Diabetes mellitus management by Dr. Basil Tumaini, a presentation done at Mwananyamala hospital in Dar es Salaam

1. DIABETES MELLITUS
management
Dr Basil Tumaini
Intern doctor
26 July 2011

2. MOVIE SUMMARY
26 July 2011

3. Clinical presentation and diagnosis
A complete medical history should include:
 Symptoms of the disease
 Risk factors
 Development of complications
 Management that has been done
26 July 2011

4. Clinical presentation (2)
Common presenting symptoms of DM include
excess thirst (polydipsia), excess urination
(polyuria), weight loss, fatigue, weakness,
blurred vision, frequent superficial infections,
general itchiness, and poor wound healing.
A complete medical history should be
obtained with special emphasis on weight,
exercise, ethanol use, family history of DM,
and risk factors for cardiovascular disease.
26 July 2011

5. Clinical presentation (3)
In a patient with established DM, assessment of
prior diabetes care, HbA1c levels, self-monitoring
blood glucose results, frequency of
hypoglycemia, and pt’s knowledge about DM
should be obtained.
On physical exam special attention should be
given to retinal exam, orthostatic BP, foot exam
(including vibratory sensation and monofilament
testing), peripheral pulses, and insulin injection
sites.
26 July 2011

6. Clinical presentation (4)
Criteria for the Diagnosis of Diabetes Mellitus:
 Symptoms of diabetes plus random blood
glucose concentration 11.1 mmol/L
(200 mg/dl )a or
 Fasting plasma glucose 7.0 mmol/L (126
mg/dl)b or
 Two-hour plasma glucose 11.1 mmol/L (200
mg/dl) during an oral glucose tolerance testc
26 July 2011

7. Clinical presentation (5)
Acute complications of DM that may be seen on
presentation include:
 diabetic ketoacidosis (DKA),
 hyperglycemic hyperosmolar state (HHS),
 and hypoglycemia.
Chronic complications of DM affect many organ
systems and are responsible for the majority of
morbidity and mortality associated with the
disease.
26 July 2011

8. Chronic complications
1. VASCULAR a. MICROVASCULAR retinopathy
neuropathy
nephropathy
b. MACROVASCULAR coronary artery
disease
peripheral arterial disease
cerebrovascular disease
2. NON VASCULAR gastroparesis
infections
skin changes.
26 July 2011

9. Management (1)
When you are faced with a diabetic Pt,
consider the following:
 A newly diagnosed Pt / a known Pt
 Has severe symptoms /complications /
asymptomatic
 Pt’s weight
 Response to previous management
(known Pt)
26 July 2011

10. Management (2)
Management involves one or a combination
of the following:
 Non-pharmacological means:
 lifestyle changes
 surgery
 Pharmacological means:
 oral hypoglycemic agents
 insulin therapy
26 July 2011

11. Management (3)
LIFESTYLE CHANGES
 Weight loss of 5 – 10 %.
 Reduction in fat intake < 30 % of calories
 Reduction in saturated fat intake < 10% of
calories
 Increase in fibre intake as in traditional
African diets
26 July 2011

12. Management (4)
LIFESTYLE CHANGES (cont.)
 Increase in physical activity levels. This type
of exercise (e.g. brisk walking) should last for
at least 30 min and should be undertaken at
least 3 times a week.
 Reduction in high level of alcohol intake to
less than one drink per day of any type.
 Stopping smoking
26 July 2011

13. SOME ORAL GLUCOSE LOWERING
AGENTS
NAME OF
DRUG
TABLET SIZE INITIAL
DOSAGE
MAXIMUM
DOSAGE
DURATION
OF ACTIVITY
CONTRAIND
ICATIONS
INSULIN SECRETAGOGUES
sulphonylureas Renal/liver
disease
Glibenclami
de (Daonil®)
5 mg 2.5 mg OD 10 mg BD Up to 24hrs
Chlorpropa
mide(Diabe
nese®)
250 mg 125-250 mg
BD
250 mg BD 60-90 hrs
INSULIN SPARING
biguanides liver disease
Metformin 500 mg 500 mg OD 1000 mg tds 12- 24 hrs
26 July 2011

14. Management (6)
INSULINS AND INSULIN ANALOGUES
INSULIN TYPE ONSET PEAK DURATION
SHORT ACTING
Human soluble
e.g. Actrapid®
s.c. 30-60 min
i.v. 10-30 min
2.5-5 hrs
30-60 min
6-8 hrs
30 min
INTERMEDIATE-
ACTING
Isophane e.g.
Insulatard®,
Lente®
s.c. 2-4 hrs 4-10 hrs 10-24 hrs
26 July 2011

15. Management (7)
.
Newly Pt
Severe
symptoms,
pregnancy,
infections, ill-
looking
YES
Consider admission and
insulin therapy
NO
Recommend lifestyle changes (diet and physical activity, stop
smoking) and monitor in 3 months
26 July 2011

16. Management (8)
• .
26 July 2011
lifestyle changes
Glycemic controlYES
NO
UNDERWEIGHT
YESNO
Add or start low dose SU
and increase 3-monthly
Start low dose of Metformin
and increase 3-monthly

17. Management (9)
26 July 2011
• Start low dose of Metformin
and increase 3-monthly
Add or start low dose SU and
increase 3-monthly
GLYCEMIC
CONTROL
YES
GLYCEMIC
CONTROL
YESNO
NO
Consider admission and
insulin therapy

18. Management (10)
ACUTE METABOLIC COMPLICATIONS OF DM
1. HYPOGLYCEMIA
 blood glucose < 3.0 mmol/L
 symptoms: hunger, sweating, anxiety,
awareness of heartbeat, headache,
confusion, convulsions, coma
 commonest causes: taking more exercise
than usual, delay or omission of a snack or
26 July 2011

19. Management (11)
main meal, poor injection technique, eating
insufficient carbohydrate, overuse of alcohol,
over dosage of SU.
Management:
(a) Conscious Pts:
 one carbohydrate exchange for conscious Pt with mild
symptoms (e.g. milk 200 ml, soft drink 200 ml)
 two exchanges if neuroglycopenic symptoms
 if symptoms persist after 10 min, repeat carbohydrate.
26 July 2011

20. Management (12)
(b) Unconscious Pts:
 An IV 50% glucose bolus (40-50 ml) or 20% dextrose
(100-150 ml) followed by 5-10% dextrose if necessary.
 Glucagon 1 mg IM can also be administered.
 On recovery, give a long acting carbohydrate snack.
 prolonged IV dextrose infusion (5-10% for 12-24 hrs)
may be necessary if hypoglycemia is a result of long
acting sulphonylureas/ long and intermediate acting
insulin or alcohol.
 If IV access is impossible, consider nasogastric or
rectal glucose or IM glucagon.
26 July 2011

21. Management (13)
 On recovery, attempt to identify the cause of
hypoglycemia and correct it.
 Assess the type of insulin used, injection sites, and
injection techniques.
 Enquire into and correct inappropriate habits of
eating, exercise and alcohol consumption.
 Review of other drugs therapy and renal function.
26 July 2011

22. Management (14)
2. DIABETIC KETOACIDOSIS (DKA)
 This is a medical emergency.
 Occurs in type 1 DM.
 Well defined peak at puberty.
 Mortality remains up to 5% in the best centres.
 Common precipitating factors: infection,
management errors, new cases, idiopathic in
40%.
26 July 2011

23. Management (15)
 Pt will: ((a)) Investigations
 have elevated blood glucose (check lab. Blood glucose)
 have ketones in urine (check urine analysis for ketones)
 be dehydrated, 5-10 litres deficient (check urea and
electrolytes)
 be acidotic (low pH, low HCO3
- and possible î K+)
 be obtunded, semi- or fully comatose.
 Also check ABG
 Use DKA chart to guide the treatment.
26 July 2011

24. Management (16)
(b) Insulin therapy in DKA
 Inject soluble insulin 8 units both IM and IV
at a time.
 Then give soluble insulin 8 units IM hourly.
 When BG falls to 14 mmol/L or below, give
soluble insulin S.C. 4-hourly OR I.M. 2-hourly
and continue until the Pt is able to eat again
then change to B.D. or T.I.D. insulin
26 July 2011

25. Management (17)
(c) Fluids and electrolytes replacement:
 Give 2 L of NS IV stat, then, 1 L of Darrow’s
solution hourly.
 When BG falls to 14 mmol/L or below, start
5% dextrose 500 ml 4-hourly (or 1L 8-hourly)
 Isotonic dextrose/saline (DNS) can be used in
place of 5% dextrose.
 If the Pt is still dehydrated, continue NS or
half strength Darrow’s solution as well.
26 July 2011

26. Management (18)
(d) Correction of acidosis:
With severe acidosis, NaHCO3 50 mmol
should be given under Dr’s instruction.
(e) Monitoring:
 Asses CVS for volume overload
 Check BG 2-hourly if using IM route, or 4-hourly
if using S.C. route.
26 July 2011

27. Management (19)
3. HHS/ NON-KETOTIC HYPEROSMOLAR COMA
(HONC)
 Occurs in type 2 DM
 The Pt is very dehydrated and the blood
glucose may be very high.
 There is little or no ketosis
 Serum osmolality = 2 (Na+K) +
glucose(mmol/L) + urea (mmol/L).
26 July 2011

28. Management (20)
 Normal serum osmolality is <310 but for
HONC Pts, it is usually > 330 mosm/L.
 Note:
 The Pt may be acidotic due to lactic acidosis
secondary to shock/ sepsis, etc.
 The principles of management are similar to
those in DKA but IV fluids should be replaced as
half-normal saline (0.45%) if hypernatremia or NS
if serum sodium is normal.
26 July 2011

29. Management (21)
 There is frequently an intercurrent illness, usually
sepsis, CVA or cardiac. This must be diagnosed
and treated.
 Prophylactic heparin may be used.
26 July 2011