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GUIDELINES FOR THE FOLLOW-UP OF DIABET ES MELLITUS TYPE 2 PATIENTS by T McD Kluyts University of Pretoria

GUIDELINES FOR THE FOLLOW-UP OF DIABET ES MELLITUS TYPE 2 PATIENTS by T McD Kluyts University of Pretoria. List the target organs in DM2 Indicate the main reasons for routine urinalysis Indicate the principle lifestyle modification measures that should be employed in DM2.

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GUIDELINES FOR THE FOLLOW-UP OF DIABET ES MELLITUS TYPE 2 PATIENTS by T McD Kluyts University of Pretoria

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  1. GUIDELINES FOR THE FOLLOW-UP OF DIABETESMELLITUS TYPE 2 PATIENTSbyT McD KluytsUniversity of Pretoria T McD Kluyts

  2. List the target organs in DM2 Indicate the main reasons for routine urinalysis Indicate the principle lifestyle modification measures that should be employed in DM2. CNS including autonomic system, Eyes, Kidney, C-V system Proteinuria, Ketonuria, Occult infection Diet, exercise, weight loss, addiction management. PRE-TEST T McD Kluyts

  3. CRITERIA FOR THE DIAGNOSIS OF DIABETES MELLITUS Fasting plasma glucose  7.0 mmol/l. orSymptoms of diabetes plus:casual plasma glucose concentration  11.1 mmol/l.1or2-h PG  11.1 mmol/l during an OGTT. T McD Kluyts

  4. Diabetes Mellitus Type 2 • Previously NIDDM, Adult type DM, type 2 DM • DM 2 • Not insulin dependent for survival • Age 30+ at diagnosis • Usually obese • Few classic symptoms • Ketoacidosis rare T McD Kluyts

  5. The following measures are directed towards :Glycaemic control andPrevention of complications T McD Kluyts

  6. SUBJECTIVEComplianceComplicationsPatients questionsOBJECTIVEExaminationsSideroom proceduresSpecial investigations MONTHLY FOLLOW-UP T McD Kluyts

  7. SUBJECTIVE • Compliance: • Check the patients medicines • Discuss the taking of medicines • Establish supervision and • monitor bloodglucose, diet and exercise records T McD Kluyts

  8. SUBJECTIVE Complications: Ask about: Vision Feet Infections Pains and Sensations

  9. SUBJECTIVE Questions from the Patient: • Encourage patient to talk and to ask questions • Re-affirm treatment schedule • Explore family situation T McD Kluyts

  10. OBJECTIVE • Physical examination: • Pulse, bloodpressure, temperature, respiratory rate. • Eyes: Cataracts and vision • CVS: Heart and peripheral circulation • CNS: Muscle strength, reflexes, sensation, proprioception • BMI T McD Kluyts

  11. OBJECTIVE • Sideroom procedures: • Blood glucose • Urine Labstix • Urine microscopy • Special investigations: • Never routinely, only as and when indicated by examination Objective

  12. OBJECTIVE • Urine: • glucose and ketones are important • Blood glucose: • measure with glucometer • Foot examination: • skin,circulation, shoes • Look at home monitoring chart T McD Kluyts

  13. Three- to six monthly : • As monthly + lab tests: • HbA1c – measurement • Urine for proteinuria • Snellen test, visual fields • ECG • Lipid profile • Feet examination T McD Kluyts

  14. ANNUALLY • Monthly examination + Lab tests • Neurological status • Cerebral function • Micro-circulation • Lipid profile • Micro-albuminuria • ECG • Fundoscopy T McD Kluyts

  15. KEY TESTS T McD Kluyts

  16. PATIENT EDUCATION • This is the cornerstone of effective diabetes care. • Sufficient time and resources should be made available in order to do this effectively. T McD Kluyts

  17. RECORD DEGREE OF CONTROL • Patients with poor or brittle control, should be seen at least once a month. • Well controlled diabetics can be seen at longer intervals eg 2-4 monthly. T McD Kluyts

  18. Criteria for intervention T McD Kluyts

  19. WEIGHT • As obesity virtually always accompanies type 2 diabetes, it should be targeted in its own right. • A weight loss of 5-10% should be the initial aim. It has been shown to improve insulin resistance and all its associated parameters T McD Kluyts

  20. WeightBody Mass Index (BMI) = Mass in kg/Length in meter2 T McD Kluyts

  21. WEIGHT Evidence demonstrates that: • structured, intensive lifestyle programsinvolving participant education, • reduced dietary fat and energy intake, • regular physical activity • and frequent participant contact are necessary to produce long-termweight loss of >5% of starting weight. T McD Kluyts

  22. GLUCOSE TREATMENT RECOMMENDATIONS FOR DM2 • Always provide or refer for dietary and lifestyle advice at diagnosis • If random glucose values > 15 mmol/L ~ consider starting oral agents together with lifestyle modification from the start • If overweight (BMI > 25) ~ consider metformin unless contra-indicated • If postprandial glucose values constitute the major abnormality or sulphonylureas contra-indicated (e.g. renal failure) ~ acarbose or meglitinides may be considered T McD Kluyts

  23. GLUCOSE TREATMENT(Continued) • If insulin resistance is the major abnormality , metformin should be considered as first line or add on therapy. If metformin is contra-indicated or poorly tolerated (e.g. raised serum creatinine or major cardio-pulmonary risks),then thiazolidinediones may be used. • Always start with monotherapy and titrate dosage to maximum over 1-3 months T McD Kluyts

  24. GLUCOSE TREATMENT (Continued) • If goals still not reached, add second agent (lowest dose, titrate when necessary). • If goals still not attained despite good compliance and absence of major stressors such as infection, consider insulin therapy • In such cases, insulin therapy may be initiated as intermediate or long-acting insulin at bedtime (titrate against pre-breakfast reading), with or without oral agents. If possible, self glucose monitoring should be done in all patients on insulin. T McD Kluyts

  25. GLUCOSE TREATMENT (Continued) • Initial insulin dose is 0.2-0.3 U/kg • If more than 30 U per day are required or clinical judgment indicates, use twice daily biphasic insulin (2/3 intermediate, 1/3 short acting). Consider referral. T McD Kluyts

  26. BLOOD PRESSURE GOALS T McD Kluyts

  27. BLOOD PRESSURE TREATMENT • Angiotensin converting enzyme (ACE) inhibitor based • Low dose diuretics, eg hydrochlorothiazide (HCTZ) 12.5mg or Indapamide 1.25 -2.5 mg/day may be appropriate first line agents • Most patients will require at least 2 agents T McD Kluyts

  28. BLOOD PRESSURE (continued) • ACE inhibitors or angiotensin II receptor antagonists areindicated in the presence of micro- or macroalbuminuria • In patients over age 55 yrs with or without hypertension, but with another cardiovascular risk factor, an ACE inhibitor should be considered to reduce the risk of cardiovascular events. T McD Kluyts

  29. LIPID GOALS T McD Kluyts

  30. LIPID TREATMENT • LDL-cholesterol above 3 mmol/l ~ consider a statin as therapy • Triglycerides above 1.5 mmol/l ~ check for secondary causes, consider using a fibrate • LDL-cholesterol and triglycerides elevated ~ statin and fibrate if persistant • Fibrates contra-indicted with impaired renal function ~ refer. T McD Kluyts

  31. ASPIRIN RECOMMENDATIONS • As a primary preventionstrategy in high-risk men and women with type 1 or type 2 diabetes including diabetic subjects with the following: • a family history of coronary heart disease, • cigarette smoking, • hypertension, • obesity, • albuminuria (micro or macro), • age>30 years or • dyslipidaemia. T McD Kluyts

  32. ASPIRIN RECOMMENDATIONS(continued) • Use aspirin therapy as a secondary prevention strategy in individuals who have evidence of large vessel disease, eg • a history of myocardial infarction, • vascular bypass procedure, • stroke or transient ischaemicattack, • peripheral vascular disease, • claudication and/or • angina. T McD Kluyts

  33. ASPIRIN RECOMMENDATIONS(continued) • Use 150-300 mg aspirin per day (enteric coated if possible) • People with aspirin allergy, bleeding tendency, anticoagulanttherapy, recent gastrointestinal bleeding, and clinically activehepatic disease are not candidates for aspirin therapy. T McD Kluyts

  34. ASPIRIN RECOMMENDATIONS (continued) • Aspirintherapy should not be recommended for patients underthe ageof 21 years because of the increased risk of Reye’ssyndromeassociated with aspirin use in this population T McD Kluyts

  35. Exercise Record • The exercise parameters are as follow: • To reach a pulse rate of max – 20% for age and sex and maintain for 20 minutes at least • 3 times per week at least • Walking or running or cycling or swimming or any combination thereof T McD Kluyts

  36. Weight and diet record • This should include weekly weight measurements • Dietary notes where indicated to explain weight changes • Doctor/dietician’s comments T McD Kluyts

  37. Glucose control record • The ideal would be twice daily blood-glucose recording: morning and evening. • This might be impossible for unsubsidised patients to attain, and daily urine testing will have to suffice as a minimum requirement. • Blood glucose should be done fasting in the mornings, and 2 hours postprandial at night. • Urine glucose should be measured fasting in the morning 1 hour after emptying the overnight bladder, and/or 15 minutes after emptying the 2 hour postprandial bladder in the evening. T McD Kluyts

  38. SCENARIO 1 • A 24 year old male student presents to you with a history of Diabetes Mellitus 2 for 2 years, complicated by systolic hypertension. He tells the story that he suddenly became ill while attending a rugby training camp 2 years ago. He has never before been ill in his life except for a chronic seasonal rhinitis for which he has been taking numerous treatment regimes in the past. T McD Kluyts

  39. SCENARIO 1 (Continued) • At the moment he is taking Glucophage and Diamicron one each twice daily • On examination he is well built, weighs 110kg and is 1,8m tall • His BP is 128/84 • His father’s sister is a diabetic T McD Kluyts

  40. SCENARIO 1 (Continued) • He is still participating in sport, but had to retire from provincial level participation since the start of his illness • He is complaining of tiring easily • His random blood glucose today is 8.6mmol/l • He is not keeping record of his exercise efforts or his diet T McD Kluyts

  41. SOLVING THE PROBLEM T McD Kluyts

  42. SCENARIO 2 • A 38 year old lady with Diabetes Mellitus 2 on insulin replacement therapy visits you for a renewal of her medication • She has been on Humoloc Mix 25 but when she went to the chemist last month for a repeat, she was told that it was no longer “on code” T McD Kluyts

  43. SCENARIO 2 (Cont) • She was not given any instruction on how to use it • She is using 46 Units nocte • On examination her blood pressure is 160/90; blood glucose = 18,6; she has 1+ oedema of the legs; her BMI = 31,5 • She is also taking Coversyl 4mg daily with Natrilix 2,5mg daily for her blood pressure T McD Kluyts

  44. SOLVING THE PROBLEM T McD Kluyts

  45. ACKNOWLEDGEMENT • Parts adapted from SEMDSA guidelines 2002 (Prof Paul Rheeder) • ADA clinical practice recommendations 2002. Diabetes Care 2002; 25(1) supl 1 • WEBSITE: http://www.novonordisk.com T McD Kluyts

  46. Thanks ! T McD Kluyts

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