Stm5

4.Chronic dis.qxp:STM5 7/4/10 9:38 PM Page 253 Diabetes
Common – Type 2 diabetes, gestational diabetesLess common – Type 1 diabetes, pancreatic insufficiency/disease • Type 2 diabetes – initially increased insulin levels but body doesn’t use
it properly. Later less insulin made – often need insulin injections late
diseases
• In Indigenous people diabetes more common, more severe, happens at a
• Heart attack at a young age a major cause of death. May happen with
no chest pain, or with symptoms like tiredness or problems breathing Diabetes is important
People with diabetes are very likely to develop other health problems, eg
• High BP, heart attacks, strokes
• Kidney disease, kidney failure
• Eye damage, loss of vision
• Nerve damage (neuropathy) to feet causing ulcers, amputations
• Serious infections
• Dental/oral disease, tooth loss
• Depression
Risk factors for diabetes
• Family history of diabetes
• Overweight or obese – BMI more than 25
• Waist circumference – women more than 80cm, men more than 94cm
• Women – history of gestational diabetes or polycystic ovarian disease
• Impaired glucose tolerance
Prevention
Healthy diet, physical activity, good oral hygiene, not smoking andweight loss if overweight/obese lessen the chance of getting diabetes andslow progress of the disease. (Messages for health p220, Tobacco p224,Brief interventions p216). Diagnosis
Usually no symptoms until late in disease when complications develop.
See Testing for diabetes (p234) for how to diagnose.
• Early diagnosis through screening may prevent complications
Adult Health Check (p212) is very important 4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 254 Diabetes
• Also check for diabetes if someone has any of these symptoms
Frequent infections, eg boils, UTIsTirednessPassing urine too often, especially at nightWeight changeEyesight problemsOften thirsty • If person sick with anything else at time of diagnosis, BGL of more
than 20mmol/L, ketones in urine – may need to send to hospital Ketones in urine can mean person has not eaten, or may have undiagnosed Type 1 diabetes (needs insulin). Medical consult
Management
Impaired glucose tolerance or impaired HbA1c
• Do cardiovascular risk assessment (p229)
• Medical review
• Management plan including yearly BGL, HbA1c, follow-up schedule
• Give advice about diet, physical activity, losing weight to lessen risk of
diabetes (Messages for health p220) • Think about starting metformin, talk with physician
Gestational diabetes
• See WBM (p121)
• Yearly BGL, HbA1c
Type 2 diabetes
• See Combined checks (p238) – monthly checks for first 3 months then
• Give advice about diet, physical activity, losing weight and quitting
smoking (Messages for health p 220, Tobacco p224) • Pre-pregnancy counselling (WBM p79)
• Good diabetes care looks after the whole person, not just blood glucose
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 255 Diabetes
Medicines for best diabetes control
Usually a combination of medicines to control blood glucose, BP,
blood fats (lipids) and cardiovascular risk.
Blood glucose control
diseases
• Aim for
Random or after meal BGL 4–8mmol/LHbA1c less than or equal to 7% (good average blood glucose over last 3 months)– Any decrease in HbA1c is good and lessens risk of complications– High HbA1c levels increase person’s risk of heart attack, kidney • Review weekly for 1 month when changing treatment
• BGL self-monitoring helps person to understand and manage their
diabetes. Most useful for younger people, person on insulin, during
changes in drug treatment, or if unstable
If person on insulin can’t self monitor – do in clinic
• Offer enough medicine to achieve best control (Flowchart 4.2 p257) –
to lessen risk of heart attack, kidney failure, foot amputation, blindness • You should get better glucose control by adding a second medicine
rather than using a maximum dose of one medicine alone 4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 256 Diabetes
Table 4.19: Oral medicines for glucose control
Sulphonylureas
Glitazone
Metformin
Gliclazide Gliclazide Glimepiride Pioglitazone
daily with daily with daily with dailyfood Maximum • 2g daily often
• 3g daily maximum
– can give 1.5gtwice a day (bd)with food Metformin XR
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 257 Diabetes
Flowchart 4.2: Blood glucose control
Diagnosis of diabetes (p234)
diseases
Diet and exercise AND metformin (if no contraindications)
Add sulfonylurea
Regular check-ups afterHbA1c controlled at lessthan or equal to 7% Add glitazone or insulin
Add a fourth medicine or increase insulin
Specialist consult
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 258 Diabetes
Insulin treatment is needed by most people with diabetes after 6–10
years due to decreased ability of pancreas to produce insulin.
Think about starting insulin if
• Person is taking maximum tolerated oral medicines
• 2 or more HbA1c results more than 7% OR BGL always more than 8–
• Symptoms of high blood glucose (p254)
Starting insulin needs time for education about insulin, injecting and
monitoring, thinking it over, and talking with another person who is on
insulin.
• Get help from diabetes educator (could be by phone) (p410)
• Discuss practical ways to store insulin, monitor BGL
• There are many easy-to-use injecting devices available
• Clinic staff need to be positive and supportive about using insulin
Start with daily insulin – keep adjusting doses until good BGL control.
Change to twice a day insulin if
• Not controlled with maximum daily insulin AND oral medicines
• Able to manage a more complex treatment plan
• Eating regular meals – as higher risk of low blood glucose with mixed
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 259 Diabetes
Table 4.20: Insulin treatment
Twice a day
Glargine – same time each
Novomix 30 OR
Humalog Mix 25–75 OR
diseases
OR Protophane – bedtime
Mixtard 30–70
1/ 2
Starting dose
Maximum dose
When good BGL control –may be more than 50 units,often up to 100 units Adjusting dose
• BGL less than 4mmol/L
• BGL 4–6mmol/L – use
• BGL 6–8mmol/L – increase
• BGL more than 8mmol/L –
BGL aim –
Monitoring
Oral medicines continue unchanged
Complications
Eye disease
Includes diabetic retinopathy, cataract. Any change in vision should be
assessed straight away by ophthalmologist, especially if sudden onset.
Risk of blindness is less with
• Regular screening (fundoscopy or retinal camera) (Combined checks
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 260 Diabetes
• If diabetic eye damage – more frequent eye specialist examination
• Laser treatment, if needed
• Good BP control (p264) and blood glucose control (p255)
Foot problems
Foot problems are the most common complication of nerve damage
(peripheral neuropathy) – may lead to infection, foot ulcers, amputation.
Do regular foot checks (Combined checks p238, CRANA✛ CPM p121)
Foot ulcers and infections
• Every new ulcer or infection is serious
• Medical consult – may need to send to hospital
• If infected – swelling, red, warmth, pain (may be very little pain). Give
Amoxicillin-clavulanate (doses p394)
OR Cephalexin (doses p397) AND metronidazole oral (doses p401)
High risk feet
Person with identified high risk feet will need
• More frequent foot checks
• Management plan
• Education about foot care, foot protection
See CRANA✛ CPM (p121, p124)
Dental problems
Person with Type 2 diabetes has higher risk of more frequent and severe
dental/oral disease. Risk increased by poor dental hygiene, smoking, poor
control of diabetes. Dental/oral disease makes it harder to control
diabetes.
Problems include infections, bone and tooth loss, loose and painful teeth.
• Encourage and support
Good oral hygieneStopping smoking (Tobacco p224) • Make sure of regular visits to dentist (as often as every 3 months if

Source: http://www.clinicalinfonet.net.au/PDF/000203.pdf