Transcript GUIDELINES FOR THE FOLLOW

GUIDELINES FOR THE
FOLLOW-UP OF DIABETES
MELLITUS TYPE 2
PATIENTS
by
T McD Kluyts
University of Pretoria
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PRE-TEST

List the target organs in
DM2

Indicate the main
reasons for routine
urinalysis


Indicate the principle
lifestyle modification
measures that should be
employed in DM2.


CNS including
autonomic system,
Eyes, Kidney, C-V
system
Proteinuria,
Ketonuria, Occult
infection
Diet, exercise,
weight loss,
addiction
management.
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CRITERIA FOR THE DIAGNOSIS OF
DIABETES MELLITUS
Fasting plasma glucose  7.0 mmol/l.
or
Symptoms of diabetes
plus:
casual plasma glucose concentration
 11.1 mmol/l.1
or
2-h PG  11.1 mmol/l during an OGTT.
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Diabetes Mellitus Type 2
Previously NIDDM, Adult type DM,
type 2 DM
 DM 2
• Not insulin dependent for survival
• Age 30+ at diagnosis
• Usually obese
• Few classic symptoms
• Ketoacidosis rare

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The following measures are
directed towards :
Glycaemic control
and
Prevention of
complications
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MONTHLY FOLLOW-UP
SUBJECTIVE
Compliance
Complications
Patients questions
OBJECTIVE
Examinations
Sideroom procedures
Special investigations
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SUBJECTIVE
Compliance:
•Check the patients medicines
•Discuss the taking of medicines
•Establish supervision and
•monitor bloodglucose, diet and exercise
records
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SUBJECTIVE
Complications:
Ask about:

Vision

Feet

Infections

Pains and Sensations
SUBJECTIVE
Questions from the Patient:
•
Encourage patient to talk and to ask
questions
•
Re-affirm treatment schedule
•
Explore family situation
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OBJECTIVE

Physical examination:
• Pulse, bloodpressure, temperature,
respiratory rate.
• Eyes: Cataracts and vision
• CVS: Heart and peripheral circulation
• CNS: Muscle strength, reflexes,
sensation, proprioception
• BMI
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OBJECTIVE
Objective
Sideroom procedures:
•Blood glucose
•Urine Labstix
•Urine microscopy
Special investigations:
•Never
routinely, only as and when
indicated by examination
OBJECTIVE
 Urine:
• glucose and ketones are
important
 Blood glucose:
• measure with glucometer
 Foot examination:
• skin,circulation, shoes
 Look at home monitoring chart
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Three- to six monthly :
 As monthly + lab tests:
• HbA1c – measurement
•
•
•
•
•
Urine for proteinuria
Snellen test, visual fields
ECG
Lipid profile
Feet examination
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ANNUALLY








Monthly examination + Lab tests
Neurological status
Cerebral function
Micro-circulation
Lipid profile
Micro-albuminuria
ECG
Fundoscopy
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KEY TESTS
TEST OR EXAM
Glycated Hb
Fundoscopy
Foot exam
Lipid profile
S-createnine
Microalbuminuria
Blood pressure
BMI
ECG
FREQUENCY
2x per year
1x per year
Quaterly
1-2 yearly
Yearly
Yearly
Each visit
Each visit
2x per year
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PATIENT EDUCATION
This is the cornerstone of
effective diabetes care.
Sufficient time and resources
should be made available in order
to do this effectively.
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RECORD DEGREE OF
CONTROL

Patients with poor or brittle
control, should be seen at least
once a month.

Well controlled diabetics can be
seen at longer intervals eg 2-4
monthly.
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Criteria for intervention
CRITERIA
BLOOD
GLUCOSE
FASTING
POSTPRANDIAL
GLYCATED
Hb %
OPTIMAL ACCEPTABLE
ACTION
NEEDED
4-6
4-8
6-8
8-10
>8
>10
<7
7-8
>8
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WEIGHT

As obesity virtually always
accompanies type 2 diabetes, it
should be targeted in its own right.

A weight loss of 5-10% should be the
initial aim. It has been shown to
improve insulin resistance and all its
associated parameters
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Weight
Body Mass Index (BMI) = Mass in
kg/Length in meter2
Optimal Acceptable
BMI
<25
20 - 26
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Action needed
>27
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WEIGHT
Evidence demonstrates that:
• structured, intensive
lifestyle programs involving
participant education,
• reduced dietary fat and
energy intake,
• regular physical activity
• and frequent participant
contact
are necessary to produce
long-term weight loss of
>5% of starting weight.
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GLUCOSE TREATMENT
RECOMMENDATIONS FOR DM2




Always provide or refer for dietary and
lifestyle advice at diagnosis
If random glucose values > 15 mmol/L ~
consider starting oral agents together with
lifestyle modification from the start
If overweight (BMI > 25) ~ consider
metformin unless contra-indicated
If postprandial glucose values constitute the
major abnormality or sulphonylureas contraindicated (e.g. renal failure) ~ acarbose or
meglitinides may be considered
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GLUCOSE TREATMENT
(Continued)

If insulin resistance is the major
abnormality , metformin should be
considered as first line or add on therapy. If
metformin is contra-indicated or poorly
tolerated (e.g. raised serum creatinine or
major cardio-pulmonary risks),then
thiazolidinediones may be used.

Always start with monotherapy and titrate
dosage to maximum over 1-3 months
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GLUCOSE TREATMENT
(Continued)

If goals still not reached, add second agent
(lowest dose, titrate when necessary).

If goals still not attained despite good
compliance and absence of major stressors
such as infection, consider insulin therapy

In such cases, insulin therapy may be
initiated as intermediate or long-acting
insulin at bedtime (titrate against prebreakfast reading), with or without oral
agents. If possible, self glucose monitoring
should be done in all patients on insulin.
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GLUCOSE TREATMENT
(Continued)

Initial insulin dose is 0.2-0.3 U/kg

If more than 30 U per day are required or
clinical judgment indicates, use twice
daily biphasic insulin (2/3 intermediate,
1/3 short acting). Consider referral.
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BLOOD PRESSURE GOALS
SYSTOLIC
<130
DIASTOLIC
<80
With Proteinuria
SYSTOLIC
<120
DIASTOLIC
<70
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BLOOD PRESSURE TREATMENT
 Angiotensin converting enzyme
(ACE) inhibitor based
 Low dose diuretics, eg
hydrochlorothiazide (HCTZ) 12.5mg
or Indapamide 1.25 -2.5 mg/day
may be appropriate first line agents
 Most patients will require at least 2
agents
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BLOOD PRESSURE
(continued)

ACE inhibitors or angiotensin II
receptor antagonists are indicated
in the presence of micro- or
macroalbuminuria

In patients over age 55 yrs with
or without hypertension, but with
another cardiovascular risk factor,
an ACE inhibitor should be
considered to reduce the risk of
cardiovascular events.
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LIPID GOALS
Total
Cholesterol
<5.0
LDL
<3.0
HDL
>1.2
Triglycerides
<1.5
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LIPID TREATMENT

LDL-cholesterol above 3 mmol/l ~ consider a
statin as therapy

Triglycerides above 1.5 mmol/l ~ check for
secondary causes, consider using a fibrate

LDL-cholesterol and triglycerides elevated ~
statin and fibrate if persistant

Fibrates contra-indicted with impaired renal
function ~ refer.
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ASPIRIN RECOMMENDATIONS

As a primary prevention strategy in high-risk
men and women with type 1 or type 2
diabetes including diabetic subjects with
the following:
• a family history of coronary heart disease,
• cigarette smoking,
• hypertension,
• obesity,
• albuminuria (micro or macro),
• age >30 years or
• dyslipidaemia.
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ASPIRIN RECOMMENDATIONS
(continued)

Use aspirin therapy as a secondary
prevention strategy in individuals who
have evidence of large vessel disease, eg
• a history of myocardial infarction,
• vascular bypass procedure,
• stroke or transient ischaemic attack,
• peripheral vascular disease,
• claudication and/or
• angina.
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ASPIRIN RECOMMENDATIONS
(continued)
 Use 150-300 mg aspirin per day
(enteric coated if possible)
 People with aspirin allergy, bleeding
tendency, anticoagulant therapy,
recent gastrointestinal bleeding, and
clinically active hepatic disease are
not candidates for aspirin therapy.
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ASPIRIN RECOMMENDATIONS
(continued)

Aspirin therapy should not be
recommended for patients under the
age of 21 years because of the
increased risk of Reye’s syndrome
associated with aspirin use in this
population
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Exercise Record

The exercise parameters are as
follow:
• To reach a pulse rate of max – 20%
for age and sex and maintain for 20
minutes at least
• 3 times per week at least
• Walking or running or cycling or
swimming or any combination
thereof
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Weight and diet record

This should include weekly weight
measurements

Dietary notes where indicated to explain
weight changes

Doctor/dietician’s comments
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Glucose control record
 The ideal would be twice daily blood-glucose
recording: morning and evening.
 This might be impossible for unsubsidised patients
to attain, and daily urine testing will have to suffice
as a minimum requirement.
 Blood glucose should be done fasting in the
mornings, and 2 hours postprandial at night.
 Urine glucose should be measured fasting in
the morning 1 hour after emptying the
overnight bladder, and/or 15 minutes after
emptying the 2 hour postprandial bladder in
the evening.
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SCENARIO 1

A 24 year old male student presents to you
with a history of Diabetes Mellitus 2 for 2
years, complicated by systolic
hypertension. He tells the story that he
suddenly became ill while attending a
rugby training camp 2 years ago. He has
never before been ill in his life except for a
chronic seasonal rhinitis for which he has
been taking numerous treatment regimes in
the past.
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SCENARIO 1
(Continued)

At the moment he is taking Glucophage and
Diamicron one each twice daily

On examination he is well built, weighs
110kg and is 1,8m tall

His BP is 128/84

His father’s sister is a diabetic
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SCENARIO 1
(Continued)

He is still participating in sport, but had to
retire from provincial level participation
since the start of his illness

He is complaining of tiring easily

His random blood glucose today is
8.6mmol/l

He is not keeping record of his exercise
efforts or his diet
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SOLVING THE PROBLEM
Main problem
Additional factors
Help seeking
Education
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SCENARIO 2


A 38 year old lady with Diabetes Mellitus
2 on insulin replacement therapy visits
you for a renewal of her medication
She has been on Humoloc Mix 25 but
when she went to the chemist last month
for a repeat, she was told that it was no
longer “on code”
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SCENARIO 2
(Cont)




She was not given any instruction on
how to use it
She is using 46 Units nocte
On examination her blood pressure is
160/90; blood glucose = 18,6; she
has 1+ oedema of the legs; her BMI
= 31,5
She is also taking Coversyl 4mg daily
with Natrilix 2,5mg daily for her
blood pressure
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SOLVING THE PROBLEM
Main problem
Additional factors
Help seeking
Education
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ACKNOWLEDGEMENT

Parts adapted from SEMDSA guidelines
2002 (Prof Paul Rheeder)

ADA clinical practice recommendations
2002. Diabetes Care 2002; 25(1) supl 1

WEBSITE:
http://www.novonordisk.com
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Thanks !
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