Diabetes occurs either because of a lack of insulin (type 1)or because of the The majority of adolescents have Type 1 diabetes. …
CHAPTER 3
ENDOCRINE SYSTEM
301 Diabetes mellitus
Description
Diabetes occurs either because of a lack of insulin type 1or because of
the presence of factors that oppose the action of insulin type 2 The
result is an increase in blood glucose concentration
Diagnostic criteria
1 Symptoms of diabetes plus a random plasma glucose ? 111 mmol/L
Random is defined as any time of day without regard to time since last
meal The classic symptoms of diabetes include polyphagia, polyuria and,
polydypsia, and in type 1 diabetes, unexplained weight loss
2 Fasting plasma glucose ? 70 mmol/L Fasting is defined as no caloric
intake for at least 8 hours
3 Two hour plasma glucose ? 111 mmol/L during oral glucose tolerance test
using a 75 g glucose load
Non drug treatment
achieve and maintain optimum weight
diet - Dietary emphasis should be on fruit, vegetables, and low-fat dairy
products on the one hand; and reduced amounts of fat, red meat, sweets,
and sugar-containing beverages on the other
High in fruit and vegetables
Low fat dairy products
Variety of unsalted nuts
Fish/skinless
chicken in preference to red meat
Small amounts of red meat
Person centred approach to diet therapy
The following issues need to be explored before educational intervention,
agreed goals or advice can be given:
Weight and preferably weight history
Most recent and previous glycosylated haemoglobin HbA1c results
Diabetes medication
Diet assessment
Lifestyle and physical activity
Cultural, social and economic issues
Comprehensive care of diabetics needs a range of services eg screening
and detection of complications, treatment of complications:
Monitoring
HbA1 C annually in patients who meet treatment goals and 3-6 monthly in
patients whose therapy has changed
blood glucose should ideally be monitored at home in all patients on more
than 2 daily doses of insulin
weight and blood pressure at every visit
potassium, creatinine and lipids annually
fundoscopy annually
proteinuria annually - See chapter 9
|Biochemical Index |Optimal |Acceptab|Addition|
| | |le |al |
| | | |action |
| | | |suggeste|
|
| | |d |
|Capillary blood glucose | | | |
|values finger-prick |4-6 |6-8 | 8 |
|fasting mmol/L |4-8 |8-10 | 10 |
|2-hour post-prandial | | | |
|mmol/L | | | |
|HbA1c | 7 |7-8 | 8 |
|Weight BMI kg/m2 | 25 | | 27 |
DMT 1 is always treated with insulin; in diabetes type 2 drug treatment is
initiated with oral hypoglycaemic agents, insulin may be needed at a later
stage
3011 Diabetes mellitus type 1 in children
E10
Description
Diabetes mellitus type 1, previously known as juvenile onset diabetes
mellitus and as insulin-dependent diabetes mellitus IDDM
Suspect diabetes in any child presenting with the following symptoms:
loss of weight despite a good appetite
polyuria
polydipsia
sweet smell on the breath with a positive test for urine ketones with or
without loss or impairment of consciousness
tiredness
Referral
All children with suspected or confirmed diabetes mellitus type 1 should be
referred to hospital immediately for:
confirmation of diagnosis
initiation and stabilisation of therapy
education
long term monitoring of control
all type 1 diabetic children should ideally be managed at a hospital
with specialised services
Diagnosis
A diagnosis can be made when the classic symptoms of polyuria and
polydipsia are associated with hyperglycaemia:
random blood glucose RBG 111 mmol/L or higher
or
fasting blood glucose FBG 7 mmol/L or higher
A small proportion of children present with less severe symptoms and may
require fasting blood glucose measurement and referral to a specialist
centre for assessment Others may present with features of ketoacidosis in
the absence of obvious causes
Non-drug treatment
a regular meal pattern is important
regular exercise
lifestyle modification, including self care practices
the patient should be told to carry a disease identification bracelet,
necklace or card
Drug treatment
oral antidiabetic drugs should not be used to treat patients with Type
1 diabetes
almost all childhood diabetics require several insulin injections per
day to control their diabetes
prefilled insulin syringes should be made available for all children
the regimen is individualized depending on factors such as compliance
If compliance is good, then these patients may be candidates for
basal / bolus regimens Other children may be managed with biphasic
insulin given twice daily
Adherence to insulin treatment regimens should be emphasised
3012 Type 2 diabetes mellitus in adolescents
Description
The majority of adolescents have Type 1 diabetes However, an increasing
number of adolescents are being diagnosed with type 2 diabetes These
patients may be diagnosed on screening; later presentation includes the
classical symptoms of diabetes
Criteria for Screening for Diabetes in children
Body mass index is 85 for age and gender
Family history of diabetes
Presence of hyperlipidaemia, hypertension or, polycystic ovarian
syndrome
AND
Physical signs of puberty OR age 10 years
Referral
All
3013 Diabetes mellitus type 1 in adults
E10
Description
Diabetes mellitus type 1, previously known as juvenile onset diabetes
mellitus and as insulin-dependent diabetes mellitus IDDM
Diabetes mellitus type 1 presents with:
|hunger |thirst |
|polyuria |weight loss
|
|ketoacidosis |tiredness |
Note
All patients must be referred on presentation for diagnosis, stabilisation,
initiation of treatment and planning
Non-drug treatment
dietary control, regular exercise and self care practices are important
control factors
regular home blood glucose monitoring
Note
The patient should be advised to carry a disease identification bracelet,
necklace or card
Drug treatment
As diabetes mellitus type 1 usually presents with diabetic ketoacidosis,
treatment is usually initiated with insulin and the patient is stabilised
at hospital level
Types of insulins
insulin, short acting, SC, three times daily, 30 minutes prior to meals
Regular human insulin
Onset of action: 30 minutes
Peak action: 2-5 hours
Duration of action: 5-8 hours
insulin, intermediate acting, SC, once or twice daily usually at night
Neutral Protamine Hagedorn NPH insulin
Onset of action: 1-3 hours
Peak action: 6-12 hours
Duration of action: 16-24 hours
insulin, biphasic, SC, once or twice daily
Mixtures of regular human insulin and NPH insulin in different
proportions, eg 30/70 30 regular insulin and 70 NPH
insulin
Onset of action: 30 minutes
Peak action: 2-12 hours
Duration of action: 16-24 hours
Drawing up insulin from vials
Clean the top of the insulin bottle with an antiseptic swab
Draw air into the syringe to the number of marks of insulin required and
inject this into the bottle; then draw the required dose of insulin into
the syringe, and before withdrawing the needle from the insulin bottle,
expel the air bubble if one has formed
The skin need not be specially cleaned Repeated application of antiseptics
hardens the skin
Stretching the skin at the injection site is the best way to obtain a
painless injection; in thin people it may be necessary to pinch the skin
between thumb and forefinger of the left hand
The needle should be inserted briskly at almost 90 degrees to the skin to
almost its whole length needles are usually 06cm to 12 cm long
Inject the insulin
To avoid insulin leakage, wait 5 seconds before withdrawing the needle
Injection sites need to be rotated to avoid lipohypertrophy
Referral
All patients
3014 Diabetic emergencies
Description
Diabetics may present with a decreased level of consciousness due to
hyperglycaemia diabetic
ketoacidosis DKA or hyperosmolar non-ketotic
coma HONK or hypoglycaemia A blood glucose determination and urine test
for ketones are essential to distinguish these conditions, as each one
needs urgent management
In all patients with abnormal levels of consciousness, try to determine if
the blood glucose level is high or low
If a diagnosis cannot be made, treat as hypoglycaemia and refer urgently
Low blood glucose presents the most immediate danger to life
Diagnostic criteria
| |Hyperglycaemia |Hypoglycaem|
| | |ia |
| |DKA |HONK | |
|blood |111 mmol/L or higher |35 mmol/L |
|glucose test| |or lower |
|urine test |usually |Negative |usually |
|for ketones |positive and| |negative |
| | 1 | | |
Hypoglycaemia in Diabetics
Description
Diabetic patients on therapy may experience hypoglycaemia for reasons such
as intercurrent illness eg diarrhoea, missed meals, inadvertent
intramuscular injections of insulin or miscalculated doses of insulin,
alcohol ingestion, and exercise
without appropriate dietary preparation
Hypoglycaemia in diabetic patients can graded according to the table below:
|MILD |MODERATE |SEVERE |
|HYPOGLYCAEMIA |HYPOGLYCAEMIA |HYPOGLYCAEMIA |
|Capable of self |Cannot respond to |Semi -conscious|
|treatment |hypoglycaemia | |
| except children| |Or |
|less than 6 years| |Unconscious/ |
| | |Comatose |
| |Requires help from |Requires |
| |someone else |medical help |
| |May respond to | |
| |prompting | |
| |Oral treatment is | |
| |successful | |
|Symptoms |Neurological |Neurological |
|autonomic |symptoms |signs |
| |neuroglycopenia |neuroglycopeni|
| | |a |
|Tremors, |Headache, mood |Depressed level|
|palpitations, |changes, low |of |
|sweating,
|attentiveness |Consciousness/ |
|hunger, fatigue | |convulsions |
NB: Children, particularly under 6 years of age, generally are not capable
of self management and are reliant on supervision from an adult
Patients may fail to recognise that they are hypoglycaemic when
neuroglycopenia impaired thinking, mood changes, irritability, dizziness,
tiredness occurs before autonomic activation
Diagnosis
blood glucose 35 mmol/L with symptoms in a known diabetic patient
symptomatic hypoglycaemia can occur at levels up to 4 mmol/L in an
uncontrolled diabetic
If possible, blood glucose levels should be measured with a glucometer to
confirm hypoglycaemia
|Hypoglycaemia must be managed as an emergency |
|If a diabetic patient presents with an altered level |
|of consciousness and a glucometer is not available, |
|treat as hypoglycaemia |
Treatment
MILD OR MODERATE HYPOGLYCAEMIA
Immediate: oral rapidly absorbed simple carbohydrate, eg
sugar, oral, 5-15 g 1-3 teaspoons
Wait 10-15 minutes
If no response, repeat above
As symptoms improve: the next meal or oral complex carbohydrate should be
ingested, eg
fruit, bread, cereal, milk, etc
SEVERE HYPOGLYCAEMIA
CHILDREN
dextrose 10, IV, 2- 5 mL/kg over 5 minutes
10 solution - dilute 1 part dextrose 50 with 4 parts water for
injection
or
dextrose 10, 5 mL/kg via a carefully placed nasogastric tube if the IV
route is not easily accessible
Give adequate glucose to maintain normal blood glucose levels
ADULTS
See section 19
Diabetic Ketoacidosis
Description
Clinical features of DKA include
abdominal pain
vomiting
Deep sighing respiration
Drowsiness, confusion, coma
sweet smelling breath
Dehydration
Drug treatment
NB Early administration of large amounts of fluid initially is life saving
ADULTS
Average deficit 6 L, and may be as much as 12 L
Be cautious in renal and cardiac disease
In the absence of renal or cardiac compromise:
sodium chloride 09, IV, 15-20 mL/kg in the first hour
Subsequent infusion rate varies from 5-15 mL/kg/hour depending on the
clinical condition
Correction of estimated deficits should take place over 24 hours
The volume infused in the first 4 hours should not exceed 50 mL/kg
Refer urgently with drip in place and running at planned rate
When referral will take more than
2 hours and a diagnosis of diabetes with
hyperglycaemia is confirmed:
insulin, short acting, IM, 01 unit/kg
| |
|CAUTION |
|do not administer IV short-acting insulin if the |
|serum electrolyte status, especially potassium is |
|not known |
|continue with IV fluids but delay giving insulin in |
|these cases in consultation with referral facility |
|as this delay should not negatively influence the |
|patient, but |
|hypokalaemia with resultant cardiac dysrhythmias |
|definitely will See section 19 |
CHILDREN
if in shock
sodium chloride 09, IV, 20 mL/kg within 1 hour as a bolus
if shock not corrected, repeat the bolus
if no shock or after shock is corrected
sodium chloride 09, IV
|10 to 20 kg|60 mL/hour |
|20 to 30 kg|70 mL/hour |
|30 to 40 kg|75 mL/hour |
|40 to 50 kg|80 mL/hour |
Refer urgently with drip in place and running at planned rate
When referral will take more than 2 hours and a diagnosis of diabetes with
hyperglycaemia is confirmed and provided
glucose is monitored hourly
insulin, short acting, IM, 01 units/kg as a bolus
When giving insulin IM, do not use insulin needle
3016 Metabolic syndrome/obesity/dyslipidaemia
DESCRIPTION
The metabolic syndrome is a cluster of risk factors:
Impaired glucose metabolism
Central obesity
Dyslipidaemia
Hypertension
DIAGNOSTIC CRITERIA
There is still some controversy as to whether the metabolic syndrome is a
true syndrome or a cluster of risk factors There is also varying
diagnostic criteria around the world
the more components of the syndrome, the higher the risk
Abdominal obesity Waist circumference 102 cm in men, and 88cm in
women
BMI :determined by weight in kg/height in m2
BMI of 185-249kg/m2 is normal,
250-299kg/m2 is overweight
300-349kg/m2 is mildly obese
350-399kg/m2 is moderately obese
40kg/m2 extremely obese
Fasting plasma triglycerides 170 mmol/L HDL cholesterol 104mmol/L
in men, and 130 mmol/L in women
Blood pressure 130/85 mm Hg
Fasting blood glucose 610 mmol/L
NON DRUG TREATMENT
Eat less and walk more which is crucial to losing weight
DRUG TREATMENT
The treatment of metabolic risk factors, ie
dyslipidemia, hypertension,
and hyperglycemia
1Hyperlipidemia:
Dyslipidemia may be successfully treated through lifestyle
modifications alone, however LDL-lowering medications may be indicated
to achieve target LDL levels in higher risk patients, and reduce risk
for major cardiovascular disease events
Statins: are the first-choice lipid-lowering agents
2 Hypertension: see section
3 Hyperglycaemia: see section
3017 Diabetes mellitus type 2, adults
E11
Description
Diabetes mellitus type 2 is a chronic debilitating metabolic disease
characterised by an abnormally high blood glucose level with serious acute
and chronic complications It is an important component of the metabolic
syndrome syndrome X
In adults the condition may only be diagnosed when complications are
discovered, eg:
ischaemic heart disease
peripheral artery disease
stroke
deteriorating eyesight
foot ulcers
Symptoms of an abnormally high blood sugar level are:
thirst, especially noticed at night
polyuria
tiredness
periodic changes in vision due to fluctuations in the blood glucose level
susceptibility to infections, especially of the urinary tract,
respiratory tract and skin
Note
It is important to distinguish diabetes mellitus type 2 from diabetes
mellitus type 1
Treatment targets
|Biochemical Index |Optimal |Acceptab|Addition|
| | |le |al |
| | | |action |
| | | |suggeste|
| | | |d |
|Capillary blood glucose | | | |
|values finger-prick |4-6 |6-8 | 8 |
|fasting mmol/L |4-8 |8-10 | 10 |
|2-hour post-prandial | | | |
|mmol/L | | | |
|Glycated haemoglobin HbA1c| 7 |7-8 | 8 |
| | | | |
|Weight BMI kg/m2 | 25 | | 27 |
control the blood sugar level and HbA1C value within acceptable limits
determined by the physician glycaemic control
prevent acute complications, eg hyperglycaemic and hypoglycaemic coma
manage chronic conditions associated with diabetes
prevent complications, eg foot care to prevent gangrene
Non-drug
treatment
Step 1 - Diet and lifestyle
Patients with Impaired Glucose Tolerance IGT and Impaired Fasting Glucose
IFG should be given advice on weight loss of 5-10 of body weight,
increased physical activity to at least 150 min/week of moderate activity
such as walking and dietary modification including reduced dietary intake
of kilojoules and fat, in order to reduce the risk of developing diabetes
Add ideal weight table
NB some risk factors are preventable by lifestyle modification
Lifestyle changes include:
weight loss
advise moderate daily exercise and take up of physical activity eg
walking at least half an hour for 3 days a week, clean house, climb
stairs, etc
health diets no special products are required
Diet rich in fruit and vegetables
o eat 4 or 5 portions on a daily basis of which one is a good source of
vitamin C eg tomato, cabbage family, citrus fruit and guavas, one
dark green vegetable eg broccoli, green beans, spinach and baby
marrow or one dark yellow/ orange vegetable eg carrots, pumpkin
and butternut prepared without butter
o Eat only one fruit fresh at a time Fruit must preferably be eaten
with a meal or snack When
eating dried fruit, limit the portion to
the equivalent of a fresh fruit eg 2 dried pear halves 1 pear
low fat dairy products adults need 2 cups of milk per day ie skimmed
milk
limit the intake of cheese to a 30g portion a matchbox size or a third
cup grated cheese three times per week Where possible use low fat
cheese
nuts
Fish/chicken in preference to red meatnote: chicken without the skin
; fish should not be fried but steamed or grilled
Small amounts of red meat lean portions not more than three times per
week
reduce total intake of fat and saturated fat
o use healthy types of fat eg avocado pear, nuts, peanut butter,
canola oil, canola margarine, olive oil and olives
o unhealthy fats include: hard margarine, butter, cheese and any type of
oil heated to a high temperature Soft low fat margarine in the tub
should preferably be used instead of butter or hard margarine
o never use 2 fats on bread eg when using a spread containing fat,
use it instead of margarine
restrict the intake of food high in cholesterol eg egg yolks, tripe,
caviar, fish roe, calamari, prawns and meatA maximum of 1 egg a
day
is allowed
increasing intake of fibre
avoid refined foods eg sweets and sugary foods use food and drinks
containing sugar sparingly and not between meals
make starchy foods the basis of most meals eg whole-wheat or brown
bread, rye bread, high fibre porridge oats or whole wheat cereals,
other recommended foods : legumes dried peas and beans, lentils and
soya products, brown rice, barley samp, and whole-wheat pasta
water : women should drink at least 4 glassesof 250 ml of water per
day and men at least 6 glasses of 250ml of clean safe water per day
|Entry to Step 1 |Treatment and|Target |
| |duration | |
| | | |
|typical symptoms - |lifestyle |random blood |
|thirst, tiredness, |modification |glucose below 10 |
|polyuria |for life |mmol/L |
|and | |or |
|random blood |appropriate |fasting glucose |
|glucose above |diet |6-8 mmol/L |
|11 mmol/L | |and/or |
|or |weight loss |HbA1C 6-75
|
|fasting blood |until at | |
|glucose level ? 7 |ideal weight | |
|mmol/L | | |
| |assess | |
| |monthly | |
| | | |
| |if indicated:| |
| | | |
| |aspirin | |
| |simvastatin | |
Drug treatment
1 To prevent long-term complications of diabetes:
Aspirin, unless on warfarin or other contraindications, should be used in
all adult diabetics:
with existing cardiovascular disease CVD
in patients older than 40 years of age and who have one or more other
CVD risk factors see page xxx
aspirin, soluble, oral, 150 mg daily
Statin therapy should be added to lifestyle therapy, regardless of baseline
lipid levels, for type 2 diabetic patients:
with existing CVD
in patients older than 40 years of age and who have one or more other
CVD risk factors see page xxx
HMGCoA reductase inhibitors which
lowers LDL by at least 25, eg
simvastatin, oral, 10 mg daily maximum dose at PHC level
Step 2
|Entry to Step 2 |Treatment and |Target |
| |duration | |
| | | |
|Failed step 1 |Continue |random blood |
| |lifestyle |glucose below 10 |
|OR |modification as |mmol/L |
| |in Step 1 |or |
|fasting blood |and |fasting glucose |
|glucose above 8 |initiate drug |6-8 mmol/L |
|mmol/L |therapy with: | |
|despite 3 months |metformin |and/or |
|of adherence with|or |HbA1C 6-75 |
|treatment plan in|sulphonylurea | |
|step 1 eg | | |
|dietary changes | | |
|or | | |
|patients with | | |
|symptoms of | | |
|severe thirst, | | |
|polyuria, blurred| |
|
|vision and | | |
|weakness | | |
|or | | |
|random blood | | |
|glucose above 20 | | |
|mmol/L | | |
|or | | |
|fasting blood | | |
|glucose above 15 | | |
|mmol/L | | |
|or | | |
|HbA1C 8 | | |
Biguanide or sulphonylurea
In overweight patients biguanides should be the first choice unless
contraindicated
Biguanides metformin
Contraindicated in:
chronic kidney disease, CrCl 60 ml/min
severe hepatic impairment
pregnancy
metformin, oral, 500 mg daily
dose increments if the blood glucose is uncontrolled:
increase to 500 mg twice daily after two weeks
increase to 850 mg twice daily after another two weeks if needed
maximum dose of 850 mg three times daily
Sulphonylureas glibenclamide
or gliclazide
Contraindicated in:
chronic kidney disease, CrCl 60 ml/min
severe hepatic impairment
pregnancy
| |
|Missing meals while taking sulphonylureas may lead to|
|hypoglycaemia |
glibenclamide, oral, 25 mg in the morning with a meal
dose increments if the blood glucose is uncontrolled:
increase with 25 mg daily at two-weekly intervals
maximum dose - 15 mg daily
if 75 mg daily or more is needed, divide the total daily dose into two,
with the larger dose in the morning
Use with caution in the elderly due to an increased risk of hypoglycaemia
every dose should be taken with a meal
or
gliclazide, oral, 40 mg daily in the morning with a meal
dose increments if the blood glucose is uncontrolled:
increase with 40 mg daily at two-weekly intervals
maximum dose - 160 mg twice daily
if more than 80 mg daily is needed then divide the total daily dose into
two
every dose should be taken with a meal
Continue lifestyle modification and initiate drug treatment according to
the following schedule:
Step 3
Biguanides and sulphonylurea
|Entry to Step 3
|Treatment and |Target |
| |duration | |
|Failed step 2: | | |
|HbA1C 8 or |lifestyle |random blood |
|fasting blood |modification |glucose below 10|
|glucose above 8 |And |mmol/L |
|mmol/L |Combination oral |or |
| |hypoglycaemic |fasting glucose |
|or |agents, ie |6-8 mmol/L |
|random blood |metformin |And/or |
|glucose above 10|and |HbA1C 6-75 |
|mmol/L |sulphonylurea | |
|despite | | |
|adherence with | | |
|treatment plan | | |
|in step 2 and | | |
|maximal dose of | | |
|single agent for| | |
|2-3 months | | |
Step 4
Insulin therapy refer section 301
insulin is indicated when oral combination therapy fails
continue lifestyle modification
insulin therapy must be initiated by a doctor
sulphonylurea should be discontinued once insulin therapy is initiated
but continue with meformin
Education on insulin therapy should include:
types of insulin
injection technique and sites
insulin storage
glucose monitoring, urine and blood
meal frequency as this varies according to the type and frequency of
insulin, eg patients may need a snack at night about 3-4 hours after
the evening meal
recognition and treatment of acute complications, eg hypoglycaemia and
hyperglycaemia
|Insulin type |Starting dose|Increment |Maximum |
| | | |daily dose |
| | | | |
|intermediate |10 units in |if 10 units |20 units |
|to |the evening |not | |
|long-acting |before |effective, | |
|as add on |bedtime |increase | |
|therapy | |gradually to| |
| | |20 units | |
| | | | |
|biphasic as |twice daily |4 units |30 units |
|substitution | |weekly | |
|
|total daily | |refer if |
| |dose: |first |more than 30|
| |15 units |increment is|units are |
| |divided as |added to |needed |
| |follows: |dose before | |
| | |breakfast | |
| |2/3 of total | | |
| |daily dose, |second | |
| |ie 10 |increment is| |
| |units, 30 |added to | |
| |minutes |dose before | |
| |before |supper | |
| |breakfast | | |
| | | | |
| |1/3 of total | | |
| |daily dose, | | |
| |ie 5 units,| | |
| |30 minutes | | |
| |before supper| | |
| | | | |
| | | | |
Referral
URGENT - same day
metabolic complications:
dehydration and hypotension
nausea and vomiting
ketonuria more than 1
keto-acidosis
hyperglycaemia over 25 mmol/L
complications, eg infections which may have the following symptoms:
slow onset of progressive apathy leading to confusion, stupor, pre-coma
and coma
gangrene
sudden deterioration of vision
serious infections
Note
Before transferring very ill patients, consider IV infusion with sodium
chloride 09
Referral
Six-monthly or annual for assessment of progress and potential
complications including some facilities may have capacity to do these
fundoscopy
renal
cardiovascular
neurological
feet
laboratory
Referral
all type 1 diabetics
pregnancy
failure of step 4 to control diabetes
3018 MICROVASCULAR COMPLICATIONS OF DIABETES
3041 DIABETIC FOOT
DESCRIPTION
Ulcers develop at the tips of the toes and on the plantar surfaces of the
metatarsal heads and are often preceded by callus formation
If the callus is not removed then haemorrhage and tissue necrosis occurs
below the plaque of callus which leads to ulceration Ulcers can be
secondarily infected by staphylococci, streptococci, coliforms, and
anaerobic
bacteria which can lead to cellulites, abscess formation, and
osteomylelitis
DIAGNOSIS
The three main factors that lead to tissue necrosis in the diabetic foot
are neuropathy, infection, and ischaemia
NON-DRUG TREATMENT
Excess keratin should be pared away with a scalpel blade by a chiropodist
to expose the floor of the ulcer and allow efficient drainage of the
lesion
DRUG TREATMENT
Co-amoxiclav, oral, 500/125 mg 8 hourly for 10 days
Daily dressings a simple non adherent dressing should be applied after
cleaning the ulcer with physiological saline
If the ulcer is associated with cellulites, abscess, discolouration of
surrounding skin, or crepitus the limb is threatened and urgent hospital
admission should be arranged
Diabetes care should ideally not be compartmentalized
the scope for the primary book allows for some flexibility :organization of
diabetes care needs a good network of communication between primary care
and specialized services
DIABETIC NEPHROPATHY
DESCRIPTION
Significant proteinuria spot urine protein creatinine ratio of 01
g/mmol or ACR albumin-creatinine ratio 100 g/mol, confirm as positive
if raised on at least 2 of 3 occasions, in the absence of
infection,
cardiac failure and menstruation
NON DRUG TREATMENT
Screening
check annually for proteinuria in an early morning urine sample using a
dipstix
if dipstix positive
o check for urinary tract infection
o obtain a laboratory urine protein: creatinine ratio PCR
if dipstix negative, check urine albumin using :
o laboratory or site-of-care urine albumin:creatinine ratio
measure serum creatinine annually, and calculate GFR
o If PCR or ACR is raised, repeat within 4 months
o Confirm as positive if proteinuria or raised urine albumin on
both occasions
DRUG TREATMENT
Manage those with raised urine albumin or proteinuria or reduced GFR as
follows:
Start treatment with an ACE inhibitor and increase gradually to maximal
dose if tolerated, eg, enalapril, oral, 10 mg twice daily
Monitor potassium
Intensify management of blood pressure actively target BP 130/80
Intensify management of blood glucose target HbA1C 7
Limit protein intake 08 g/kg daily if proteinuric
Intensify other renal and cardiovascular protection measures not
smoking, aspirin therapy, lipid lowering therapy
REFERRAL
Refer to
nephrologists when GFR 60 ml/min or earlier if symptomatic
Source:uscaa.org
