Diabetes in

special
population
Disediakan oleh : Nur ‘Afiqah
Ruslan
1. Acute illnesses, Stress and Surgery

– Diagnosis of T2DM in an inpatient hospital setting is based on the following :

- History of T2DM
- No history of T2DM : BG > 7.8mmol/L and elevated A1c
– During hospital admission, OADS should be stopped for the
following :
- Poor oral intake
- Acute kidney injury
- Exposure to IV contrast dye (specifically for metformin)
- Illness becomes critical
- Organ failure
– Stable patients without above contraindications can have their
home medications continued while in the hospital
– Basal-bolus therapy may be used. The target preprandial glucose is
recommended between 5 – 8 mmol/L with random BG < 10 mmol/L
as long these targets can be safely achieved without hypoglycaemia

A. Non critically ill patient

– Intensive insuli therapy has been associated with an increased risk
of hypoglycaemia and mortality in ICU setting
– It is recommended to maintain BG levels between 8 and 10
mmol/L. A lower BG target (not <6mmol/L) may be appropriate in
post-CABG patients
– Insulin infusion protocols with proven efficacy and safety are
recommended to minimise the risk of hypoglycaemia

B. Critically ill patients

– Acute hyperglycaemia during major surgery increases
postsurgical complications,morbidity and mortality
– Tight glycaemic control to achieve normoglycaemia while
avoiding hypoglycaemia is recommended

C. Major surgery
– Insulin can be administered with the PN. An IV insulin infusion of regular insulin is often
used to estimate the total daily dose (TDD) of insulin required.
– For premixed insulin, the TDD is divided by 3 and given 3 times a day to match the feeding
time
– Alternatively, use a long acting and less peak basal insulin alone
– For basal bolus regime, 50% of TDD is provided as basal insulin and 50% as bolus insulin
which is in divided doses
– Short acting insulin is preferred over rapid acting because of the longer duration of action
– In the event that the tube feeds are interrupted, IV dextrose may be required to prevent
hypoglycaemia

D.Enteral or Parenteral feeding

Although the optimal management of hyperglycaemia in patients
receiving high dose oral corticosteroid has not been clearly defined,
glycaemic monitoring for at least 48 hours is recommended.
– Insulin is generally preferred with an emphasis on adjusting bolus
insulin doses and avoiding hypoglycaemia
– During tapering of corticosteroid therapy, insulin dosing should be
proactively titrated to prevent hypoglycaemia

E. Corticosteroid therapy
 2. Pregnancy and Gestational DM
Pre-conception counseling
– The discussion should include :
1. Pregnancy has to be planned and to occur only when the woman has good glycaemic control, has
had appropriate assessment and management of comorbidities and has discontinued potentially
unsafe medications during pregnancy
2. The importance of smoking cessation
3. The time, commitment and effort required by the patient in both self-management and
engagement with the health care team
4. Importance of notifying the health care team without delay in the event of conception
Pre-pregnancy management
– Keep A1c as normal as possible
– Weight reduction in those overweight and obese before pregnancy
– Folic acid supplementation should be started 3 months before withdrawal of contraception
– Women on OADs can be switched to insulin for better glycaemic control before planning
pregnancy
– Screen for retinopathy and nephropathy
– BP control of <130/80 mmHg is necessary. (safe antiHTN : methyldopa, labetalol, nifedipine,
diltiazem, prazosin)
– Statin should be discontinued
– Patient with multiple CV risk factors should undergo CV risk assessment prior to withdrawal of
contraception. MI during pregnancy is associated with adverse maternal and foetal outcomes.
GDM
• GDM is any degree of glucose intolerance which is first recognised
during pregnancy, whether or not the condition persisted after
pregnancy
• The risk of adverse maternal, foetal and neonatal outcomes
continuously increased as a function of maternal glycaemia at 24-28
weeks, even within ranges previously considered normal for
pregnancy
Screening and Diagnosis
• Screening should be performed between week 24 to 28 gestation using
mOGTT.
• Initial screening of high risk women at booking can be performed by
using either 75gmOGTT , with 0 and 120 plasma glucose measurement or
FPG
• In those who have the above risk factors and initial screening results are
normal, a repeat OGTT should be performed 4-6 weeks later.
• A single abnormal resultis sufficient to confirm the diagnosis
Management
– Nutrition
– Weight management
– Insulin therapy
 Should be considered if the blood glucose targets are not met 1-2 weeks after introducing
changes to diet and initiating exercise
 The best insulin regime is multiple daily injections
 In the first trimester,there is often decrease in TDD of insulin. In the second trimester,
rapidly increasing insulin resistance requires biweekly titration in insulin dose
 Long acting insulin analogue may be used in cases of repeated nocturnal hypoglycaemia
Cont…
– OAD therapy
 Use of metformin in GDM is not associated with any birth defects, pre-ecclampsia or any
adverse maternal nor foetal outcomes
 Metformin may be offered to well-informed pregnant women after discussion on the safety
and off label use of it
 Use of MTF in women with PCOS is associated with reductions in miscarriage in early
pregnancy, weight, fasting serum insulin levels and the indicidence of gestational diabetes
 MTF leads to better maternal outcomes in term of weight gain, postprandial blood glucose,
and pregnancy induced HTN ; while foetal outcomes were better in terms of severe
neonatal hypoglycaemia but worse in terms of preterm birth
 The use of glibenclamide in GDM is associated with increased of neonatal hypoglycaemia,
high maternal weight gain and macrosomia
Cont…
– SMBG
 Monitoring should be done at fasting and before each meal ; 1 or 2 hours after the
start of each meal ; bedtime and during nightif indicated
 Monitoring should preferably be done at home. The traditional blood sugar profile
performed in the hospital may not reflect the actual day-to-day blood sugar levels
– Intrapartum
 Monitor capillary plasma glucose every hour to maintain between 4-7 mmol/L
 Infusion should be initiated if the blood glucose is not maintained.
– Postpartum
 Insulin requirement drop immediately after delivery by 60-75%
 When breastfeeding, if glycaemic control is inadequate with diet therapy alone, insulin therapy should
be continued at a lower dose
 In non breastfeeding mothers, OAD can be continued
 Low dose MTF can be safely used in nursing mothers.
 Those whose blood sugar normalised immediately after delivery should have mOGTT performed 6
weeks later. A1c may be falsely elevated in those who are taking iron supplements
 Women with a history of GDM should have annual screening for diabetes. Lifestyle modifications or
MTF therapy post-GDM has been shown to prevent the development of diabetes
 3. Adolescents
– Rapidly increasing in tandem with rising sedentary lifestyles and prevalence of obesity
– Ketosis is not uncommon at presentation of T2DM among adolescents. This presentation may be
responsible for the misclassification of T2DM patients as T1DM
– T2DM may be misdiagnosed as T1DM :
 In non obese adolescents with diabetes
 When ketosis is present at onset
 When pancreatic autoantibodies are positive
– Other types of DM may be misdiagnosed as T2DM :
 Obese T1DM
 T1DM with low autoimmunity
 Monogenic diabetes
 Screening and Diagnosis
– Adolescent should be screened if they are symptoatic or if they are overweight,and have 2 or more of the following risk
 Family history of T2DM in first or second degree relative
 Signs of insulin resistance or conditions associated with insulin resistance
 Maternal history of GDM during child’s gestation
– Screen every 2 years starting at the age of 10 or at onset of puberty if puberty occurs at younger age. A glucose load of
1.75g/kg (max 75g) for OGTT is used
– Fasting insulin and C peptide have been used to aid in the diagnosis. However their measurement should be interpreted with
caution due to considerable overlap between T1DM , T2DM and monogenic diabetes at onset and within 2 years of
diagnosis.
– This overlap due to initial recovery phase of T1DM, glucotoxicity and lipotoxicity impairing insulin and C peptide secretion.
Such measurement are of little value in the acute phase of the illness. However, persistent elevation of C-peptide would be
unusual in T1DM after 12-24 months from diagnosis
– C-peptide should be measured if thereis worsening diabetes control in overweight/obese adolescent on oral agents, in order
to revise the diabetes classification
 Management

– Treatment of T2DM in adolescent follow the same rationale as does treatment in adult
– Among all the OADs currently used in adults, only metformin and insulin are FDA
approved for use for < 18 years ago
– Metformin should be started with 500mg daily for 7 days. Gradual dose increment by
500mg once a week over 3-4 weeks until the maximal dose of 1000mg BD is achieved
– Insulin may be required for initial metabolic control. Transition from insulin to metformin
can usually be made when metabolic stability is reached. This may take 2-6 weeks
– In adolescent, long acting or immediate acting insulin may be added at a dose of
0.5IU/kg at bed time
4. Elderly

– They are at an increase rate of concomitant illnesses eg: hypertension, renal

impairment, ischaemic heart disease, and functional disabilities Elderly with
diabetes also have a higher incidence of age-related problems which may be
exacerbated by diabetes eg: cognitive impairment, incontinence and
polypharmacy
– The life expectancy within this elderly diabetic population is highly variable
Management

– Greater variability of glucose value is associated with poorer cognition despite equivalent
glycemic control.This is not suprising given that hypo episodes are more common in the
elderly. Cognitive dysfunction and frailty increases the risk of hypo and this causes further
impairment of cognitive dysfunction and exacerbate frailty
– Thus, the decision of how tight the glycaemic control is less dependent on the chronological
age but more on the degree of frailty and overall life expectancy of each individual
– SUs should be used with caution because the risk of severe or fatal hypoglycaemia increases
exponentially with age and is higher with glibenclamide than gliclazide and glimepride
– The use of insulin in the elderly is associated with increased risk of hypoglycaemia, therefore
every effort should be made to minimize the risk
5. Ramadhan

– There are several potential risks associated with fasting in Ramadhan namely
hypoglycaemia/hyperglycaemia, DKA and dehydration
– It is important to categorise patient who intend to fast based on risk
stratification as listed in Appendix 8. Those in high and very high risk categories
should abstain from fasting
 Preparation prior to Ramadhan

– Patient and care givers should receive education concerning self-care on the following :

 Risk from fasting

 Blood glucose monitoring

 When to stop the fast

 Adequate fluid intake

 Meal planning and food choices

 Physical activity-timing and intensity

 Medication administration – timing and dosing

 Management of acute complication

– Patient must immediately end their fast when :

 Blood glucose <3.3mmol/L at any time during fast

 Blood glucose <3.9 mmol/L in the first few hours of fasting esp taking Sus,meglitinides or insulin

 Blood glucose > 16.7 mmol/L

 Experience symptoms of hypiglycaemia

 Symptoms suggestive of severe dehydration such as syncope and confusion

Adjustment of the Diet Protocol for
Fasting
– Never skip Sahur. Sahur should consist of a balanced meal with adequate
carbohydrate taken as late as possible just before imsak to avoid unnecessarily
prolonged fasting
– Do not delay the iftar. Limit intake of high sugar foods. However, 1-2 kurma at the
start of iftar may be taken as part of carbohydrate exchange. The main meal is
encouraged after the performance of maghrib prayers
– Supper (moreh) can be considered as a pre-bed snack during non-fasting month
– Limit intake of salty foods to reduce the risk of dehydration
– Sufficient fluid must be taken to replenish fluid loss during the day. Aim 8 glasses of
fluid a day
Physical activity

– Light and moderate intensity exercise on a regular basis

– Avoid rigorous exercise during daytime because of the risk of hypoglycaemia
– The timing of exercise is preferably performed 1-2 hours after the break of fast
– Performance of Tarawih prayers is a form of physical activity
 OADs
– In principle, the non-fasting morning dose should be taken during iftar,
and the non-fasting evening dose should be taken during sahur
GLP-1RA
Insulin