All diabetics must be educated about the disease and the need for day to day control of the disease. The modem method is for the patient to take part in the control. One way is the self-monitoring of blood glucose using a glucometer. Here, the patient can be trained to check blood glucose by using capillary blood from a finger prick. The patient can be taught how to increase and decrease the level of insulin depending on the self+checked glucose levels, by writing down, an algorithm. At periodic intervals a doctor or specially trained nurse-practitioner should go over the glucose readings with the patient and give feedback.
Ambulatory Control
Goals of Treatment
The aim of treatment of diabetes is as follows:
1) Achieve HBA-1C values of 7 per cent, fasting glucose below 126 mg per cent,and two hour post- prandial value below 200 rngs per cent, without producing hypoglycemia.
2) Promote weight reduction and encourage other lifestyle behavioural changes which prevent atheroscelrosis.
3) Monitor, and detect the presence of chronic complications of diabetes, and offer appropriate treatment.
4) Effective management of acute complications of diabetes.
1) Newly Detected Diabetic
Step 1: Diet
When a new diabetic presents for control, the first advice is regarding diet and weight reduction Section), and if required, the start of drugs. Dietary advice alone is sufficient if the person is overweight and the blood glucose values are consistent with impaired glucose tolerance or Impaired fasting glucose (IGT, IFG section). Diet and weight reduction alone is also sufficient for mild diabetics whose fasting glucose values are approximately below 150 rngs, and the post-prandial values are around 250 rngs .
Step 2: Start One B u g
If the blood glucose values are very high (> 200 rngs fasting and >300 rngs PP), it is unlikely that diet alone will be sufficient, and hence along with dietary advice, oral drugs can be started. In overweight patients (BMI greater than 28), Metfom~in is the ideal first line drug as it will promote weight loss. Sulphonylureas may be started in non-obese. All drugs should be started at the lowest doses once a day, and at 1-2 weekly intervals doses can be increased based on blood glucose values, till the maximum dose of the drug is achieved. There is no benefit in changing to another SU.Failure with one drug indicates failure to d l drugs in the class.
Step 3: Add on Second Drug
If blood glucose levels do not reach target levels with the first drug, the second drug is added; a SU is added if the patient was first started on metformin, and vice versa.Maximum dose is arrived at by testing at two to four week intervals and at each visit,dietary advice is reinforced.
Step 4: Add on Third Drug
Thiazolidenedione (insulin sensitizers) is added on as a third drug. Pioglitazone in dose of 15 rngs once a day, gradually increased to 45 mgs once a day. Rosiglitazone 2to 4 mgs per day is ailother alternative drug. Jaundice, and known liver disease are absolute contraindications for use of these drugs. Some experts advise monitoring the liver function tests at the start and subsequent two monthly (NICE guidelines, UK).However, these drugs are quite safe and regular monitoring is not mandatory.how ever, since the first drug (troglitazone) in this group was withdrawn because of hepato-toxicity, it is wise to withdraw the drug in the event of any liver function test abnormality.
These drugs are very potent and are likely to result in blood glucose loweiing to desired levels.The NICE guidelines referred to above, recommend that in step 4, the second drug should be replaced by a glitazone, rather than adding on the glitazone. However, fairly extensive experience with 3 drugs suggest that 3 drugs given concurrently is safe, but more observational research is needed.Heart failure is a relative contraindication to use of this group as fluid and salt retention is significant enough to exacerbate the condition.An alternative to the above drug is acarbose. This is a relatively weak divg and is a natural choice if the person is elderly, or has renal failure because the chance of hypoglycemia is reduced.
Step 5: Start Zrisulin
If the combination of three drugs does not achieve the goals of glycemic control, then the patient should be advised to start insulin. Tlie best option is to use a biphasic insulin once a day before breakfast. If required a second dose is added before dinner.Oral drugs are often continued. Usually metformin and/or glitazones are continued with insulin as these drugs are known to increase insulin sensitivity.
Primary and Secondary Failure to OHA's
This applies to type I1 diabetes only. When a type JI diabetic cannot be controlled on a combinatioil of all available OHA's right from the time of diagnosis, the patient has to be started on insulin. This is known as "piin~suy failure to OHA", and is indicative of marked pancreatic insufficiency and insulin resistance. When a patient is controlled for several y e a s on OHA's and then needs to be put on insulin, then it is known as "secondaru failure to OHA's. Most diabetics need increasing doses of OHA's and a small proportion need to be put on insulin. Many estimates suggest that five per cent patients per year (in a cohort of patients) will progress to severe insulin deficiency.
Comprehensive Care of a Diabetic on Clinic Visits
A well controlled diabetic should be seen at the clinic between three or four times a year, whereas those with poor control should be seen at one or two weekly intervals to achieve control. If infection is concomitantly present the inpatient therapy is generally advisable. At each visit, the following should be checked:
1) Weight,
2) Blood pressure.
4) Fasting and two hour post-prandial plasma blood glucose.
5) Compliance with diet and medications.
The HBA-1C is the best criteria to assess control over a long period ol time, such as three months and the target level is at 7 per cent.
Ambulatory Control
Goals of Treatment
The aim of treatment of diabetes is as follows:
1) Achieve HBA-1C values of 7 per cent, fasting glucose below 126 mg per cent,and two hour post- prandial value below 200 rngs per cent, without producing hypoglycemia.
2) Promote weight reduction and encourage other lifestyle behavioural changes which prevent atheroscelrosis.
3) Monitor, and detect the presence of chronic complications of diabetes, and offer appropriate treatment.
4) Effective management of acute complications of diabetes.
1) Newly Detected Diabetic
Step 1: Diet
When a new diabetic presents for control, the first advice is regarding diet and weight reduction Section), and if required, the start of drugs. Dietary advice alone is sufficient if the person is overweight and the blood glucose values are consistent with impaired glucose tolerance or Impaired fasting glucose (IGT, IFG section). Diet and weight reduction alone is also sufficient for mild diabetics whose fasting glucose values are approximately below 150 rngs, and the post-prandial values are around 250 rngs .
Step 2: Start One B u g
If the blood glucose values are very high (> 200 rngs fasting and >300 rngs PP), it is unlikely that diet alone will be sufficient, and hence along with dietary advice, oral drugs can be started. In overweight patients (BMI greater than 28), Metfom~in is the ideal first line drug as it will promote weight loss. Sulphonylureas may be started in non-obese. All drugs should be started at the lowest doses once a day, and at 1-2 weekly intervals doses can be increased based on blood glucose values, till the maximum dose of the drug is achieved. There is no benefit in changing to another SU.Failure with one drug indicates failure to d l drugs in the class.
Step 3: Add on Second Drug
If blood glucose levels do not reach target levels with the first drug, the second drug is added; a SU is added if the patient was first started on metformin, and vice versa.Maximum dose is arrived at by testing at two to four week intervals and at each visit,dietary advice is reinforced.
Step 4: Add on Third Drug
Thiazolidenedione (insulin sensitizers) is added on as a third drug. Pioglitazone in dose of 15 rngs once a day, gradually increased to 45 mgs once a day. Rosiglitazone 2to 4 mgs per day is ailother alternative drug. Jaundice, and known liver disease are absolute contraindications for use of these drugs. Some experts advise monitoring the liver function tests at the start and subsequent two monthly (NICE guidelines, UK).However, these drugs are quite safe and regular monitoring is not mandatory.how ever, since the first drug (troglitazone) in this group was withdrawn because of hepato-toxicity, it is wise to withdraw the drug in the event of any liver function test abnormality.
These drugs are very potent and are likely to result in blood glucose loweiing to desired levels.The NICE guidelines referred to above, recommend that in step 4, the second drug should be replaced by a glitazone, rather than adding on the glitazone. However, fairly extensive experience with 3 drugs suggest that 3 drugs given concurrently is safe, but more observational research is needed.Heart failure is a relative contraindication to use of this group as fluid and salt retention is significant enough to exacerbate the condition.An alternative to the above drug is acarbose. This is a relatively weak divg and is a natural choice if the person is elderly, or has renal failure because the chance of hypoglycemia is reduced.
Step 5: Start Zrisulin
If the combination of three drugs does not achieve the goals of glycemic control, then the patient should be advised to start insulin. Tlie best option is to use a biphasic insulin once a day before breakfast. If required a second dose is added before dinner.Oral drugs are often continued. Usually metformin and/or glitazones are continued with insulin as these drugs are known to increase insulin sensitivity.
Primary and Secondary Failure to OHA's
This applies to type I1 diabetes only. When a type JI diabetic cannot be controlled on a combinatioil of all available OHA's right from the time of diagnosis, the patient has to be started on insulin. This is known as "piin~suy failure to OHA", and is indicative of marked pancreatic insufficiency and insulin resistance. When a patient is controlled for several y e a s on OHA's and then needs to be put on insulin, then it is known as "secondaru failure to OHA's. Most diabetics need increasing doses of OHA's and a small proportion need to be put on insulin. Many estimates suggest that five per cent patients per year (in a cohort of patients) will progress to severe insulin deficiency.
Comprehensive Care of a Diabetic on Clinic Visits
A well controlled diabetic should be seen at the clinic between three or four times a year, whereas those with poor control should be seen at one or two weekly intervals to achieve control. If infection is concomitantly present the inpatient therapy is generally advisable. At each visit, the following should be checked:
1) Weight,
2) Blood pressure.
4) Fasting and two hour post-prandial plasma blood glucose.
5) Compliance with diet and medications.
The HBA-1C is the best criteria to assess control over a long period ol time, such as three months and the target level is at 7 per cent.
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