Diabetes update

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Diabetes update

• Mary Scott
• Diabetes MCN Manager
• Lothian

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Content

• Diagnostic criteria
• Nutritional management
• Oral Hypoglycaemic agents
• Insulin in Type 2 diabetes
• Hypoglycaemia
• Foot care

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Diagnosis

• Symptoms 1 abnormal blood glucose value
• or
• 2 abnormal blood glucose values
• (not using a home blood glucose monitoring kit)

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Symptoms

• Polyuria
• Polydipsia/nocturia
• Tiredness
• Weight loss (Type 1)
• Blurred vision
• Ketones in urine (Type 1)
• Dehydration

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Diagnostic blood glucose values

• FBG gt 7 mmol/l
• RBG gt 11.1mmol/l
• IFG gt6mmol/l and lt7 mmol/l
• OGTT
• IGT 2 hour BG gt7.8 mmol/l and lt11.1mmol/l

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Nutritional management
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Dietary recommendations for diabetes

• Eat starchy foods regularly
• Eat more fruit and vegetables
• Reduce animal or saturated fat
• Cut down on sugar
• Reduce salt

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Balancing food choices
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Eat starchy foods regularly

• Bread
• Potatoes
• Rice
• Pasta
• Cereals
• Chapatis

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Eat more fruit and vegetables

• Fresh
• Frozen
• Tinned
• Dried
• Juice

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Reduce animal or saturated fat intake

• Use low fat milk
• Use low fat spread instead of butter
• Use oil high in unsaturated fat, eg olive oil,
  rapeseed oil

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Use less fat in cooking

• Grill
• Dry-roast
• Microwave
• Steam

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Choose the right sort of fat

• SATURATED
• Full fat dairy produce (eg cheese, butter, full
  cream milk)
• Pies
• Biscuits
• Savoury snacks
• Lard
• Hard vegetable fat

• MONO- UNSATURATED
• Olive oil
• Rapeseed oil
• Groundnut oil

• POLY- UNSATURATED
• Sunflower oil (products)
• Oily fish

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Cut down on sugary foods

• Not a sugar free diet
• Cut out sweets
• Cut out sugary drinks

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Choose low sugar products

• Use diet or low calorie, sugar free drinks

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Intense sweeteners

• Tablet
• Liquid
• Granulated

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Avoid diabetic products

• Cost
• Laxative effects
• Focus on sugar free
• Still raise blood glucose levels
• Still contain same calories

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Reduce salt intake

• Cut down on added salt
• Use alternative seasonings
• Look out for reduced/low sodium foods, eg bread
• Avoid salt substitutes

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Eat regular meals based on carbohydrate
Breakfast
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Lunch or snack meal
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Main meal
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Drink alcohol in moderation
1 unit of alcohol
1/2 pint beer or lager or cider
1 standard glass of wine
1 pub measure of sherry, vermouth, aperitif or
liqueur
1 pub measure of spirit, eg gin, vodka or whisky
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Oral agents
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Oral agents

• Sulphonylureas
• Biguanides
• Thiazolidinediones (the glitazones)
• Post-prandial glucose regulators
• Acarbose

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Sulphonylureas

• Augment insulin secretion from beta cells, so
  must be some activity remaining.
• Hypoglycaemia may occur
• Glipizide and gliclazide most commonly used
• Can be used in combination

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Sulphonylureas..side effects

• Can cause weight gain, metformin 1st choice in
  obese
• Care in renal or hepatic failure
• Contraindicated in breast feeding and change to
  insulin if pregnant or other severe illnesses.

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Sulphonylureas..more side effects

• Hypoglycaemia
• weight gain
• GI disturbances
• Liver disturbances, cholestatic jaundice,
  hepatitis
• Hypersensitivity reactions including
  photosensitivity
• Blood Disorders.

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Biguanides (well.metformin!)

• Inhibits gluconeogenesis
• Increases peripheral utilisation of glucose
• (Reduces appetite??)
• Dose

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Metformin..

• Drug of choice in obese Type 2 patients
• Not associated with weight gain
• Is effective as monotherapy as well as in
  combination with an SU, TZD, nateglinide or
  insulin
• Used alone it can reduce FBG by 22 - 26
• Used alone it can reduce HbA1c by 12 - 17
• UKPDS demonstrated a reduction in macrovascular
  complications and mortality with the use of
  metformin in obese Type 2 DM

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Metformin..contraindications

• Renal failure (local consensus at serum
  creatinine gt150?mol/L)
• Acute renal failure may lead to lactic acidosis
• Hepatic impairment
• Alcohol abuse
• Significant cardiac disease
• Pregnancy and lactation
• Age not proven to be an independent risk factor
  for metformin use.

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Metforminthe side-effects

• Dose requires titration to minimise GI
  side-effects
• 20 - 30 of patients experience abdominal
  discomfort, nausea, anorexia or a metallic taste
• Significant proportion of these patients go on to
  tolerate metformin well
• Evidence of malabsorption of vitamin B12 although
  very rarely clinically manifested.

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Thiazolidinediones (TZDs, the glitazones)
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Mode of action

• These act by activating PPAR? (a nuclear receptor
  responsible for activating insulin-sensitive
  genes) and hence reducing insulin resistance and
  increasing the uptake of glucose by the tissues.
• Rosiglitazone (Avandia)

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Prandial Glucose Regulators(the meglitinides)
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The Meglitinides...

• Repaglinide (Novonorm) and Nateglinide
  (Starlix)
• Both stimulate insulin release but are chemically
  distinct and have different mechanisms of action
• Both compounds have very short actions which deal
  effectively with postprandial glycaemic peaks,
  and are omitted if a meal is missed

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Mode of action.

• Nateglinide
• Works by restoring early phase insulin release
  within the ? cells, and has a synergistic action
  with metformin.
• Licensed for combination with metformin only.

• Repaglinide.
• Stimulates the same secretory mechanism as SUs,
  but does not promote insulin release in the
  absence of glucose.
• Licensed for monotherapy and combination

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Acarbose

• alpha glucosidase inhibitor
• delay digestion and absorption of starch and
  sucrose
• use on own or as adjunct
• cause GI upset, flatulence common
• cannot cause hypoglycaemia

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Insulin Management
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Those requiring insulin

• Type 1 patients
• Type 2 deteriorating control
• Prevention of progression of complications
• Poor tolerance of OHAs
• Acute situations
• Pregnancy

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Employment issues

• Group II licence
• Services
• Police
• Fire service
• Diving/deep sea work
• High work/scaffolding
• Planes/boats/trains

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Hypoglycaemia
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Hypoglycaemia

• Blood glucose below 3.0 mmol/L
• Hypoglycaemic unawareness is a major risk factor
• Shaky, sweaty, tingling in lips, heart pounding,
  irritability and confusion
• Hypos and alcohol
• Hypos in Type 2 Diabetes

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Treatment of Severe Hypoglycaemia

• Oral glucose - Lucozade, Hypostop followed by
  more complex CHO - bread
• IV dextrose 50
• IV, IM S/C Glucagon 1 mg

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Complications of severe hypoglycaemia

• Transient hemiplegia
• Dysphasia
• Pulmonary oedema
• Cerebral oedema
• Permanent brain damage

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The diabetic foot

• Neuropathy
• Ischaemia
• Combination of neuropathy and ischaemia

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Ischaemia

• Reduced/absent pulses
• Dry shiny atrophic skin
• Intermittent claudication
• Nocturnal cramps
• Rest pain

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Neuropathy

• Nerve damage
• Reduced sensation
• Ulceration
• Not noticed by the patient

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Signs of neuropathy

• Lack of sensation
• Numbness/parasthaesia
• Painful neuropathy
• Foot deformity
• Bounding pulses
• Venous distension
• Warm pink skin

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Ischaemia and Neuropathy

• Co-exist in diabetic foot
• Ulceration
• Infection
• Gangrene
• Amputation

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Foot ulceration risk factors

• History of previous ulceration
• PVD
• Neuropathy
• Foot deformity
• Nephropathy

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Foot ulceration risk factors

• Smoking
• Footwear
• Self treatment
• Poor sight
• Living alone
• Immobility
• Male sex

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Clinical features of ulcerationNeuroischaemia
has features of both
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Patient education

• Daily foot check
• Avoid walking barefoot
• Moisturise dry skin
• No self-treating
• Avoid direct heat
• Suitable footwear
• If in doubt, seek professional help

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Prevention

• Perform a simple foot assessment
• Check bare feet
• Determine risk
• Refer urgently to podiatrist or doctor if
• Ulceration
• Infection
• Necrosis