with increasing prevalence of obesity more children are now presenting with type 2 diabetes, particularly from ethnic

minorities. In the USA, in some areas, up to 50% of children with diabetes are now presenting with the type 2 form. Latent autoimmune diabetes in adults (LADA) is thought to comprise about 5% of all patients with type 2 diabetes. These people have autoantibodies usually seen in type 1 diabetes, but their clinical presentation is like someone with type 2 diabetes. This is a group that may present an excellent opportunity for subsequent prevention of diabetes if an effective intervention can be developed to prevent further beta cell destruction. Monogenic diabetes (previously referred to as maturity onset diabetes in the young, MODY) Monogenic diabetes is the term used for a collection of conditions that cause diabetes now shown to result from single gene defects. One feature of these conditions is that they show autosomal dominant inheritance patterns where the disease appears to be vertically transmitted (e.g. through several generations). It is also diagnosed before the age of 25 years, but, unlike type 1 diabetes patients, monogenic diabetes patients do not often require insulin for at least 5 years after diagnosis. Genetic testing in these cases can confirm the particular sub-type of diabetes. This can have significant clinical implications. Patients with HNF1a (hepatocyte nuclear factor 1a) mutations, for example, exhibit exquisite sensitivity

to sulphonylureas and can be successfully treated with tablets. Knowledge of the mutation, therefore, can help in the management of this disorder, even in children who would otherwise have been put onto insulin. This is also one form of type 2 diabetes where we would use a sulphonylurea in preference to metformin when initiating therapy. Patients with HNF1 have renal cysts. Patients with glucokinase mutations are less common but the diagnosis is significant for the individual and their families. Such patients are much less likely to develop complications of diabetes because they mainly have mild fasting hyperglycaemia without significant post meal hyperglycaemia. Maternally inherited diabetes with deafness (MIDD) This is a form of diabetes due to mutations in mitochondria, most commonly related to 3243A > G mitochondrial DNA mutation. Mitochondria in an individual are inherited from the mother rather than from the father, therefore one clue would be evidence of strong maternal transmission of diabetes, particularly when this is associated with a sensorineural deafness. Some patients may also have peripheral vision problems, particularly night blindness. These patientsAbuse is a complex psychosocial problem that affects large numbers of adults as well as children throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) under the heading of Other Conditions That May Be a

Focus of Clinical Attention. Although abuse was first defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse in a number of different circumstances. Abuse refers to harmful or injurious tlude not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education, workplace absenteeism, and long-term health problems of abuse survivors. Types of abuse Physical often require insulin. Infusion strategy Initially reduce total daily insulin dose by 30%. Give half the daily insulin dose as the constant basal pump
rate (usually around 1 unit/hour). Give half the daily insulin dose divided between the three main meals, giving the insulin boost immediately before the meal. The patient is taught to count carbohydrate portions (see page 12) and thereafter will give the bolus doses in direct relation to the amount of carbohydrate consumed (for example, 1 unit for every 10 g of carbohydrate). During the first few days adjustments need to be made as follows: basal rate determined by assessment of fasting and 3 am blood glucose readings preprandial boosts are adjusted by assessment of postprandial blood glucose readings. Note: Specific instructions are given for exercise, and basal rates should be reduced during and after exercise.

Dose adjustment for normal eating (DAFNE)

A more liberal dietary pattern for Type 1 diabetic patients has become possible by using the DAFNE approach, ideal for some people who thus regain considerable freedom while at the same time maintaining good control. It is based on: a 5-day structured, group education programme delivered by quality assured diabetes educators the educational approach is based on adult educational principles to facilitate new learning two injections of medium acting insulin each day

which can be pulled off in strings), Phos. (black crusts). - tongue c. with mucus. Bell, (brown), Carbo. veg. (yellow-brown), Kali bi. (ropy), Merc, sol., Nitr.- ac. (tough, ropy, with ulcers), Phos. ac. (clammy, tough). Puls, (tenacious), Psorin,(whitish-yellow), Rhus. tox. (brown), Sil.(brownish). - tongue c. with ulcers. Caps, (flat, sensitive, spreading), Kali bi. (small, painful), Natr. mur. (also vesicles). - tongue c. with vesicles, Ars. (painful, burning), Apis* (stinging), Canth. (at base). Hell., Natr. mur. (smarting and burning when touched by food), Spong., Zinc. Cracked. Ailanth., Apis, Arum., Bapt., Bar., Bell., Benz. ac, Bry., Calc. fl., Cham., China, Cic, Cur., Hyos., Kali bi, I^yc, Magn. mur., Nux-vom., Phos., Phos. ac, Plb., Podo., Puls., Ran.sc, Rhus tox., Sacch., Spig., Sulph., Ver. alb. - edges, Nux vom. (rest black or red). - middle, across the, Cobalt. - tip, Lach. - tongue dry, parched and cracked, Ailanth. - tongue dry, parched and cracked in typhus, Bapt. - chronic inflammation of tongue; c, swollen and bleeding, Podo. - tongue swollen, dry, c, sore, ulcerated, covered with vesicles. Apis - tongue, painful and burning. Arum. - tongue yellow along center, first white with reddish papillae; followed by yellow-brown coating in center, edges dark red and shining; dry brown down center (Plb.); c, sore, ulcerated, Bapt., (Apis, Ars., Rhus tox). - smarting, burning pain in tip of tongue, sore and c. Bar. carb. - tongue rough, c, and often of a dark- brown color, Bry. - tongue dry, smooth, red, c. (in dysentery). Kali bi. - tongue dry, red, brown, c, and tremulous, Hyos. - tongue dry, red, c, black stiff, Lach., Rhus tox. - tongue coated yellow, burning with blisters, c, Spig. - tongue smooth, red and c, dry and red, coated - thick whitish-yellow, ulcerated. Kali bi. - mouth very sore, parched and dry, mucous membrane c. and bleeding, tongue swollen and covered - with blisters on each side, Lach.

(see page 21) injections of short acting insulin every time meals are taken testing blood glucose before each injection. This programme enables people to eat more or less what they like when they like, and not to eat if they do not wish to do so. It depends on a quantitative understanding of the carbohydrate values of individual foods, and calculating by trial and error the correct amount of soluble insulin needed for a specified quantity of carbohydrate, developing an insulin/carbohydrate ratio for each individual patient. DAFNE has been used in continental Europe for many years: the- tongue covered with fur. Bell, (white and clammy,

- dry, black or c. tongue, Lj^c. (Ars., Lach., Phos., Rhus tox. ) - tongue cold, dry, blackish, c, red and swollen, Ver. alb. - brown, parched, c. tongue, Sulph. - tongue c. or coated yellow, with red tip and edges, Ver. alb. - and burning, Arum tr.. Bell., Bry., Ran. sc., Sulph., Ver. alb. - black and dry, stiff as a board, Ars. - on edges, black or dark red, Nux. vom. - and dry (tip). Kali bi., Lach., Rhus tox., Sulph. Crack deep, Adverse reactions
Common: drowsiness. Serious: hypotension, bradycardia, tachycardia, confusion, respiratory depression, physical and psychologic dependence, addiction. Clinically important drug interactions: Drugs that increase effects/toxicity of narcotic analgesics: Alcohol, benzodiazepines, antihistamines, phenothiazines, butyrophenones, triyclic antidepressants, MAO inhibitors. Parameters to monitor Signs and symptoms of pain: restlessness, anorexia, elevated pulse, increased respiratory rate. Differentiate restlessness associated with pain and that caused by CNS stimulation caused by the drug. This paradoxical reaction is seen mainly in women and elderly patients. Monitor respiratory status prior to and following drug administration. Note rate, depth, and rhythm of respirations. If rate falls below 12/min, withhold drug unless patient is receiving ventilatory support. Consider administering an antagonist, eg, naloxone 0.10.5 mg IV every 23 min. Be aware that respiratory depression may occur even at small doses. Restlessness may also be a symptom of hypoxia. Monitor character of cough reflex. Encourage postoperative patient to change position frequently (at least every 2 hours), breathe deeply, and cough at regular intervals, unless coughing is contraindicated. These steps will help prevent atelectasis. Signs and symptoms of urinary retention, particularly in patients with prostatic hypertrophy or urethral stricture. Monitor output/intake and check for oliguria or urinary retention. Signs of tolerance or dependence. Determine whether patient is attempting to obtain more drug than prescribed as this may indicate onset of tolerance and possibility of dependence. If tolerance develops to one opiate, there is generally cross-tolerance to all drugs in this class. Physical dependence is generally not a problem if the drug is given for less than 2 weeks.
126 BUTORPHANOL

Monitor patients BP. If systolic pressure falls below 90 mm Hg, do not administer the drug unless there is ventilatory support. Be aware that the elderly and those receiving drugs with hypotensive properties are most susceptible to sharp fall in BP. Patients heart rate. Withhold drug if adult pulse rate is below 60 bpm. Alternatively, administer atropine. Respiratory status of newborn baby and possible withdrawal reaction. If the mother has received an opiate just prior to delivery, the neonate may experience severe respiratory depression. Resuscitation, as well as a narcotic antgonist, eg, Narcan, may be necessary. Alternatively, the neonate may experience severe withdrawal symptoms 14 days after birth. In such circumstances, administer opium tincture or paregoric. Signs and symptoms of constipation. If patient is on drug for more than 23 days, administer a laxative. For patients on longterm

therapy, administer a bulk or fiber laxative, eg, psyllium, 1 teaspoon in 240 mL liquid/d. Encourage patient to drink large amounts of fluid, 2.5 to 3 L/d. Editorial comments: This drug is indicated for treatment of moderate to severe pain. Intranasal formulation allows for rapid onset of pain relief.
BUTORPHANOL 127

Calcitonin
Brand names: Calcimar (salmon), Cibacalcin (human), Miacalcin (salmon). Class of drug: Calcium-lowering agent, treatment for Pagets disease, antiosteoporosis agent. Mechanism of action: Promotes renal excretion of calcium and phosphate, inhibits osteoclastic bone resorption Indications/dosage/route: IM, SC, intranasal. Note: Prior to treatment, a skin test must be performed (see Warnings/ Precautions). Pagets disease Adults, salmon calcitonin: Initial: SC or IM 100 units/d. Maintenance: 50 units/d. Adults, human calcitonin: Initial: SC 0.5 mg/d. Maintenance: 0.5 mg 2 or 3 times/wk. Hypercalcemia Adults, salmon calcitonin: IM, SC 4 units/kg q12h. Maximum: 8 units/kg q6h. Postmenopausal osteoporosis Adults, salmon calcitonin: IM, SC 100 units/d. Intranasal: 1 spray (200 units)/day. Combine with oral calcium carbonate, vitamin D. Osteogenesis imperfecta Adults: IM, SC 2 units/kg 3 times/wk. Combine with oral calcium. Children: Safety and efficacy have not been established.
Onset of Action Duration Hypercalcemia 2 h 68 h

Pregnancy: Category C. Lactation: No data available. Best to avoid. Contraindications: Hypersensitivity reaction to salmon calcitonin or its gelatin diluent.
128 CALCITONIN

Warnings/precautions When using salmon calcitonin determine whether patient is allergic by performing skin test before administration. One unit is injected into the skin. Observe for 15 minutes for development of erythema or wheal. Have emergency equipment available during administration. Potential for hypocalcemic tetany. Advice to patient Learn the correct way to use the nasal spray. Calcium and vitamin D supplements are part of the treatment for osteoporosis. Employ sterile techniques for injection. Alternate injection sites. Adverse reactions Common: None. Serious: Allergic reactions, hypocalcemia, tetany (overdose). Clinically important drug interactions: None reported. Parameters to monitor Serum electrolytes, calcium, alkaline phosphatase. Signs of hypersensitivity reactions. BP, pulse, ECG. Signs and symptoms of hypercalcemia: bone pain, thirst, nausea, vomiting, anorexia, constipation.

 Signs and symptoms of hypocalcemic tetany: convulsions, tetanic spasms, muscle twitching. Administer calcium parenterally. Editorial comments The most frequent use for calcitonin is postmenopausal osteoporosis. It is also useful to prevent and treat corticosteroidinduced osteoporosis. Consider an alternative drug such as alendronate (Fosamax) for these indications.

Calcitriol
Brand names: Calcijex, Rocaltrol.
CALCITRIOL 129

Class of drug: Vitamin D analog, calcium-raising agent. Mechanism of action: Promotes intestinal absorption of calcium. Promotes renal calcium resorption. Indications/dosage/route: Oral, IV. Hypocalcemic patients undergoing chronic dialysis Adults, PO: Initial: 0.25 g/d. Maintenance: 0.25 g/d 2 days, increase dose up to 1 g/d by 0.25 g/d. Check serum calcium levels q2wk during titration. Children, PO: 0.252 g/d; 0.0140.041 g/kg/d (not on dialysis). Adults, IV dosing for hypocalcemia Initial: 0.5 g 3 times/wk. Maintenance: 0.53 g 3 times/wk. Children, IV: 0.010.05 g/kg 3 times/wk. Hypoparathyroidism Adults, children >5 years: Initial: PO 0.25 g/d. Maintenance: 0.52.0 g/d. Children <1 year, PO 0.040.08 g/kg/d. Children 15 years: PO 0.250.75 g/d. Vitamin D-dependent rickets PO 1 g/d. Adjustment of dosage Kidney disease: Reduce dose in severe disease. Liver disease: None. Elderly: None. Pediatric: Safety and efficacy have not been established.
Onset of Action Peak Effect Duration Treatment of Hypocalcemia Approx 26 h 10 h 35 d

Food: Patient should have diet rich in calcium. Pregnancy: Category C. Could be toxic to fetus if dose exceeds recommended dose. Lactation: Appears in breast milk. Contraindicated. Contraindications: Hypercalcemia, vitamin D toxicity, hypersensitivity to calcitriol.
130 CALCITRIOL

Warnings/precautions This drug must be given with calcium supplements. Serum phosphate must be controlled before initiating therapy. Instruct patient how to avoid excessive phosphorus intake. May produce vitamin D overdose: Do not allow serum [Ca] [phosphate] to exceed 70 (see Parameters to monitor). Advice to patient Limit intake of vitamin D, ie, avoid megavitamins and limit intake of vitamin D-rich foods: fortified milk, fish liver oils, cereals. Avoid magnesium-containing antacids. Maintain a high fluid intake. Avoid excessive phosphorus intake. Adverse reactions Common: None. Serious (seen with hypervitaminosis only): hypertension, arrhythmias, hypotension, hyperthermia, psychosis, pancreatitis, hematitis, ectopic calcification, nephrocalciumesis.

Clinically important drug interactions Drugs that increase effects/toxicity of calcitriol: thiazide diuretics. Drugs that decrease effects/toxicity of calcitriol: cholestyramine, cholestipol, barbiturates, phenytoin, corticosteroids. Parameters to monitor Serum calcium, phosphorus, albumin, BUN and creatinine. Urinary output, fluid intake. Calcium concentration should be maintained between 9 and 10 mg/dL. If the product of calcium (mg/dL) and phosphate (mg/dL) is greater than 70, discontinue therapy. Urinary calcium and creatinine. If the calcium:creatinine ratio is less than 0.18, discontinue therapy. Serum alkaline phosphatase levels. If enzyme level falls significantly, this may be a sign of impending hypercalcemia. Signs of hypocalcemia: laryngospasm, paresthesia, arrhythmia, Chvosteks or Trousseaus sign. Signs of hypercalcemia: Early: headache, anorexia, weakness, dry mouth, metallic taste, abdominal cramps, ataxia. Later:
CALCITRIOL