Edited by

3alam el-teb
worldmedicine-mahmoud.blogspot.com

Preface
In the name of Allah the Merciful
This note contains all the required for house officers& new
GPs about DM from practical point of view
I dedicate this work to everyone involved in the
dissemination of science wherever & to my mother,
family and all my friends.

By 3alam el-teb

 3
1st detection
Follow up
Complications
1st detection :

. DM ( 1
( 2
( 3

Step1
. DM .1
1) Poly symptoms
2) Vague symptoms
a) Anorexia
b) Abdominal pain
c) Blurred vision
d) Infection
3) Coma
a) Hypoglycemia
b) DKA
c) HHNK(Hyperglycemic Hyperosmolar non Ketotic Coma)

Step 2
.2
RBS
200mg
DM
3

By 3alam el-teb

Step3

.3

)FBS (fasting blood sugar) PPS(post prandial sugar
110--70
140
200 126

Iifjbdfl,./,

mg/dl
Normal
DM

Fegviujggn
impaired fasting glucose
impaired glucose tolerance

If fasting 110-126
If PP 140-200

Prediabetic
!!

Blood glucose level is higher than normal but not high
enough to cause DM
Many people of prediabetic develop type 2 DM within 2
years
& Prediabetic patients with high risk of heart diseases
stroke
Low or modest body weight with moderate physical

.




...
....

By 3alam el-teb

 : type 1 & type 2

By 3alam el-teb

 : Hypoglycemic coma

By 3alam el-teb

 :
)Metabolic syndrome ( syndrome X

By 3alam el-teb



.
Life style
modification

Medication

Exercise

Health
Education

Diet

1. Diet


.

) (

6 2
)(
) (
)(
) (
:
By 3alam el-teb


Type 1 DM

hypoglycemia 18
type2

Type 2 DM

As above
6
3 main meals
3 snack in between

fibers ) (.

2. Exercise

3. Health education

Nature of disease
Emergency
Diet & drug
Follow up

By 3alam el-teb

4. Medications
Insulin sensitizers
(Biguanides)

Insulin secretions
Increase insulin release
from B cell (mainly)

Metformin

Diamacron
Amaryl
30,60

1,2,3,4

Max dose
120

Max dose 8

Glucophage
Cidophage

500,850,1000
1500-2000

Max
dose

2500
3
500

S/ E
C/I

Metallic taste
GIT upset
Lactic acidosis
Organ failure
infection

!
Golden rules
DM is not curable but controllable
Target of treatment ()
110
140

Hyperglycemic side
10

By 3alam el-teb

Old age

hypoglycemia tolerance

Any organ failure

As (liver-kidney-lung)
Due to decreases insulin degradation by these organs)
hypoglycemia

IHD
As hypoglycemia precipitates angina & infarction

hyperglycemic side
300 200

normal 30-50

Insulin
Indications
Type 2 DM

Uncontrolled
Operation
Pregnancy
Ischemia
Infection
Trauma
Organ failure

Type 1 DM

type2 oral

11

By 3alam el-teb


1) Hyperkalemia
2) DKA, HHNK
3) Insulin test in hypothalamic hypophyseal adrenal axis
4) Insulin stimulation test for GH assessment

Ultra short Short acting intermediate

Apadra
Humalin R
Humalin N

Crystalloid

) (

) 3(


)(child, pregnant
7

20

4

strict control

Long acting
)(Lantos-levimore

mixed
Mixtard 30/70
30
70

Intermediate
N

Short acting
R

Mixtard 30/70

By 3alam el-teb

12

Start with low dose

Rough method Accurate method

0.3- 0.8 Unit/Kg
) (0.5

Fasting/5

2/3 1 /3

Arm
Thigh
Lower abdomen

S.C
90

FBS
PPS

range 5 10
5 5 10

1.Hypoglycemia
)(most common
2.Insulin lipodystrophy
) (
3.Insulin allergy
) (antihistaminic
4. Somogi effect
morning hyperglycemia
counter regulatory hormones nocturnal insulin
hypoglycemia counter regulatory hormones

By 3alam el-teb

13

5.Insulin resistance

Increase serum insulin level
With
Increase or normal blood glucose

insulin AB
obesity
Organ failure
infection
surgery

immunosuppressive(corticosteroids)
Biguanides

...

Acute therapy of hypoglycemia

14

By 3alam el-teb

Management of DKA

15

By 3alam el-teb

Algorithm approach to patient

Suspected or documented
With hypoglycemia

16

By 3alam el-teb



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17

By 3alam el-teb