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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


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


2


Diabetic peripheral neuropathy rx

2

Diabetic Peripheral Neuropathy RX



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 *


After insulin use discontinue sulfonylurea or decreased dose
After Insulin useDiscontinue Sulfonylurea (or decreased dose)


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


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)



Thank you for your attention
THANK YOU Diagnosis of DMFOR YOUR ATTENTION


Fasting glucose is best hba1c can t be used for dx
Fasting glucose is best ! Diagnosis of DMHbA1ccan’t be used for DX


  • OGTT is better Diagnosis of DMtest with much complicated steps , used limitedly eg. After IFG


GDM Diagnosis of DM

  • Develop DM after Pregnancy = overt DM

  • Different number from harrison

Harrison target Fasting <105

Post Prandial <120


  • High Risk Diagnosis of DM 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 !!!




New

Check K


Pregnant = risk progress DR

Check DR at preg, along and 1yr post partum


  • A. Cardiovascular Diseases Glucose control (A)

  • 1. BP control

  • 2. Dyslipidemia

  • 3. ASA (detail=above)

  • 4. Smoking cessation

  • 5. CHD screening & treatment


DN Glucose control (A)



K immunization
K. Immunization Glucose control (A)

  • 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 Glucose control (A)

  • 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


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