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Guide to diabetes

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Title: Guide to diabetes


1
Guide to diabetes
2
Definition
  • Diabetes mellitus is a syndrome characterised by
    chronic hyperglycaemia and disturbance of
    carbohydrate, fat and protein metabolism
    associated with absolute or relative deficiency
    in in insulin secretion and\or insulin action.

3
  • Insulin allows glucose (sugar) to enter body
    cells to convert it into energy. Insulin is also
    needed to synthesize protein and store fats. In
    un controlled diabetes, glucose and lipids (fats)
    remain in the blood stream and, with time damage
    the bodys vital organs and contribute to heart
    disease.

4
Classification
  • Diabetes is classified into three main types
  • Type 1 previously called insulin-dependent
    diabetes mellitus (IDDM)
  • Type 2 previously called non-insulin-dependent
    diabetes mellitus(NIDDM)
  • Gestational Diabetes Mellitus(GDM)

5
Type 1 Diabetes
  • Occurrence
  • Autoimmune disease wherein the immune system
    attacks B-cells of pancreas and destroys them.
    The pancreas then produce little or no insulin.
  • Scientists do not know exactly what causes the
    bodys immune system to attack the B-cells, but
    they believe that both genetic factors and
    environmental factors and possibly viruses, are
    involved.

6
Characteristics
  • Often develops in children and young adults, but
    the disorder can appear at any age.
  • Symptoms usually develop over a short period,
    although B-cell destruction can begin year
    earlier.
  • If not diagnosed and treated with insulin, a
    person can lapse into a life-threatening diabetic
    coma, also known as diabetic ketoacidosis.

7
Type 2 diabetes
  • Occurrence
  • The most common form of diabetes.
  • Due to reduce insulin secretion or peripheral
    resistance to action of insulin.
  • The result is the same as for Type 1 diabetes,
    glucose builds up in the blood and the body
    cannot make efficient use of its main source of
    fuel.

8
  • Often part of a metabolic syndrome that includes
    obesity, elevated blood pressure, and high levels
    of blood lipids.

9
Characteristics
  • Contributes 90 to 95 of total diabetes and
    one-third not been diagnosed.
  • This form of diabetes usually develops in adults.
  • About 80 of people with Type 2 diabetes are
    overweight.
  • Increase in incidence of childhood obesity leads
    to Type 2 diabetes becoming more common in young
    people

10
Symptoms Management for Type 1 and Type 2
Diabetes
  • Symptoms
  • Increased thirst and urination.
  • Constant hunger.
  • Weight loss.
  • Blurred vision
  • Extreme fatigue.
  • Slow healing of wounds or sores.

11
Management
  • Diet
  • Exercise
  • Insulin for Type 1 and OHAs or insulin in Type 2
  • Education
  • Monitoring blood glucose and therapy

12
Gestational Diabetes
  • Occurrence
  • Develops in pregnancy and disappears after
    delivery, however with increased risk in getting
    later in life
  • Insulin resistance due to pregnancy.
  • Genetic predisposition.

13
Management
  • Diet provide adequate calories which will not
    lead to hyperglycemia or ketonemia.
  • Exercise that does not cause fetal distress,
    contractions or hypertension.
  • Insulin to maintain blood glucose,
    fastinglt95mg/dl (lt5.3 mmol/l) one hour post
    prandially lt120mg/dl(lt6.7 mmol/l).

14
Diagnosis
  • The fasting plasma glucose test in the
    preferred test for diagnosis Type 1 or Type 2
    diabetes. However, a diagnosis of diabetes is
    made by an one of the three positive tests, with
    a second positive on a different day

15
  • A random Plasma glucose value (taken any time of
    day) of 200mg/dl or more, along with the presence
    of diabetes symptoms.
  • A plasma glucose value of 126/mgdL or more, after
    a person has fasted for 8 hours

16
  • An oral glucose tolerance test (OGTT) plasma
    glucose value of 200 mg/dL or more in the blood
    sample, taken 2 hours after a person has consumed
    a drink containing 75 grams of glucose dissolved
    in water. This test, taken in a laboratory or the
    doctors office, measures plasma glucose at timed
    intervals over a 3-hour period.

17
Gestational Diabetes
  • Diagnosed based on plasma glucose values
    measured during the OGTT. Glucose levels are
    normally lower during pregnancy, so the threshold
    values for diagnosis of diabetes in pregnancy are
    lower. If women has two plasma glucose values
    equal to or more than any of the following values
    after a 100gm OGTT, she has gestational diabetes

18
  • 1-hour level of 180 mg/dL
  • 2-hour level of 155 mg/dL or 3-hour level of 140
    mg/dL
  • Fasting plasma glucose level of 95mg/dL

19
  • People with impaired glucose metabolism, a
    state between normal and diabetes are at risk for
    developing diabetes, heart attacks, and strokes.
    There are two forms of impaired glucose
    metabolism.

20
Impaired Fasting Glucose (IFG)
  • Fasting plasma glucose level of 110 to 125 mg/dL,
    a level higher than normal but less than the
    level indicating a diagnosis of diabetes.

21
Impared Glucose Tolerance (IGT)
  • Means that blood glucose during the oral
    glucose tolerance test is higher than normal but
    not high enough for a diagnosis of diabetes. IGT
    is diagnosed when the glucose level is 141 to 199
    mg/dL, 2 hours after a person is given a drink
    containing 75 grams of glucose.

22
OGTT
  • OGTT is performed using a 75 or 100 gm oral
    glucose load in the morning after a noncaloric
    8-hour fast. Water is allowed, but not coffee or
    smoking.
  • Test should be performed on an individual without
    underlying illness and/or interfering drugs. OGTT
    is not appropriate for a patient who is
    malnourished, on a restricted carbohydrate diet,
    or with acute and chronic illness.

23
  • Patient should be ambulatory and not to bed rest,
    hospitalized , or immobilized. During the test,
    patient should be resting comfortably.
  • Patient should consume an unrestricted diet
    containing at least 150g carbohydrate daily for
    three days before test.
  • Just a confirmatory test, not to be done
    regularly.

24
Glycated Hemoglobin (HbA1c) Test
  • Indicates blood glucose control over a period of
    approximately 3 months.
  • Normal range varies depending on the method the
    lab uses usually 4-7, correlating to average
    blood glucose of 60-150 mg/dl (3.3-8.3 mmol/l)

25
  • Should be prescribed by health care provider
    every three months for Type 1 diabetes and at 3-6
    months intervals for Type 2, to help determine
    overall control.
  • Patient does not need to be fasting to have this
    blood test performed

26
Ketone Test
  • Ketone is by product of fat metabolism presence
    of ketone indicates that the body is not
    metabolizing food properly because of lack of
    available insulin or carbohydrate may indicate
    impeding or established diabetic ketoacidosis
    (DKA), a condition that requires immediate
    medical attention.

27
Method Dipstick
  • When to test
  • When blood glucose level is consistently gt300
    mg/dl (16.7 mmol/l).
  • During period of acute illness (illness is a
    stress that can cause and hyperglycemia).
  • When symptoms of hyperglycemia accompanied by
    nausea, vomiting and abdominal pain are present.

28
Treatment strategy
29
Goals Of Treatment
  • Control high blood glucose (hyperglycemia)
  • Avoid low blood glucose (hypoglycemia).
  • Treatment of associated conditions, such as high
    blood pressure, cholesterol disorder and obesity.
  • Prevent or retard the progression of
    complications of diabetes such as blindness,
    kidney failure, heart disease, stroke and
    amputation of legs.

30
Treatment Plan
  • Management of Blood Glucose
  • Target Blood Glucose values
  • (as recommended by the American Diabetes
    Association)

31
  • However, not every person is a candidate for such
    tight blood glucose control. This should not be
    attempted in
  • Frail, elderly person who have already developed
    the complications of diabetes such as blindness
    and end-stage kidney failure.
  • Elderly patients having frequent low blood
    glucose episodes.

32
Management of cholesterol
  • Target Cholesterol Levels
  • (as recommended by the American diabetes
    association)

33
Management of High Blood Pressure
  • Target blood pressure in diabetic patients should
    be less than systolic 130/ diastolic 85 mm Hg, as
    recommended by the American diabetes Association.
  • The treatment strategy also involves correct
    nutrition, moderate exercise and proper
    medication.

34
Nutrition
  • Nutrition is an important element in diabetes
    management.
  • Diet content should be 10-2- protein, 60
    carbohydrates and 20 fats.

35
Dos of diabetic diets
  • Consistency in diet and meal timings according to
    medicines.
  • Multivitamin containing an antioxidant such as
    vitamin ,beta-carotene, vitamins C and E.
  • Minimum of 1200 kcal/day for women and 1500
    kcal/day for men.

36
  • Sodium level (salt intake) should be maintained
    between 2.4 and 3.0 gm/day for people without
    hypertension and gt2.4 gm/day for people with mild
    to moderate hypertension.
  • Fibre of approximately 20- 35 gm/day from a
    variety of food sources should be consumed

37
Donts of diabetic diets
  • Avoid alcohol especially if diabetes is not in
    control.
  • Avoid in-between meals. Adhere to the time and
    size of the meal decided.
  • Avoid fasts and fasting alters body metabolism,
    adversely affecting the diabetic state.

38
Exercise
  • Exercise can improve the health and outlook of
    life. Regular and controlled exercise not only
    helps to increase glucose utilization but also
    helps to maintain desirable health.

39
Dos in exercise
  • Check the patients for blood pressure, blood fat
    levels, HbA1c, health of heart, circulatory and
    nervous systems, kidney function, eyes and feet.
  • Choose exercises that fit the patients health.
  • Exercise should be preceded and followed by 5-10
    minutes of slow, continuous, aerobic activities.

40
  • Remember the feet.Advice them to wear the
    comfortable shoes for the sport.
  • Watch the low blood sugar, insulin or oral
    diabetes medicine may lead to low blood sugar
    levels.
  • Advice the patients to keep a snack handy to
    avoid low blood sugar levels during the exercise.

41
Donts in exercise
  • Advise not to snack unnecessarily before
    exercise.
  • Uncomfortable shoes should not be worn while
    exercising.
  • Avoid exercising in extreme cold or heat.
  • Exceeding target heart rate of 60 to 80 of
    estimated maximum heart rate.

42
Oral Hypoglycemic Agents
  • OHAs are primarily used in type 2 diabetes
    adjunct to nutrition therapy and exercise.
  • Oral agents are broadly classified as follows

43
First generation sulfonylureas
44
Second generation sulfonylureas
45
Agents enhancing effects of insulin
46
Agents enhancing effects of insulin
47
Agents enhancing effects of insulin
48
Other Oral agents
49
Incidence of HOA failure
  • Primary failure
  • About one third of of Type 2 patients fail to
    respond to sulphonylurea treatment within one
    month of initiation of therapy.

50
Secondary failure
  • Of the patients that initially achieve
    satisfactory glycaemic control, about 5 to 10 go
    on to develop secondary failure each year, so
    that after 10 years only about half of the
    patients continue to have satisfactory response.

51
Secondary failure (continued)
  • From the data of the UKPD study, it appears by
    the sixth year,approximately 50 of the patients
    randomized to sulphonylurea needed supplemental
    insulin to maintain adequate glycemic control.

52
Diagnosis OHA failure
  • It is a condition in which an individual does not
    respond adequately/ satisfactorily with OHAs.
  • Clinically, following parameters can be of great
    relevance in diagnosing OHA failure
  • 1. Inadequate improvement in the classical
    signs and symptoms of diabetes viz., polydypsia,
    polyuria, polyphagia and fatigue.

53
  • 2.Weight loss accompanied by rising blood glucose
    and recurring infections.
  • 3.Inadequate/deteriorating blood glucose control.
    The objective to the pursued on this front is

54
  • 4.High and increasing number of tablets with
    inadequate control especially exceeding two to
    two and a half tablets in case of commonly used
    OHA.

55
Dose at which review is essential
56
Dose at which review is essential
  • Poor performance with the above doses indicates
    the necessity to review the entire therapy and
    the therapeutic alternative to be considered at
    this point of time is initiation of insulin
    therapy

57
In case of Type 2 diabetes, there are 2
possibilities
  • Stop HOA treatment and start insulin therapy
    (substitution) or
  • Continue OHA treatment and add insulin therapy
    (supplement)

58
  • Oral antidiabetics are contraindicated in Type
    1 diabetes and in Type 2 diabetes undergoing
    surgery, serve infections, liver and kidney
    disease, and gestational diabetes.

59
Insulin
  • Insulin are always used in patients with Type
    1 diabetes and may be required in patients with
    Type 2 diabetes or gestational diabetes.
  • Insulin can be broadly classified on the basis
    of species, action profile and strength.

60
Sources of insulin human, porcine and Bovine
61
Action profile of insulin
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66
Amounts of insulin
  • Insulin regimen should be individualized
    depending on lifestyle, activity level and eating
    pattern.
  • Continuous treatment and monitoring are the main
    stay.
  • Efforts should be taken to keep blood glucose as
    close to the target range (72 mg/dl before a
    meal, 180 or less two hours after a meal).

67
Insulin Initiation
  • Substitutions
  • Stop OHA tablets.
  • Start with Intermediate insulin 0.2 units /kg
    body weight before breakfast or at bed time (upto
    a maximum of 20 units).
  • Increases by 2-6 units every 3-4 days if
    necessary.

68
Note
  • If post prandial blood glucose levels are too
    high add Rapid action insulin. Alternatively,
    Pre-mixed insulin could be used. If the dose
    exceeds 30-40 units, divide the dose into daily
    injections 2/3rd before breakfast and 1/3rd
    before dinner.

69
Supplement
  • Continue with OHA tablet with out any change in
    dose.
  • Start with 0.1 to 0.2 units of intermediate
    insulin per Kg body weight before breakfast or
    bed time.

70
Supplement (continued)
  • Increase dose by 2-4 units every 3-4 days if
    necessary
  • If more than 30-36 I.U. is required for adequate
    control ( i.e FGBlt140 mg/100ml), consider
    stopping OHA and continue on insulin

71
Suggested Guidelines For Fine Tuning Split Mix
Regimens
  • Response to insulin treatment may be different in
    different patients may require adjustment to the
    insulin regimen. The table given below depicts a
    simple way to adjust the dose.

72
Adjustment to morning injections
73
Adjustment to evening injection
74
Mixing Insulin
  • NPH and short-acting insulin formulations when
    mixed may be used immediately or stored up to 2
    weeks.
  • Mixing of regular and lente is not recommended
    unless injected immediately after preparation
    binding action of regular and lente begins
    immediately and effect of regular may be blunted.

75
Insulin Administration
  • Choose a syringe compatible with the insulin
    strength (i.e.40 I.U. insulin)
  • For cloudy insulin (suspension) invert the vial a
    few times until the suspension has been mixed
    well.
  • Draw air into syringe corresponding to the
    prescribed dose of insulin and slowly inject air
    into vial held vertically at eye level, then draw
    up insulin

76
Insulin Administration continued
  • Inject excess amount of insulin back into the
    vial held vertically at eye level and pull out
    the needle.
  • Lift up the skin at the injection site in a broad
    fold and insert needle at an angle of 45 into the
    sub-cutaneous tissue, inject insulin slowly.
  • In order not to injure the tissue beneath the
    skin rotate the injection site in the chosen area.

77
Delivery Devises
  • Needle and Syringe
  • A common way of administering insulin is with a
    needle and syringe.
  • Syringes come in a range of capacities (1ml,
    0.5ml, or0.3ml) and different strengths.
  • Most suitable size can be selected to deliver the
    insulin dosage as per the requirement.

78
  • Needles also come in different gauges and
    lengths, and have very fine points and special
    coatings to make them relatively pain-free
    although some people find them daunting and not
    very convenient.

79
Insulin Pens (NovoPen 3)
  • Easiest and the most convenient way of
    administrating insulin.
  • Accurate even at extremely low dosage.
  • NovoPen 3 reduces the insulin administration to
    mere two step procedure Dial the dose and
    inject.

80
Advantages
  • Combination of insulin pens and Penfills
    completely eliminates the need to handle syringes
    and vials.
  • No need to mix and measure and therefore improves
    dosage accuracy.
  • NovoPen 3 is compact enough to fit easily into a
    purse or pocket and convenient to carry anywhere.

81
  • Launch of single penfills has further enhanced
    convenience to buy and has also offered economy
    to the patient by avoiding huge investment at one
    single time.

82
Disposable Pens (NovoLet)
  • Premixed, prefilled and ready to use disposable
    insulin delivery devices.
  • Patients just have to dial dose, inject and
    dispose the pen after use of 300 units of
    insulin.
  • NovoLets useful in initiating insulin therapy
  • in

83
  • OHA inadequacy and failure
  • Pre and post operative conditions
  • Gestational diabetes mellitus
  • NovoLets are available in all the varieties of
  • insulin viz.
  • Mixtard 30 NovoLet, Mixtard 50 NovoLet,
  • Actrapid NovoLet, Insulatard NovoLet

84
Storage of Insulin
  • Refrigerate unopened insulin (will be good until
    the expiration date on the vial).
  • The vial of insulin is used within 30 days of
    opening, may be stored at room temperature (gt2
    degree Celsius and lt30 degree Celsius) insulin
    ac activity decreases after 30 days at room
    temperature.
  • Unlike other medications insulin requires a
    special storage and transportation arrangement.

85
  • Needs to be stored between 2 degree Celsius to 8
    degree Celsius without dampness and direct
    exposure to sunlight.
  • In transportation it is to be dispatched with
    coolants and thermocol boxes.

86
  • Neutral insulin should be a clear solution
    whereas premixed and intermediate insulin are
    suspensions.
  • Magnus Novo Nordisk offer complete range of
    insulin with C4 (Complete care cool chain)
    guarantee.

87
Diabetes Treatment Chart
  • Define individual Aims of therapy

Very symptomatic Severe hypoglyceamia Ketosis
Pregnancy
Diet and Exercise
Glycemic goals
Glycemic goals achived
Monotherapy Repaglinide Sulphonylurea Biguanide
Alpha-glucosidase inhibitor Thiazolidinedione
Insulin
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90
Traditional Medicines
  • Due to chronic nature of the disease, patients
    try various therapies available in the market,
    which are clinically not proven. The basis of the
    usage of these medicines is no side-effects but
    then efficacy is always a question mark. Some
    of the traditional medicines used in the
    treatment are

91
  • Better substances like Neem leaves, Bittergourd,
    Methi etc.
  • Ayurvedic drugs viz. Vijasar, Bittergourd, Jamoon
    Seeds and Nisha Amlakki are used commonly.
    However their clinical results have not been
    either conclusive or not published.
  • Spirulina (fresh water algae) that grows in water
    tanks is used, but not significant effect seen on
    blood sugar.

92
Precautions
  • It is essential to provide the efficacy and
    safety of traditional medicines in wide variety
    of patents and to look for long term safety and
    efficacy in human beings.
  • Any system of medicine that claims that it has
    cure or relief for Diabetes has to under go the
    clinical safety tests before it is accepted.

93
  • Scientific proof and clinical study should
    authenticate any such claims in magazines and
    newspapers.

94
Drugs that may alter the glycemic control of
sulfonylureas
  • A. Enhance hypoglycemic effect (decrease blood
    glucose)

95
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96
Decrease hypoglycemic effect(increase blood
glucose)
97
Drugs that interact with insulin
  • Enhance hypoglycemic effect (decrease blood
    glucose)

98
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99
Decrease hypoglycemic effect (increase blood
glucose)
100
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101
Low Blood Sugar (Hypoglycemia)
  • A common problem in diabetic patients whether on
    oral antidiabetics Or insulin.
  • Hypoglycemia can be longer serious with some
    oral antidiabetics because of their longer
    duration of action and unpredictable
    pharmacokinetics.

102
Symptoms of Hypoglycemia
  • Frequent hunger
  • Feeling of passing out
  • Decreased concentrating ability
  • Inappropriate behavior
  • Loss of conciousness
  • Sweating
  • Palpitations
  • Shakiness
  • Blurry vision
  • Headache

103
Treatment of Hypoglycemia
  • Check blood glucose to exclude other reasons.
  • If glucose meter not readily available, then
    presume hypoglycemia and institute testament
    immediately.
  • Provide glucose tablets, fruit juices,candy,etc.
  • If the patient becomes unconscious, a Glucagon
    injection (GlucaGen Hypokit) Should be
    administered.
  • Recheck blood glucose after 30 minutes.

104
  • Hypoglycemia can be recurrent on administration
    of long acting insulin or drugs such as
    Glyburide, Glipizide especially if patients also
    have kidney disease.
  • Patients are generally monitored in the hospital
    for 24 48 hours for any recurrent hypoglycemia.

105
Diabetic ketoacidosis
  • Symptoms
  • Anorexia, nausea, vomiting
  • Thirst, Polyuria
  • Weakness
  • Abdominal pain
  • Visual disturbance
  • Weight loss

106
Signs
  • Elevated blood glucose (gt250mg/dl)
  • Ketonuria/Ketonemia
  • Plasma bicarbonate lt15meq/L
  • Dehydration
  • Warm dry skin
  • Tachycardia
  • Rapid/deep breathing, acetone odour
  • Somnolence, coma

107
Treatment
  • Replacement of fluid loss to correct dehydration
    hyperosmolarity
  • Replacement of electrolysis with potassium
    containing saline
  • Correction of hyperglycemia by insulin and fluid
    replacement
  • Ketosis and acidosis are simultaneously corrected
    by above measures
  • Identification and correction of precipitatory
    causes.

108
Complications Long Term
  • Diabetes is the silent killer as it affects
    almost all the organs of the body and usually
    leads to a host of complications if not
    controlled aggressively.

109
Kidney Disease
  • Symptoms
  • Hypertension, edema, proteinuria and renal
    insufficiency

110
Diagnosis
  • Urinary microalbumin excretion testing
  • Spot urine sample testing

111
Treatment
  • Tight control of blood glucose in most diabetic
    patients.
  • Dietary protein restrictions.
  • Excessive urinary microalbumin excretion should
    be treated with an ACE-inhibitor agent (provided
    there are no contraindications) even if their
    blood pressure is not elevated. This helps to
    control intraglomerular hypertension.
  • High blood pressure should be aggressively
    treated in diabetic patients and target blood
    pressure should be less than 130/85mg Hg.

112
Monitoring
  • Urinary albumin excretion test on a yearly basis

113
Eye Disease
  • Symptoms
  • Diminished visual activity frequent change in
    power of lens, painful eye

114
Diagnosis
  • Check visual acuity with Snellens chart,
    seperately for each eye
  • Dilate pupils
  • Examine fundi by ophthalmoscope
  • Microaneurysms, retinal hemorrhages,hard exudates
    from eye.

115
Treatment
  • Aggressive control of blood glucose and blood
    pressure in most diabetic patients.
  • Laser photocoagulation surgery for diabetic
    macular edema or proliferative retinopathy.
  • Vitrectomy surgery for vitreous hemorrhage or
    severe progressive neovascularization.

116
Monitoring
  • Yearly eye examination of the diabetic patient by
    an ophthalmologist

117
Foot Problem
  • Symptoms
  • Tingling, pins needle sensation, burning
    sensation, numbness or pain.

118
Diagnosis
  • Carefully inspect the feet (whole foot, nails)
  • Check peripheral pulses
  • Examine for neuropathy i.e touch and vibration

119
Treatment
  • Best treatment is regular care of the feet.
  • Tight blood glucose control is crucial.
  • The mode of treatment depends upon
  • the degree of lesions,
  • neuropathic vascular assessment
  • and X-ray.
  • Treatment can range from bed rest, antibiotics
    according to culture and sensitivity, plaster,
    special shoes to ampulation.

120
Mentoring
  • A podiatrist should be visited for regular foot
    checking.

121
Erectile Dysfunction
  • Erectile dysfunction is the most common male
    sexual dysfunction in diabetes.

122
Treatment options for diabetic erectile
dysfunction
  • General measures
  • Improving diabetic control
  • Reduce alcohol intake
  • Withdraw causative drugs
  • Nonhormonal therapy
  • Alpha-2-adgrenergic blocking agents (yohimbine
    hydrochloride)
  • Type-specific phosphodiesterase inhibitors
    (sildenafil citrate)

123
Noninvasive Therapy
  • Vacuum erection devices
  • Intracavernosal injection of vasoactive agents
    (mixture of papaverine, phentolamine,
    prostaglandin E1)
  • Invasive therapy
  • Penile prosthesis (malleable versus inflatable
    device)
  • Microvascular arterial bypass surgery

124
Heart Disease
  • Symptoms
  • Augina symptoms chest, arm, and/or jaw pain
    (discomfort), Shortness of breath, cold clammy
    sweat
  • Myocardial infraction (ML)- silentML more
    common.

125
Diagnosis
  • Examine blood pressure
  • Electrocardiogram monitoring particularly
    ambulatory
  • ECG monitoring for silent ischemia
  • Stress testing for coronary heart disease
  • Echocardiography (with Doppler)
  • Testing of cholesterol

126
Treatment
  • Antiplatelet / anticoagulants
  • Start Aspirin 80 to 325mg/d if not
    contraindicated Manage warfarin to international
    normalised ratio 2 to 3.5 for post ML-patients
    not able to take aspirin

127
ACE inhibitors in post-ML patients
  • Start early post-ML in stable high risk patients
    (anterior ML, previous ML, Killip class II
  • Continue indefinitely for all with LV dysfunction
  • Use as needed to manage blood pressure or
    symptoms in all other patients

128
Beta-blockers
  • Start in high risk post-ML patients (arrhythymia,
    LV dysfunction, inducible ischemia) at 5 to 28
    days with continuation for six months minimum
  • Use as needed to manage angina, rhythym, or blood
    pressure in all other patients

129
Pregnancy and Diabetes Insulin treated diabetes
  • Planned Pregnancy
  • Good glycemic control be obtained before
    conception. In some situations intensive
    stabilization pre-pregnancy may be necessary
  • Good glycemic control before and throughout
    pregnancy reduces the risk of complications for
    the mother and foetus.

130
  • For pre-pregnancy stabilization use at least a
    twice daily mixtures of short and intermediate
    acting insulin.
  • Reinforce education on diet and insulin self
    adjustment.

131
Preconception goal for glycemic control
  • Premeal glucose 70 to 100 mg/100 ml (3.8 to 5.5
    mmol/l)
  • 1 to 2 hour post meal glucose at or below 150
    mg/100ml(lt 8.3 mmol/ol)
  • Serial H BA1c levels to be maintained at the
    normal or near normal value.

132
Other Assesments
  • Asses for any diabetic complications
    (hypertension, ischemic heart disease,
    nephropathy, neuropathy, retinopathy and severe
    gastroenteropathy).
  • Obsteric assessment
  • Thyroid function test as per local practice

133
Optimal Target Index for Glycemic Control During
Pregnancy with diabetes
  • Blood Glucose Goals in Diabetic Pregnancy

134
Oral hypoglycemic treated diabetes
  • Oral hypoglycemic drugs should be discontinued
    and human insulin therapy instituted.
  • Planning for pregnancy preconceptions goals for
    glycemic control other assessment and Optimal
    Target Index for glycemic control during
    pregnancy with diabetes.

135
Gestational diabetes
  • Gestational diabetes mellitus develops in
    approximately 2-5 of pregnant women. GDM are at
    increased risk for the development of Type 2
    diabetes later in life and their infants are at
    risk for macrosomia.

136
Screening, diagnosis and treatement
  • All pregnant women should be screened for glucose
    intolerance between 24th and 28th week

137
Diagnosed GDM
Diet monitor glycemia, foetus
Fasting blood glucose lt 105 mg/100ml (lt5.8
mmol/l) and 2-hour postprandial lt120 mg/100 ml
(lt 6.7 mmol/l)
Fasting blood glucose gt 105 mg/100ml (gt5.8
mmol/l) and 2-hour postprandial gt120 mg/100 ml
(gt6.7 mmol/l)
Continue diet and monitor glycemia and foetus
Initiate Human Insulin treatment monitor
glycemia and foetus
138
  • Diabetes is frequently associated with infections
    as seen in clinical practice, but not clearly
    proved. Defects in both cell mediated immunity
    and polymorphonuclear functions have seen
    experimentally shown, but their exact role in
    human beings is yet to be clearly shown.

139
  • A decreased perfusion due to abnormality in
    microvascular circulation and neuropathy may
    worsen the prognosis as infection sets in.
  • The entire immune system is altered to defense
    against microbial invasion, certain defects may
    be more directly associated with certain
    infections in diabetes.

140
Skin infections
  • Due to compromised host defense and high blood
    sugars, microbes withy low virulence easily cause
    infections of the damaged skin.
  • Staphylococcus aurous infection causing boils,
    carbuncles and abscesses are the most common skin
    infections.

141
Diagnosis
  • Confirmation is by biopsy of the affected area
  • Treatment
  • Board-spectrum antibiotics, antifungul agents

142
Tuberculosis
  • Tuberculosis is common with diabetes in India.
  • Diagnosis
  • Chest X-ray
  • Sputum and urine examination
  • Hematology

143
Symptoms
  • Weight loss
  • Fever with chills
  • Weakness
  • Excessive urination

144
Treatment
  • Antitubercular therapy of INH, Rifampicin,
    Ethambutol and Pyrazinamide.
  • Rifampicin and INH interact with OHAs and
    therefore choose insulin to initiate antidiabetic
    treatment.

145
Surgery
  • During surgery utmost care is required from the
    family physician in co-ordination with
    anesthetist to achieve proper glycemic control
    and avoid complications. The management differs
    as per the current treatment and status of
    diabetes. Broadly surgery management in diabetics
    is undertaken in following three phases

146
Pre-operative Management
  • In patients managed on diet, assess for metabolic
    control with proper diet. If uncontrolled, admit
    patient 1-2 days before operation and initiate
    Human Actrapid.
  • In patients managed on oral anti-diabetics, shift
    to shorter acting sulphonylurea. Biguanide should
    be stopped one week before and the patient should
    be shifted to insulin for stabilisation

147
  • In patients on insulin, shift from intermediate
    acting insulin to short acting insulin (Human
    Actrapid)
  • Frequent monitoring is required.
  • If optimal control is not achieved with
    subcutaneous Human Actrapid, considered
    intervevous infusion.

148
Peri-operative (during surgery) Management
  • In patients only managed on diet institute
    insulin if hyperglycemia develops persists post
    operatively.
  • In patients managed on oral medication, avoid
    breakfast and no medication on day of treatment.
    Treats as non diabetic if blood glucose islt126
    mg/dl.
  • If blood glucose increase more than 126mg/dl then
    initiate insulin (human Actrapid)
  • In major surgery set up Human Actrapid insulin
    infusion.

149
  • In patients managed on insulin,set up i.V,
    infusion (10 Dextrose 500ml I.U. Human
    Actrapid10 mmol KCL) and regimen adjust as per
    patients requirement.
  • Monitor patient frequently (1-2 times every hour)
    during operation.

150
Post-operative (after surgery) Management
  • In diet treated diabetics, return to
    pre-operative dietary management incase of minor
    surgery. In major surgery, treat with Human
    Actrpid (8-12 units) t.d.s before each meal.
    Further titrate the dose as per the requirement.

151
  • In patients managed on oral medication recommence
    sulphonylureas with first meal in case of minor
    surgery. In major surgery, treat with Human
    Actrapid (8-12 units) t.d.s. before each meal.
    Further titrate the dose as per the requirement.

152
  • In patients managed on insulin, continue the
    infusion at the same rate until oral feeding
    commences. If infusion is prolonged (24 hrs),
    check electrolytes daily (Na/K).
  • Initiate Human Actrapid (equivalent to
    pre-operative dose) with oral feeding
  • After 2-3 days, restabilise on suitable regimen
    for the patients.
  • Measure Ketone bodies and blood glucose frequently

153
  • Being sick can make the blood glucose level go up
    very high.
  • It can also cause serious conditions that can put
    up the patient in a coma.

154
What Happens When the Patient is Sick
  • Patient when sick is under stress leading to
    release of hormones, which raises blood glucose
    levels, and interferes with the glucose-lowering
    effects of insulin.
  • Easy to lose control of the diabetes leading to
    ketoacidosis and diabetic coma particularly in
    people with Type 1 diabetes.
  • People with Type 2 diabetes, especially older
    people, can develop a similar condition called
    hyperosmolar hyperglycemic nonketotic coma.

155
Diabetes Medicines
  • Type 1 diabetes, it is advisable to take extra
    insulin to bring down the higher blood sugar
    levels.
  • Type 2 diabetes, may be able to take pills, or
    may need to use insulin for a short time.

156
Food
  • Eating and drinking can be a big problem. But it
    is important to stick to the normal meal plan.
  • Easy to run low on fluids when one is vomiting or
    has fever or diarrhea. Extra fluids will also
    helps get rid of the extra sugar (and possibly
    ketones) in the blood.

157
Medicines to Watch Out For
  • Advice to check the label of over- the-counter
    medicines before buying them to see if they have
    sugar. Small doses of medicines with sugar are
    usually okey.
  • Many medicines when taken for short-term
    illnesses can affect blood sugar levels, even if
    they dont contain sugar. For example, aspirin In
    large doses can lower blood sugar levels

158
  • Some antibiotics lower blood sugar levels in
    people with Type 2 diabetes who take diabetes
    pills.
  • Decongestant and some products for treating colds
    raise blood sugar levels.
  • Monitoring Glucose level
  • Regular / frequent monitoring required

159
Travel
  • Before a long trip, medical examination is
    necessary to make sure diabetes is in good
    control.

160
Packing Tips
  • Whether traveling by car, plane, boat, bike,
    or foot, the patient will want keep this
    carry-on bag with him at all times. Pack this
    bag with
  • All the insulin and syringes needed for the trip
    blood and urine testing supplies (include extra
    batteries for the glucose meter)
  • All Oral medications (an extra supply is a good
    idea)

161
  • Other medications or medical supplies, such as
    glucagon, antidiarrhea medication, antibiotic
    ointment, antiemetic drugs
  • ID and Diabetes identity card
  • A well-wrapped, air-tight snack pack of crackers
    or cheese, peanut butter, fruit, a juice box, and
    some form of sugar (hard candy or glucose
    tablets) to treat low blood glucose.

162
Insulin During Travel
  • Insulin stored in very hot or very cold
    temperature may lose strength. Dont store
    insulin in the glove compartment or trunk of the
    car
  • Insulin used in India are of the strength 40 and
    100 I.U.
  • In foreign countries, insulin may come as I.U.40
    or I.u.80. If the patient needs to use these
    insulin, one must buy new syringes to match the
    new insulin to avoid mistake in the insulin dose.

163
Crossing Time Zones
  • If one takes insulin shots and will be
    crossing the time zones, remember
  • Eastward travel means a shorter day, less insulin
    may be needed.
  • Westward travel means a longer day, so more
    insulin may be needed.
  • To keep track of shots and meals through changing
    time zones, advice the patient to keep his watch
    on his home time zone until the morning after he
    arrives.

164
After Arrival
  • After a long flight, it is advisable to take it
    easy for a few days. Test the blood sugar often.
  • If one takes insulin, plan the activities so that
    one can adjust insulin dose and meals.
  • Ask for a list of ingredients for unfamiliar
    foods. Some foods may upset the stomach and hurt
    the diabetes control.
  • Always advice to wear comfortable shoes and never
    go barefoot. Check the feet every day.
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