Guide Management of Diabetes Mellitus: A Guide to the Pattern Approach, Sixth Edition

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Adequacy of follow-up is extremely important. Whether insulin is given in the ED is of less consequence and can be decided on an individual basis. Patients with type 1 DM can have coexisting illnesses that aggravate hyperglycemia, such as infection, coronary artery disease CAD , or fever. Additionally, certain medications can aggravate the condition. DKA involves acute metabolic changes in the body that develop as a result of lack of insulin or poor response to insulin arising from stress or illness.

DKA is characterized by hyperglycemia, ketosis, and acidosis, leading to osmotic diuresis and dehydration. Volume repletion, insulin therapy, and specific metabolic corrections are the keys to treatment of DKA. See Diabetic Ketoacidosis. The dawn phenomenon is the normal tendency of the blood glucose to rise in the early morning before breakfast. This rise, which may result from the nocturnal spikes in growth hormone that cause insulin resistance, is probably enhanced by increased hepatic gluconeogenesis secondary to the diurnal rise in serum cortisol.

Augmented hepatic gluconeogenesis and glycogen cycling are known to occur in patients with type 1 DM. However, both abnormalities, regardless of the duration of diabetes, can be corrected with intensified insulin therapy. In some patients, however, nocturnal hypoglycemia may be followed by a marked increase in fasting plasma glucose with an increase in plasma ketones the Somogyi phenomenon. Thus, both the dawn phenomenon and the Somogyi phenomenon are characterized by morning hyperglycemia, but the latter is considered to be rebound counterregulation hyperglycemia.

The existence of a true Somogyi phenomenon is a matter of debate. Most endocrinologists now believe this phenomenon reflects waning of insulin action with consequent hyperglycemia.

Ministry Reports

In cases of the dawn phenomenon, the patient should check blood glucose levels at AM. The dawn and Somogyi phenomena can be ameliorated by administering intermediate insulin at bedtime. The insulin coverage, with a sliding scale for insulin administration, should not be the only intervention for correcting hyperglycemia, because it is reactive rather than proactive. Also, insulin may be used inappropriately when hyperglycemia reflects hepatic gluconeogenesis in response to previously uncorrected hypoglycemia.

Administer supplemental regular insulin on a sliding scale. Blood glucose should be monitored before meals and at bedtime. One of the first steps in managing type 1 DM is diet control. According to ADA policy, dietary treatment is based upon nutritional assessment and treatment goals. For example, patients who participate in Ramadan may be at higher risk of acute diabetic complications. Although these patients do not eat during the annual observance, they should be encouraged to actively monitor their glucose, alter the dosage and timing of their medication, and seek dietary counseling and patient education to counteract these complications.

Diet management includes education about how to adjust the timing, size, frequency, and composition of meals so as to avoid hypoglycemia or postprandial hyperglycemia. All patients on insulin should have a comprehensive diet plan, created with the help of a professional dietitian, that includes the following:.

Caloric distribution is an important aspect of dietary planning in these patients. The minimum protein requirement for good nutrition is 0. Patients should minimize consumption of sugars and ensure that they have adequate fiber intake. In some cases, midmorning and midafternoon snacks are important to avoid hypoglycemia.

Type 1 Diabetes Mellitus Treatment & Management

Exercise is an important aspect of diabetes management. Patients should be encouraged to exercise regularly.

Educate the patients about the effects of exercise on the blood glucose level. Patients must also make sure to maintain their hydration status during exercise.

Australian Diabetes Society - Position Statements

Diabetes predisposes patients to a number of infectious diseases see Infections in Patients with Diabetes Mellitus. These include the following:. Patients with preproliferative or proliferative retinopathy must immediately be referred for ophthalmologic evaluation. Laser therapy is effective in this condition, especially if it is provided before hemorrhage occurs.

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Because subsequent hemorrhages can be larger and more serious, the patient should immediately be referred to an ophthalmologist for possible laser therapy. Patients with retinal hemorrhage should be advised to limit their activity and keep their head upright even while sleeping , so that the blood settles to the inferior portion of the retina and thus obscures less of the central visual area.

Multifactorial intervention is important for slowing the progression of diabetic retinopathy. Metabolic control, smoking cessation, and blood pressure control are all protective. Patients with active proliferative diabetic retinopathy are at increased risk for retinal hemorrhage if they receive thrombolytic therapy; therefore, this condition is a relative contraindication to the use of thrombolytic agents.

Extreme care should be exercised whenever any nephrotoxic agent is used in a patient with diabetes. Potentially nephrotoxic drugs should be avoided whenever possible. See Diabetic Nephropathy. Patients with diabetes who must undergo such studies should be well hydrated before, during, and after the study, and their renal function should be carefully monitored. Current ADA guidelines recommend annual screening for nephropathy. In adults and children aged 10 years or older who have had type 1 DM for 5 or more years, annual assessment of urine albumin excretion is appropriate.

Microalbuminuria and macroalbuminuria are not permanent features in most diabetic children and adolescents.

Approach Considerations

Progression and regression of kidney disease are common even after development of persistent microalbuminuria. Tight glycemic control, lower blood pressure, and a favorable lipid profile are associated with improved outcome. When chronic kidney disease is present, reduction of protein intake may improve renal function. If kidney disease is advanced or difficult to manage or its etiology is unclear, consider referral to a physician with experience in kidney disease patient care.

Control of blood pressure is a critical element of care. An ACE inhibitor or an angiotensin II receptor blocker ARB should be used because these classes of agents decrease proteinuria and slow the decline in renal function independent of the effect on blood pressure. Autonomic dysfunction can involve any part of the sympathetic or parasympathetic chains and produce myriad manifestations. Treatment of gastroparesis is symptomatic, and symptoms tend to wax and wane.

Patients with gastroparesis may benefit from metoclopramide or erythromycin. Before these therapies are started, the degree of dehydration and metabolic imbalance must be assessed, and other serious causes of vomiting must be excluded.

Treatment and Management of Type 2 Diabetes

In severe cases, gastric pacing has been used. Patients with disabling orthostatic hypotension may be treated with salt tablets, support stockings, or fludrocortisone. Alleviating the functional abnormalities associated with the autonomic neuropathy is often difficult and frustrating for both doctor and patient. Patients with diabetes who present with wounds, infections, or ulcers of the foot should be treated intensively.

Patients should be treated by a podiatrist or an orthopedist with experience in the care of diabetic foot disease. If bone or tendon is visible, osteomyelitis is present, and hospitalization for IV antibiotic therapy is often necessary. Many patients need a vascular evaluation in conjunction with local treatment of the foot ulcer because a revascularization procedure may be required to provide adequate blood flow for wound healing. Because ulcers and foot infections are difficult to cure, their prevention is extremely important. The emergency physician can facilitate this practice by briefly inspecting the feet of patients with diabetes and by educating them about the need for proper foot care.

Charcot joint, a type of arthropathy observed in people with diabetes, is a progressive deterioration of foot joints caused by underlying neuropathy.

Tarsometatarsal and midtarsal joints are affected most commonly. Other neuromuscular foot deformities also may be present. Early diagnosis and treatment are important for preventing further joint degeneration. Hypercholesterolemia and hypertension increase the risk of specific late complications and require special attention and appropriate treatment. Although physicians can safely use beta blockers eg, propranolol in most patients, these agents can mask the adrenergic symptoms of insulin-induced hypoglycemia and can impair the normal counterregulatory response.

ACE inhibitors are the drugs of choice for hypertension because of their renal protective action, especially early in the course of the disease. The ADA advises that a systolic blood pressure below mm Hg is an appropriate goal for most patients with diabetes and hypertension, but it also recommends modifying systolic blood pressure targets in accordance with individual patient characteristics. Diastolic blood pressure should be less than 80 mm Hg. Subtle differences in the pathophysiology of atherosclerosis in patients with diabetes result in both earlier development and a more malignant course.

Therefore, lipid abnormalities must be treated aggressively to reduce the risk of serious atherosclerosis. Prediction of cardiovascular risk in diabetic patients on the basis of the lipid profile is not affected by the timing of blood specimen. Therefore, it may be unnecessary to insist on using fasting blood samples to determine the lipid profile. In a study involving diabetic adolescents and children, nocturnal hypertension was significantly associated with higher daytime blood pressure and carotid intima-media thickness, which could be precursors of atherosclerotic cardiovascular disease later in life; these findings warrant confirmation and longitudinal follow-up.

Patients with diabetes may have increased incidence of silent ischemia. Nevertheless, it is prudent to perform electrocardiography ECG in patients who have diabetes and a serious illness or who present with generalized weakness, malaise, or other nonspecific symptoms that are not usually expected to result from myocardial ischemia. Persistent lipid abnormalities remain in patients with diabetes, despite evidence supporting the benefits of lipid-modifying drugs.

Up-titration of the statin dose and addition of other lipid-modifying agents are needed. Age years: Moderate-intensity statins for those with no additional risk factors, and high-intensity statins for those with either CVD risk factors or overt CVD. Lipid monitoring for adherence is recommended as needed, and annual monitoring is advised for patients younger than 40 years who have not yet started on statins.

The goal for diastolic blood pressure was raised to 90 mm Hg from 80 mm Hg to better reflect data from randomized clinical trials. With regard to physical activity, the document now advises limiting the time spent sitting to no longer than 90 min.