Diabetes mellitus

Presentations of diabetes mellitus:1) Acute : DKA, or other types of diabetic coma

2) Subacute : poly-symptoms(polyurea, polyphagia,
polydipsia), wt loss , infections(especially fungal)
3) Complications : nephropathy, neuropathy,
retinopathy
4) Asymptomatic
In acomatosed patient with normal pulse &
Bp, suspect that he is adiabetic.
Also if there is numbness , tingling in the
foot without back pain , then suspect that
tha patient is diabetic

How to diagnose?

Prediabetics:-these are patients with

increased risk to develop diabetes later in their
life.two categories are known:1) Impaired fasting glucose:-means
fasting blood glucose from 110-125 mg/dl.

2) Impaired glucose tolerance:-means

that 2hr post prandial plasma glucose 140199 mg/dl.

Important notes before treatment: If insulin is used , use insulin syringe only.
Dont forget to train the patient to inject
insulin to himself & tell him about the
injestion sites(deltoid ,below umbilicus ,
thigh,)
The type & timing of required investigations
for any newly diagnosed diabetic patient differ
according the type:* Type I:-every 5 years
* Type II:- urgent investigations.

1) Classic sympt. + random glucose (RBS) 200

mg/dl or fasting 126 mg/dl
2) Asympt. + 2 abn. Values of fasting sugar on 2
Follow up investigations include:separate occasions
3) IGT (fasting 110-126) do GTT ( 2 hrs post
(Eye + Kidney + Foot)
prandial )
GTT :
1) Eye
a) if 200 2hrs pp = DM
2) Kidney:- albumin creatinine ratio ,
b) If 140-200 = IGT f/u after 1 month
microalbuminuria in urine.
c) If < 140 non diabetic
3) Foot:- infection , palpate for pulse ,
numbness&tingling
4) HbA1c 7% ( N = 4-6 %):-for follow up &
to know diabetic control an the last three
How to differentiate between Type I &
months.

Type II?

Diagnostics tests
1) Random blood glucose:-sample taken any
time of day.the normal value not higher than
200 mg/dl.
2) Fasting plasma glucose:-no caloric intake
for 8 hours.the normal value is 70-110 mg/dl.
3) 2hr post prandial plasma glucose:blood sample taken 2 hours after aperson has
consumed a 75 gm glucose powder dissolved in
250 ml water.the normal value doesnt exceed
140 mg/dl.

1) Type I: Young age

No family history.
Autoimmune.
Thin people.
2) Type II: Old age.
Family history.
Not autoimmune.
Obese people.

Target of treatment?
Restrict Control:-

Fasting < 100 + 2hr postprandial < 120

Type 1 + Pregnancy + Preoperative

The problem of this control is hypoglycemia

predisposition.
Usual Target:-

Fasting < 120 + 2hrs postprandial < 140

This is the Normal control for our patient.
Old age Target

Fasting < 140 + 2hrs postprandial < 180

In Elderly (because frequent hypoglycemia due
to non compliance).

Treatment:DM isnt curable but controllable.

Three items included under this category:1) Diet

2) Exercise
3) Drugs
Diet:50% CHO, 20% Protein, 30% fat +++ no smoking

*




Exercise :-

Drugs: First of all you should know that:1) Insulin is amust for Type I.
2) Oral hypoglycemic drugs are suitable for Type II
patients.(may convert to insulin).
I means by drugs ,two lines:1) Oral hypoglycemic drugs.
2) Insulin.
1) Type II & Oral hypoglycemic
drugs:
Gliclazides :All sulphonylureas have the same effect if one
type fails all will fail
Given before meals if missed meal hypoglycemia
Commonest side effect : weight gain
Egyptian market:R/ Diamicron MR 30-60

Max.dose:- 120 mg /day

Biguanides : e.g. Metformin 500-850-1000 mg
Doesnt cause hypoglycemia
st
1 line for obese pts(causes weight loss)
Better avoided in elderly pts, pts with CVS,hepatic
or renal disorders.
Max.dose:- 3 gm/day.
Egyptian market:R/Cidophage/Glucophage 500-850-1000 tab
4 3

Glimipride :
Can be given alone or with metformin .
Max.dose:- 8 mg/day
Egyptian market:R/ Amaryl 1-2-3-4 mg tab
) (

light daily exercise + foot care

Glitazones :
R/ rosizone / avandia tab
N.B the previous oral drugs give maximum response
after 2-4 weeks,so monitor for response after at least
two weeks from treatment start.

Approach to Type II

2) Type I & Insulin

Indications of insulin therapy: Your rule in the treatment is "Trial & Error" i.e. start
1) Type I diabetes:-it is amust.
with adrug then titrate either by increasing the dose
2) Type II:- see before.
,frequency or adding another drug or line of
3) Gestational diabetes mellitus.
treatment according to patient response.
4) Secondary diabetes:-due to pancreatic disease.
Start the treatment according to this approach: Insulin in our body is secreted to cover two
items:N.B:-(if the patient isnt controlled by any line of
1) Basal level:-due to continous secretion by
these drugs(six lines) , convert to the following one
pancreas.
subsequent to it)
2) Meal time:- insulin is secreted additionally to the
Metformin or Sulphonylurea
basal level to counteract the postprandial rise in
Glucose.
Metformin + sulphonylurea
Types of insulin: Short/rapid acting:Glimipride
Glimipride + metformin
Increase dose gradually
Consider insulin start (combination or alone)

Combination therapy of Insulin & Oral drugs:-

Long acting(or intermediate) insulin at bedtime

or , Mixtard before breakfast only.(i.e(
+ Oral(best metformin)
Total transition from Oral drugs to Insulin alone:-

The best is to use ''Mixtard''(premixed insulin)

with splitting the dose(2/3 before breakfast &1/3
before dinner)
When to use insulin in type II diabetic?
1) Uncontrolled hyperglycemia despite maximum
doses of oral drugs , or from the start at time of
diagnosis(fasting>300 mg/dl & random>350
mg/dl).
2) Renal,Hepatic failure.
3) Underbuilt patient.
4) Pregnant type II patient.
5) Surgery.
6) Stresses as infection & injury.
N.B:-When the case is controlled Follow up
with HbA1c every 3-6 monthes

Onset=30 minute
Duration=6 hours
Egyptian market: Actrapid
* Used mainly in emergent cases(DKA).
* The only type which can be used by the
three ways:- IM , IV & SC
Intermediate acting insulin: Onset=3hours
Duration=12-18 hours
Egyptian market: Humulin-N
Long acting insulin:-

Onset=6 hours
Duration=18-24 hours
Egyptian market: Lantus

* It is peakless insulin
Premixed insulin:

70%intermediate+30%rapid acting
The most commonly used
Onset=30-60 minutes.
Duration=14-18 hours

Important clinical points about insulin use: Sites of injections are:1) Upper outer arm.
2) Lower abdomen
3) Buttocks
4) Upper outer thighs

 The needle is to be inserted at an angle of 45-60

degree.in obese patients,insert it vertically.
The same syringe can be reused by the same
patient.upto 6-8 times(till the needle felt blunt).
Insulin dose calculation:Daily dose = 0.5 -1 unit/kg
How to start?
Three regimens are mentioned: Mixtard(70/30): For both typeII(see above) & type I

Calculate the daily dose first then ,

Divide it 2/3 before breakfast & 1/3 before
dinner.
Example:-60 kg patient needs:* Total daily dose = 600.5=30 unit
* 20 unit(2/3) Mixtard before breakfast
* 10 unit(1/3)Mixtard before dinner
Long acting & Rapid acting
For restrict control.
Lantus at night(long acting)+ Actrapid before each

meal
Calculate the daily dose then divide it as 1/2 lantus
& 1/2 rapid acting then divide Rapid acting again
by three(each before each meal).
Example:- 80 kg patient needs:* Total daily dose = 800.5=40 unit.
* 20 unit(1/2) lantus at night.
* Remaining 20 unit(1/2) Actrapid divided as
follows: 5 unit Actrapid before breakfast.
10 unit Actrapid before launch(main meal).
5 unit Actrapid before dinner.
Intermediate acting & rapid acting
For restrict control.

Humulin-N twice daily(morning & night) +

Actrapid before each meal.
Calculate as the previous regimen(1/2 intermediate
& half Actrapid) then divide intermediate by 2 &
divide Actrapid by 3.
Example:- 80kg patient needs:* Total daily dose = 80 0.5=40 unit

* 20 unit(1/2) Humulin-N divided as follow: 10 unit at morning

10 unit at night
* Remaining 20 unit(1/2) Actrapid divided as
follows: 5 unit Actrapid before breakfast.
10 unit Actrapid before launch(main meal).
5 unit Actrapid before dinner.
N.B :- in the last regimen(intermediate&Rapid)you can

mix Humulin-N & Actrapid in the morning dose only

in one syringe(this cant be done at night not to cause
hypoglycemia.
Humulin- Actrapid
N
Actrapid .
Humulin-N

How to follow up?(after 5 days at least)

If the patient use ''Mixtard'': We need 4 measures for monitoring:-

1) One Fasting blood glucose

2) Three postprandial readings
Possibilities:-

1) Fasting(high) & after dinner(high): Increase the Pre-dinner dose of''

Mixtard''(after excluding somogyi
phenomenon)
2) If after breakfast(high) & after launch(high): Increase the Pre-breakfast dose of ''Mixtard''
3) If all reading are controlled except after the
main meal
Add Actrapid before this meal
If the patient use ''Humulin-N'' &
''Actrapid'': We need 4 measures:-

1) One fasting
2) Three preprandial
Possibilities:1) Fasting(high): Increase the dose of ''Humulin-N'' at night

2) Both pre-launch & pre-dinner are(high): Increase the dose of ''Humulin-N'' at morning

3) If any Pre-prandial reading (only) is (high): Increase the dose of ''Actrapid'' which taken
before the preceding meal to it.
(i.e if pre-dinner reading is high , increase
the dose of pre-launch ''Actrapid'')

Hypoglycemic Problems in
diabetics
Diabetes Related Hypoglycemia:-

Management differ according to the attack(mild ,

moderate or severe).
A. Mild & moderate attacks:-here the patient is

Means low plasma glucose level (below 50 or 60 mg

conscious,&only complaining of the adrenergic
/dl).
symptoms(1,2&3 of above points).so,the
The most common & dangerous acute complication
management includes:of diabetes.
1) Take something containing simple sugars
Cause of hypoglycemia:(juice,honey)or,sugar dissolved in water
1) Large doses (either insulin or OHD)
()
2) Missed meals.
2) Avoid any drink containing fat like:- chocolate or
3) New site of insulin injection(due to rapid
milk.
absorption).
3) After recovery:- give asnack
4) Increased activity(exercise) either in the duration
4) Dont forget to repeat random glucose level.
or the intenisty .
The classic clinical picture of the patient:1) Excessive sweeting
B. Severe hypoglycemia:- here the patient is
2) Palpitation
3) Tremors
convulsing or comatosed.
4) Headache , blurred vision,decreased attention.
The first words to be said here is:- NEVER give drink or
5) Convulsions & finally coma
food to unconscious patient:-will suffocate(pneumonia).
N.B:- the brain needs continous flow of glucose.if blood
glucose level decreases below 50 mg/dl , the brain
doesnt function well , producing the neuroglycopenic
Rapidly canulate the patient & adminster either:symptoms(4&5 of above points).
50cc bolus of glucose 25 % or,
Approach to the Case
Glucose 5 % infusion(250-300ml)

Examine for:- bounding pulse but the blood pressure is

normal.

Rapidly measure Random blood glucose,it will be lower

than 50 mg/dl
Now , I can tell you that you have fullfil two of three
criteria of Whipples triad , which is the diagnostic tool of
hypoglycemia,it consists of:1) Symptoms & signs of hypoglycemia.
2) Random glucose<50mg/dl
3) Dramatic improvement with restoration of
glucose level to normal.

Then , note the response of the patient to therapy(&

frequently reestimate random glucose level to ensure
that you are in the correct way).
If available(usually not) glucagon injection
, give it intramuscularly.the dose:
(<5 years.half vial // >5 years.one vial)

The most important item in the management is

not to recover the patient only,but also
EDUCATE after recovery about:1) The possible causes of hypoglycemia.
2) How to recognize it early

3) How to manage himself if the attack still

mild to moderate.
Hypoglycemia Unawareness
Here the patient has hypoglycemia & go to
neuroglycopenic symptoms without warning
adrenergic symptoms.
I mean here that the threshold of glucose level at
which warning adrenergic symptoms appear has
been decreased (adaptation occurs).
Causes may be:1) Recurrent attacks of hypoglycemia.
2) Concomitant use of B-blockers(mask signs of
hypoglycemia).
Management :- only avoid any attack of
hypoglycemia(avoid low blood glucose <65 mg/dl)
for at least two weeks.this is sufficient for return of
the threshold of symptoms recognition.

Nocturnal Hypoglycemia
(Somogyi Phenomenon)
In one sentence it means:Morning hyperglycemia due to Night hypoglycemia

The patient here has hypoglycemia at night &

rebound hyperglycemia occur in response to this.
In insulin treated diabetics.
The goal for which I mention it , is that you may
increase insulin dose to the patient depending
(wrongly) on your measure at morning(morning
hyperglycemia),but the reverse should be
done(decrease the insulin dose depending on night
hypoglycemia).
So , How to avoid this?
Listen carefully to the patient asking him this question:-

Then , ask him to measure his Glucose level at this time.

(will be decreased)
Management:- either:-

1) Reduce the evening dose of insulin or

2) Take asnake at bed time.

Hyperglycemic problems in
Diabetics
Uncontrolled hyperglycemia: I mean here that the patient only has elevated
glucose level(in blood & urine) without
ketone(acetone)in his urine.
The patient complain is:1) Patient is conscious
2) Headache ,malaise
3) Blurring of vision
4) Hx of DM or patient on anti DM treatment
Approach to the Case

Ask for two labs:1) Random blood glucose(High)

2) Acetone in urine( Absent))

Rapidly adminster insulin Actrapid Subcutaneously

according to this table:

If glucose level is 200-250 5 units SC

If 250-300 10 units SC
If 300-350 15 units SC
If 350-400 20 units SC
If higher >400 25 units in 500 cc
Ringers (20 drops/minute)
Reestimate blood glucose & Acetone /12 hours
N.B -1:- dont request only ''urine analysis'' , some

labs doesnt include acetone in the results,so write

this'' please for urine analysis , acetone in urine ''
N.B -2:- if urinary ketones(acetone) is +ve(or
become +ve during follow up) refer urgently to
hospital,the case may need ICU(DKA).

Chronic Diabetic Complications

CVS disorders :
Risk factors :

1) All diabetic patients 50 yrs,

2) Patients with metabolic $(obese, DM, HTN,
dislipidemia),
3) And patients with previous CVS disorders.
Management :

1) Aspirin 75 mg to all pts 50 yrs once daily (

except HTN pts )
2) Statin once daily to decrease cholesterol level
3) Glucose control with OHDs or insulin
4) HTN control with anti HTN drugs
Example
R/ Aspocid 75 tab
R/ Lipicole tab
R/ Concor 2.5 tab

Neuropathy :

Traditional analgesics :

R/Olfen,Voltaren,Ketofan amp
3 12

Then,
R/Ketofan/ brufen/ adwiflam tab
12
Analgesics with low or no effect on GIT :

Anticox-II amp
3

Then:Melocam mobic 7.5/15 mg tab

Analgesics acting on CNS in severe neuritis

Tegretol 200 tab

Vit. B complex :
Neurovit/ Depovit/tri-B/
Nourobion/Nourobin amp
3

Tab form of these drugs are not very effective

N.B :- Becozyme amp

2