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Endocrine Topic. Salyavit Chittmittrapap. Content. 1. Early Metformin Use 2. Correctional & Basal Schedule Insulin 3. Aspirin (no new change) 4. Self monitoring blood glucose (SMBG). How to get ADA2007pdf. Computer ห้องพักแพทย์ In folder “ วิชาการแบ่งตามหน่วย ” Subfolder Endocrine

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endocrine topic

Endocrine Topic

Salyavit Chittmittrapap

content
Content
  • 1. Early Metformin Use
  • 2. Correctional & Basal Schedule Insulin
  • 3. Aspirin (no new change)
  • 4. Self monitoring blood glucose (SMBG)
how to get ada2007pdf
How to get ADA2007pdf
  • Computer ห้องพักแพทย์In folder “วิชาการแบ่งตามหน่วย” Subfolder Endocrine
  • Download from Diabetes Care Websitecare.diabetesjournals.org/
  • และจะ Upload เอาไว้ที่Website ของภาควิชา
content of ada cpr 2007
Content of ADA CPR 2007
  • Standard of Medical Care in DM 2007
  • Diagnosis and Classification of DM
  • Nutritional Recommendation for DM
  • Nutritional Intervention for DM

What\'s new

slide5

4

3

1

2

evidence grading adapted
Evidence grading (adapted)
  • A – best ; good RCT !, Meta-analysis, compelling nonexperimental evidence
  • B – good Cohort study, meta of Cohort, good Case-control study
  • C – poorly controlled / uncontrolled study observational study, poor RCT, case-series, Conflicting evidence!
  • E – Expert consensus

Not Level of Recommendation

revised position statement
Revised Position statement

1

  • Nutrition Recommendations and Interventions for Diabetes: A position statement of the American Diabetes Association
    • American Diabetes Association Diabetes Care 2007 30: S48-65.
  • Comprehensive Table3 at pageS58-60
summary of revision
Summary of Revision * * *

3

  • Diabetes Care
  • Comprehensive diabetes evaluation revised
  • Lowering A1C has been assoc. with a reduction of microvascular & neuropathic complication (A) & possibly macrovascular disease (B)
  • Medical Nutrition Therapy (MNT) extensively revised
nephropathy

Summary of Revision * * *

Nephropathy

3

  • Reduction of protein intake to 0.8-1.0 g/kg BW /day in pt. with DM & earlier stage of CKD & to 0.8 g/kg BW /day in the later stage of CKD may improve measure of renal function & is recommended (B)
  • Celiac disease (child)
dm care in the hospital

Summary of Revision * * *

DM care in the hospital

4

  • Using correction dose or “supplemental” insulin to correct premeal hyperglycemia in addition to scheduled prandial and basal insulin is recommended (C)
  • Discontinue ACEI before conception (E)
  • Diabetes care in the school & day care setting should use a plan (504 plan)by family, school nurse, diabetes health care team
diabetes mellitus
Diabetes Mellitus
  • Is Chronic illness
  • Need Continuing medical care
  • Patient self-management education
  • Prevent acute complication
  • Reduce the risk of long-termcomplication
start with metformin don t wait a second
Start with MetforminDon’t wait a second

Nathan ET.AL Management of Hyperglycemia in type 2 diabetes consensus statement from ADA and EAstudy of DM. Diabetes Care 29:1963-1972 2006

target hba1c 7
Target HbA1c <7 %
  • Keep < 7 %
  • Reconsider in patient with Short Life expectancy & Terminal illness
  • Some individual patient benefit from keep HbA1c < 6 %
  • *with higher Hypoglycemia risk *
thiazolidinedione
Thiazolidinedione
  • After titration of Dose Patient may end up with (Maximal medication) = Intensive insulin with MFM
  • With or without thiazolidinedione
  • Actos (15) =42 baht
  • Avandia (4) =64.5 baht
  • ADR= fluid retention, Weight gain
sliding scale

Manual adjust

Sliding Scale
  • จริง ๆ แล้วดี เพราะมีการคิดแบบ individual case มองทั้ง insulin maintenance และการตอบสนองต่ออินซูลินครั้งก่อน ๆ
  • แต่ไม่ดีเพราะแพทย์เจ้าของไข้ไม่ได้อยู่เวรทุกวัน และไม่มีมาตรฐานกลางในการการปรับเปลี่ยนขนาดของอินซูลิน
  • ไม่ดีเพราะไม่มีการปรับเปลี่ยนขนาดของอินซูลิน ในแต่ละวัน
  • ทำให้เกิดน้ำตาลสูง / ต่ำ เมื่อ insulin requirement เปลี่ยนแปลง
correctional dose schedule insulin
Correctional dose & Schedule Insulin
  • เมื่อนำ sliding scale มาปรับปรุงเพิ่มโดยปรับเพิ่ม-ลดในแต่ละวัน ก็ได้เป็น correctional & schedule insulin
  • มีปริมาณ Basal schedule Insulin คือปริมาณที่คนไข้ที่ระดับน้ำตาลปรกคิต้องการ เป็น maintenance dose
  • มีการเพิ่มหรือลดปริมาณ insulin ที่ฉีดตามปริมาณน้ำตาลตั้งต้น (DTX)
  • และสามารถปรับเพิ่มหรือลด scale ตามผลการควบคุมน้ำตาลที่ผ่านมา โดยปรับที่ basal insulin
correctional dose schedule insulin1
Correctional dose & Schedule Insulin
  • Continuous Order
  • If DTX <60,or >291 please notify
  • DTX 61-80 decrease insulin 4 u
  • DTX81-100decrease insulin 2 u
  • DTX 100-140 no modification
  • DTX 141-170 increase insulin 2 u
  • DTX 171-200 increase insulin 4 u
  • DTX 201-230 increase insulin 6 u
  • DTX 231-260 increase insulin 8 u
  • DTX 261-290 increase insulin 10 u
  • One day Order
  • RI 10 – 10 – 10 sc ac
  • Monotard 10 u sc hs.
example dm male 55yrs on oral feeding
Example . DM male 55yrs on oral feeding
  • Previously need total insulin 40 u /day
  • Start with 10 u basal insulin
  • DTX morning 145  RI 12 u
  • DTX noon 70  RI 6 u
  • DTX evening110  RI10 u
  • DTX hs90  Monotard 8 u
  • Continuous Order
  • DTX 61-80 decrease insulin 4 u
  • DTX81-100decrease insulin 2 u
  • DTX 100-140 no modification
  • DTX 141-170 increase insulin 2 u
  • DTX 171-200 increase insulin 4 u
  • DTX 201-230 increase insulin 6 u
  • One day Order
  • RI 10 – 10 – 10 sc ac
  • Monotard 10 u sc hs.
  • TOTAL TODAY 36
slide25

Example . DM male 55yrs on oral feeding

  • Previously need total insulin 40 u /day
  • Start with 10 u basal insulin
  • DTX morning 145  RI 12 u
  • DTX noon 190  RI 14 u
  • DTX evening180  RI14 u
  • DTX hs220  Monotard 16 u

Correctional Insulin 16 u

thenIncrease Basal inuslin

  • Continuous Order
  • DTX 61-80 decrease insulin 4 u
  • DTX81-100decrease insulin 2 u
  • DTX 100-140 no modification
  • DTX 141-170 increase insulin 2 u
  • DTX 171-200 increase insulin 4 u
  • DTX 201-230 increase insulin 6 u
  • One day Order
  • RI 10 – 10 – 10 sc ac
  • Monotard 10 u sc hs.
  • TOTAL TODAY 56
benefit
Benefit
  • Hypoglycemic Symptom = Hypoglycemia ?
  • Better Glycemic control
  • Cost ; ค่าเครื่อง (1800)
  • ค่าแถบตรวจน้ำตาล (9)
  • สำคัญกว่าคือใช้ให้ได้ประโยชน์

DM type 1 GDM

thailand situation beware
Thailand situation; Beware !
  • Increased RISK OF BLEEDING
  • NSAID abuse
  • Regular NSAID uses
  • Untreated Peptic Ulcer
  • Uninvestigated Dyspepsia
  • Undetected (&Untreated H.Pylori)
slide35
GDM
  • Develop DM after Pregnancy = overt DM
  • Different number from harrison

Harrison target Fasting <105

Post Prandial <120

slide36
High Risk  modest wt. loss, regular physical activity. Esp with IGT*** (A)
  • For IFG same (E)
  • Follow up counseling appears to be important for success (B)
  • Monitor DM in pre-DM q 1-2 years (E)
  • No Medication !!!
slide37
Reduce Risk & Slow progression of DN by Blood Pressure & Glucose control (A)
  • Screen Microalbuminuria annually
  • - type 1 ; 5yrs or more after DX
  • - type 2 ; at DX
  • - during Pregnancy (E)
  • Screen serum Cr annually(E)
slide38
ACEI & ARB
  • No Winner !!!
slide39
If cannot use ACEI & ARB ; Betablockers, Diuretics, Non-DCCBs is considered(E)

New

Check K

slide40
Reduce Risk & Slow progression of DR by Blood Pressure & Glucose control (A)
  • ASA does not prevent DR nor increase the risks of hemorrhage (A)
  • Screen by Opthalmologist or Optometrist
  • Screen annually ; start at
  • - type 1 ; 3-5yrs or more after DX
  • - type 2 ; at DX (B)

Pregnant = risk progress DR

Check DR at preg, along and 1yr post partum

slide44
A. Cardiovascular Diseases
  • 1. BP control
  • 2. Dyslipidemia
  • 3. ASA (detail=above)
  • 4. Smoking cessation
  • 5. CHD screening & treatment
slide46
=Plasma glucose <70 mg/dl
  • Repeat after RX at 15 min (B)
  • Glucagon use (E)
k immunization
K. Immunization
  • Annual Influenza virus (C)
  • One (lastlong) Pneumococcal Vaccine
  • Repeat if >65 yrs with recent vaccine >5 yrs
  • Repeat if Nephrotic Syndrome, CKD, immunocompromised state
take home message
Take Home Message
  • You should start Metformin after dx DM
  • Correctional dose & Schedule Insulin
  • DM+DN ; diabetic diet, Protein 0.8-1.0 g/kgBW/d(0.8 for Late CKD), low fat
  • Advice symptom of DKA-HHS and also Stroke & MI
  • ASA gr.I 2*1 with discussion of benefit & risk
ad