of diagnosis of
T2DM
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M ANAG EMENT
DELAY
ONSET
Glucose
Intensive glucose-lowering has been shown to prevent and/or delay onset
Blood pressure
Lowering blood pressure (BP) decreases retinopathy progression, although lowering BP
intensively (systolic BP <120 mmHg) does not impart additional benefit.
Fenofibrate use
Retinopathy progression may be slowed by addition of fenofibrate particularly in those with
non-proliferative diabetic retinopathy (NPDR).
PROGRESSION
Photocoagulation therapy
Laser photocoagulation remains the standard practice for treating diabetic retinopathy. Laser therapy is
indicated for severe NPDR and proliferative diabetic retinopathy.
Diffuse neuropathies
• distal symmetric
polyneuropathy (DSPN)and
diabetic autonomic neuropathy
(DAN) particularly CV
autonomic neuropathy
Focal neuropathies
• mononeuritis and
radiculopathies.
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MANAGEMENT
Intensive lifestyle intervention
► Intensive glycemic control
► No pharmacologic therapy has been shown to be effective in treating DSPN
► Opioids
► Tricyclic antidepressants
Cardiovascular disease
Lifestyle modification
Smoking cessation
Glycaemic control
BP control
Antiplatelet therapy
Revascularisation
Peripheral arterial disease (PAD)
PREVENTION
-proper care of feet including nail and skin care
- daily visual inspection of feet with a mirror, in those with Loss of protective sensation (LOPS),
- check for presence of foreign or penetrating objects before putting on footwear,
-advise not to walk barefoot outdoors or indoors, selection of appropriate footwear according
to foot risk, including certain prescribed footwear for high risk patients
-seek early treatment in presence of active diabetic foot problems (e.g. ulceration,
infection, gangrene or limb ischaemia).
MANAGEMENT
MANAGEMENT
Referral to a mental health specialist
Behavioral treatment interventions which include cognitive behavioural therapy and exercise
Sexual dysfunction
Erectile d y s fu n c ti o n
MANAGEMENT
-Optimization of glycaemic control, management of other co-morbidities and
lifestyle modifications should be encouraged.(Level III)
-Psychosexual counselling is recommended in functional ED.
-Referral to a urologist
-Phosphodiesterase-5 (PDE-5) inhibitors e.g. sildenafil, tadalafil and vardenafil
should be offered as first-line therapy
Female sexual dysfunction
MANAGEMENT
Emphasis should be made to treat psychosocial disorders and relationship
disharmony.
Optimisation of glycaemic control should be encouraged.
Avoid drugs that may affect sexual function such as beta blockers, alpha blockers,
calcium channel blockers, diuretics,oral contraceptive pills.
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