Diabetes Management Flashcards
Lifestyle modification?
- Maintain normal weight for adults (BMI 20-25 kg/m2)
- Reduce salt intake
- Stop alcohol intake
- Stop smoking
- Engage in regular physical exercise (eg brisk walking) for 30 minutes per day, on 5 days of per week
- Consume at least five portions/day of fresh fruit and /or vegetables
- Reduce the intake of total and saturated fat (animal fat)
Basic principles for recommended diet?
- Avoid short acting carbohydrate (sugar, sugary foods and drinks)
- Eat fruits one at a time( 2 if small) maximum 2 times/day
- Take regular meals of unrefined carbohydrate
Non insulin therapies for T2 DM?
- sulphonylureas - glibenclamide, glipizide
- biguanides - metformin
- gliptins
- SGLT2 inhibitor - dapagliflozin
- alpha glucosidase inhibitors (acarbose)
Salphonylureas?
- Stimulate the release of insulin from endogenous
- Low doses are initially indicated
Side effects of sulphonylureas?
- hypoglycaemia(common with glibenclamide)
- Use with caution in renal impairment
Glipizide?
stimulate first phase insulin release
Mechanism of action of biguanides?
increases peripheral insulin sensitivity promotes weight loss
Elimination of biguanides?
- Metformin is renally excreted
- CONTRAINDICATED if renal impairment (CKD Stage 3, 4 & above)
- Contraindicated if severe CCF or liver failure
Side effects of biguanides?
- diarrhea
- nausea
- Most serious risk of metformin
- LACTIC ACIDOSIS
Mechanism of action in Dapagliflozin?
Benefits of DAPA?
- used to reduce the risk of needing to be hospitalized for heart failure in adults who have TD2 along with heart and blood vessel disease or who have multiple risk factors for developing heart and blood vessel disease
- used to reduce the risk of worsening kidney disease
Types of insulin?
- rapid acting
- short acting
- intermediate
- long acting
Rapid acting insulin?
onset - 15 minutes
peak - 60-90 minutes
duration - 3-4 hours
Short acting insulin?
onset - 30 mins - 1 hr
peak - 2-3 hours
duration - 3-6 hours
Intermediate insulin?
onset - 2-4 hours
peak - 4-10 hours
duration - 10-16 hours
Long acting insulin?
onset - 1-2 hours
peak - no peak
duration - 24+ hrs
Insulin categories?
basal
bolus
biphasic
Basal insulin?
intermediate and long acting insulin
Bolus insulin?
rapid and short acting insulin
Biphasic insulin?
premixed combination of
rapid-acting + isophane
short acting + isophane
Insulin available in Malawi?
- protophane/cloudy/lente
- onset of action is 2-4hrs
- peak is 4-10hrs
- duration is 10-18hrs - soluble/clear/actrapid
– onset of action is 30-60min
- peak is 2-3hrs
- duration is 5-8hrs - Premixed insulin- short and intermediate
Side effect of insulin?
- hypoglycemia
- weight gain
Note: therefore in obese diabetics who need insulin, combine insulin+ metformin
Management of T1 DM?
- insulin for life
- diet to balance insulin
Management of T2 DM?
- endogenous insulin production slowly declines
- diet
- diet + metformin/suphonylurea
e.g. glibenclamide - diet + metformin + suphonylurea
e.g. glibenclamide - diet + insulin (20%) ± metformin
Danger signs?
very weak, dehydrated (low BP), drowsy or confused, vomiting
Signs of serious infection
ADMIT PATIENT
Starting insulin in T1 DM?
START treatment with diet and insulin THE SAME DAY
Insulin dose: 0.5-1.0 units/Kg body weight/24 hours
- 2/3 in am, 1/3 in pm
Rules for insulin treated T1 DM?
- They must take the injection 12 hrs apart
- They must take the injection half hour before their meal
- They MUST eat 3 regular meals per day with snacks in between meals and at bedtime
- They must not stop insulin. Remember the sick day rules
Dosage of insulin for mixing soluble and lente insulin?
Divide each dose into
2/3 lente and 1/3 soluble
Target blood glucose?
FBS<126 mg/dl (7.0 mmol/L)
HbA1C : 6.5-7.5%
Follow up review?
- If it is improving encourage the patient to continue the same
- If it is not improved review diet and injection technique
- repeat education if necessary
- if diet and injection technique are satisfactory
- increase insulin dose by 5u od
- Repeat this review each visit
Final insulin dose?
REMEMBER THE FINAL DOSE MAY BE 1u/Kg/24 hrs or more
Management in T2 DM?
FBS <300 mg/dl (16.7 mmol/l)
- start diet & life style changes
FBS ≥ 300 mg/dl
- as above + tablets
Choice of tablets in T2 DM?
Choice of tablets depends on weight and initial FBG
1. FBG 300- 400 mg/dl or 16-22 mmol/L
- If thin start diet + glibenclamide 5mg od
- If fat start diet + metformin 500 mg bd
2. FBG >400 mg/dl/>22 mmol/L
- If thin start diet + glibenclamide 5mg bd
- If fat start diet + metformin 1g bd
Review of T2 DM?
If FBG >500 mg/dl consider admission for rehydration and insulin to reduce glucose rapidly (usually overnight is sufficient)
Then start oral agents and discharge
If patient appears well manage in clinic with oral drugs but must review weekly initially.
Target blood glucose in T2 DM?
FBG <130 mg/dl (7.2 mmol/L)
Stabilising/adjusting dose for diet and tablet treated diabetics?
If the FBS is improving encourage the patient to continue the same
REPEAT THE DIET EDUCATION
If it is the same or worse- review diet, if diet is satisfactory increase dose of tablets
glibenclamide by 5 mg each time metformin by 500mg each time
- Repeat this review each visit
Continued management of T2 DM?
The maximum dose of glibenclamide is 10 mg bd
The maximum dose of metformin is 1g tds
If the patient is on the maximum dose of one agent and the FBS is still >126 mg/dl start adding the second drug:
glibenclamide (in 5mg increments)
metformin (in 500mg bd increments
Max dose of oral treatment?
THE MAXIMUM ORAL TREATMENT IS
GLIBENCLAMIDE 10mg bd PLUS METFORMIN 1g tds
Switching to insulin in T2 DM?
At least 20% of type 2 DM need insulin
-If the patient is on maximum oral hypoglycaemics and the FBS is still >126 mg/dl and diet is OK
-Then patient will need to switch to insulin
-make sure they stop oral hypoglycaemic except metformin!
-If the patient is obese use insulin PLUS metformin
