Diabetes Mellitus - Standard Treatment Guidelines

Diabetes Mellitus (DM) is a global epidemic. Type -2 diabetes which forms almost 95 % of the total diabetes in India is largely a preventable disorder. India harbours more than 50 million diabetics. DM is associated with development of specific long-term organ damage (chronic complications) including retinopathy with potential blindness, nephropathy with a risk of progression to renal failure requiring lifelong dialysis or renal transplantation, neuropathy with risk for foot ulcers, amputation, and Charcot joints and autonomic dysfunction such as sexual, bowel and bladder impairment. Patients with diabetes are at a particularly high risk for vascular complications like cardiovascular, cerebrovascular, and peripheral artery disease. A recent rise in the number of adolescent and young Type -2 diabetics in India is an alarming trend. This is largely due to lifestyle factors.Recent Indian data suggest prevelence rates of 15 to 20 % in urban areas and about half of it in rural areas.

DM poses a great threat to the health of our nation, it costs dearly the exchequer as the treatment of acute and chronic complications of diabetes are expensive. Beside this is the cost of day to day medication, tests, monitoring and loss of productive work due to illness.

Hence it is important to recognise this disorder as early as possible. Attempt should be made to detect hyperglycemia in prediabetes stage to prevent progression to diabetes. And finally the aim is to treat this disorder effectively to prevent the devastation of the chronic complications.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Diabetes Mellitus. Following are the major recommendations :

Definition

DM is a chronic metabolic disorder of carbohydrate, fat, and protein metabolism characterized by hyperglycaemia,resulting from defects of insulin secretion, insulin action, or a combination of both 1 . Type 1 diabetes is due to an absolute lack of endogenous pancreatic insulin production, whereas in Type 2 diabetes, insulin resistance is the basic defect which is contributed by a combination of genetic predisposition, physical inactivity, and obesity.

Classification

Old terms like IDDM (insulin dependant DM), NIDDM (non insulin dependant DM)adult onset diabetes or juvenile diabetes have been abondoned.

ADA classification of 1997 which was later accepted by WHO is the most widely accepted classification of DM .

Classification of Diabetes Mellitus

1. Type 1 -(beta -cell destruction, usually leading to absolute insulin deficiency) A. Autoimmune B. Idiopathic

2. Type 2 -(may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with or without insulin resistance)

3. Other specific types (see Table ) Genetic defects of b-cell function -MODY 1 to 9, mitochondrial DNA. Genetic defects in insulin action Diseases of the exocrine pancreas (pancreatitis trauma, pancreatectomy, neoplasm cystic-fibrosis etc) Endocrinopathies (acromegaly, Cushing's syndrome, gucagonoma, pheochromocytoma, hyperthyroidism etc)

Drug- or chemical-induced

Infections

Uncommon forms of immune-mediated diabetes

Other genetic syndromes sometimes associated with diabetes, e.g.: Down's syndrome, Friedreich's ataxia, Klinefelter's syndrome, Wolfram's syndrome

4. Gestational diabetes

Characteristics of Diabetes In India

Onset is about one decade earlier than the west

Occurs at a lower

BMI Central obesity is more common

Type 1- less than 5% of the total diabetes

Cardiovascular complications occur early

PVD is less common than the west

Foot problems more common

No structured treatment protocol

Lack of trained manpower like diabetes educators,endocrinologists

Cost of the treatment is a big hinderance

Social and religious factors play an important role

Diagnosis

Any one of the following:

Symptoms of diabetes + casual plasma glucose concentration > 200mg/dl (Casual - any time of the day without regard to time since last meal)

Fasting plasma glucose > 126mg/dl (Fasting - no caloric intake for atleast 8 hours)

2 Hour plasma glucose during OGTT > 200mg/dl (OGTT according to WHO criteria)

Note-HbA1c > 6.5% indicates diabetes, however it cannot be considered as a diagnostic tool in isolation.

Impaired glucose metabolism

Impaired Fasting Glucose (IFG):

FPG > 100 and 125 mg per dL

Impaired Glucose Tolerance (IGT):

2hr PGPG > 140 and 199 mg per dL

FPG > 100mg/dl and > 125mg/dl be classified as having IFG.

Prevalence of diabetes is increasing rapidly in developing countries like India

Occurs due to relative insulin deficiency in an individual with insulin resistance

Usually asymptomatic and detected during evaluation for unrelated indications, but may present with hyperglycemic symptoms-

Frequent urination, excessive thirst, excessive hunger

Weight loss, delayed healing of wounds, pain in calves, burning feet

Tiredness, Itching -especially in genital area

Tingling and numbness, blurring of vision, lethargy, somnolence,

Sometimes the symptoms are due to complications of diabetes when patient presents to a clinician for the first time with a complication like erectile dysfunction.

Type 1 DM:

Absolute insulin deficiency due to autoimmune destruction of pancreatic beta cells.

Prevalence 5% of the total diabetic population in India.

Onset is mostly in childhood or in young adults before 35 years, about may rarely occur in elderly.

Symptoms

Abrupt onset of severe hyperglycemic symptoms. Sometimes the child may present with just weakness, lethargy, bedwetting.

May present as diabetic ketoacidosis .

MODY-Maturity onset diabetes of the young:

Monogenic form of diabetes associated with mutation in a single gene

Diagnostic Criteria

• Aged less than 25 years at onset


• Autosomal dominant transmission of diabetes with three generations involved


• Absence of ketosis at any time


• Controllable without insulin at least in the early stages of the disease


• Clinical criteria are no longer acceptable and genetic analysis is needed to confirm the diagnosis.

Clinical Features

• Patients usually non-obese.Respond better to sulphonylureas in initial few years of diabetes.


• Do not need insulin initially- later may become insulin-requiring (MODY 1, 3 and 5)


• Isolated Mild fasting hyperglycemia- MODY 2- no treatment required


• Diabetes with renal cysts/ renal agenesis RCAD (renal cysts and diabetes syndrome)- MODY 5

Fibrocalculous pancreatic diabetes-(FCPD) :

Severe hyperglycemia in a lean patient from a tropical country like India with recurrent pain abdomen, evidence of chronic pancreatitis after excluding other causes of chronic pancreatitis like alcoholism ,should be considered for FCPD.Absence of ketosis and presence of pancreatic calculi is the characteristic feature.

Latent Autoimmune Diabetes Of Adults (LADA) : Type 1 Diabetes Which Presents Late GAD(Glutamic acid decarboxylase) autoantibody positive

Age at onset > 35 years

Lean patient

Insulin treatment required within one year of onset

Many patients with Type 2 diabeteswho are lean, have no family history of diabetes and who require insulin early in the course of the disease actually have LADA

Screening for Diabetes:

Ethnically every Indian falls into a high risk category however it may not be feasible to screen everyone. The following population group need screening.

Family history of diabetes

Cardiovascular disease, Hypertension

Overweight or obesity, males with a waist >90cm females with a waist >80cm

Sedentary lifestyle

Patients who are on steroids

Previously H/O IFG ,IGT

Dyslipidemia

History of gestational diabetes

People who were born with a birth weight >9 pounds or LBW

Polycystic ovary syndrome

If normal, repeat screening in 3 yrs for low risk subjects and every year for high risk subjects. If IGT or IFG repeat screening in 1 year.

All pregnant ladies should be screened at -24-28 weeks if the risk is low, or at first ante natal visit if she belongs to a high risk group.

Risk factors for GDM :

Risk factors for GDM-

Overweight or obesity

Family history of diabetes mellitus

History of IGT,IFG

Poor obstetric history

History of delivery of an infant with a birth weight >9 pounds

History of polycystic ovary syndrome

Fasting plasma glucose concentration >90 mg/dL or 2-hour postprandial glucose >140 mg/dL

Physical Examination :

• Height, weight, BMI


• Blood pressure measurement, including postural variation if indicated


• Thyroid examination


• Skin examination of insulin injection site and for acanthosis nigricans.


• Xanthelesma

Comprehensive foot examination

• Inspection-see for redness or cracks or dryness of skin and shape of the foot


• Palpation of dorsalis pedis and posterior tibial pulses


• Ankle and knee jerks


• Proprioception, vibration and monofilament sensation


• Dilated retinal examination


• Dental examination

Investigations at the time of diagnosis :

• Fasting and postprandial plasma glucose


• HbA1c


• Fasting lipid profile


• AST/ALT


• Urine complete exam, including assessment of microalbuminuria


• Serum creatinine, and estimated GFR


• TSH if there is dyslipidemia and in women >40


• ECG

Markers of glycemic status

• Plasma glucose


• Whole blood glucose (glucose meters)


• Urine glucose


• Glycosylated hemoglobin (HbA1c). HbA1c is an index of long term Glucose Control, performed on venous blood

Test results are not affected by

1. Time of the day


2. Meal intake


3. Exercise


4. Just administered diabetes drugs


5. Emotional stress


6. Patient cooperation

In certain situations HbA1c can be falsely high(uremia,alcoholism etc) or low(blood loss iron defeciency anemia,pregnancy,hemoglobinopathies ,reduced RBC survival).

C-Peptide

• It connects the A and B chain of insulin in the proinsulin molecule ,


• by-product of insulin biosynthesis


• For every molecule of insulin in the blood, there is one molecule of C-Peptide.


• Very low levels:

1. Type 1 diabetes


2. Complete surgical removal of pancreas

• Clinical utility of C-peptide measurement is very limited .Its measurement and interpretation of the results should be done by an Endocrinologist.

Microalbuminuria

• Test for presence of microalbuminuria annually in all Type 2 diabetics starting at diagnosis and Type 1 diabetic with DM more than 5 years

Methods

Measurement of the albumin to creatinine ratio in a random spot collection or 24 hour urine collection for creatinine and albumin with simultaneous measurement of serum creatinine.

	Normoalbuminuria	Microalbuminuria	Macroalbumiuria
Albumin/day	<30 mg	30-300	>300
Albumin/creatinine ratio*	<30	30-300	>300
Albumin excretion rate	<20(mcg/min)	20-200	>200

* mcg of albumin/mg creatinine

Albumin excretion rate (AER)- It is based on the albumin concentration ,the duration of the urine collection and the urine volume, and has the advantage of giving results which are independent of the ingested fluid quantity. AER is the gold standard for the diagnosis of microalbuminuria.

Foot examination- this should include examination of the shape of feet, bony prominences, calluses, deformities of the toes. Skin examination for texture ,color and loss of sweating, loss of hair. Nail examination for thickening, ingrowings, fungal infections. Inspection of interdigital webspaces for fungal infections and minor traumas Sensory examination of foot. Palpation of dorsalis pedis and posterior tibial arteries. Joint movements for checking the power of the muscles (muscle wasting) and joint integrity. Vibration test (128Hz), nylon monofilament test, ankle brachial index, peripheral doppler may provide very important information.

Continuous glucose monitoring(CGM) is indicated in pregnancy,brittle diabetes,insulin pump users. For Type -1 diabetics and elderly it can be used periodically to study hypoglycemia more closely.

Monitoring

Glucose	Frequency depends on the the kind of treatment and the severity of illness.It may be as low as twice a month to as high as 6-7 times in a day.#
A1C	Once in 3-4 months and six monthly if glycemic control is good
Lipids	Quarterly if uncontrolled, otherwiseOnce in 12 months*
Creatinine	Once*
Urine complete exam	Once*
Urine microalbumin	Once in a year*
ECG	Once in a year*
Fundoscopy	Once in a year for all Type -2 diabetics from the time of diagnosis*.In Type -1 once every year from 4-5 years after diagnosis or at the age of 10 years.More frequent exams are needed in advanced retinopathy

*Frequency of these tests can be more whereever indicated

# monitoring should include fasting,preprandial and 2-hour postprandial and bed time glucose levels. Occasionally between 2:00 -3:00AM glucose measurement is indicated to detect nocturnal hypoglycemia.Self monitoring of glucose by Glucose measuring devices at home is desirable for all diabetics.Patients on insulin need to monitor more frequently as compared to those on OADs.

Nutrition therapy : Diet therapy has to be individualised based on the likes and dislikes, calorie requirement (overweight or underweight), lifestyle and comorbidities. Carbohydrates should form 50-65 % of the total calories, proteins should form 15-20% (like non diabetics) and fats -15-25%. Average Indian diets usually contain the desired fiber content (15-25 gm/1000 cal). The saturated fat consumption should be minimised to < 10% of the total calories. If the LDL is >100 than it should be further reduced to <7%.Trans fats should preferably be eliminated completely from the diet. Vegetable oils should be used interchangeably so that the desired omega 3:6 ratio is achieved .No one kind of oil can be recommended. Coconut and palm oils should be avoided. There is no role of any additional multivitamins, trace elements ,antioxidants or any kind of neutraceuticals except Vit D. Consumption of fresh fruits ,salads and green vegetables should be encouraged which would supply all the multivitamins, trace elements, antioxidants. Absolute restriction of sucrose is not essential however it should be minimised. Restricted protein intake of 0.8 to 1.0 g/kg per day is required in patients who are in the earlier stages of chronic kidney disease and to 0.8 g/kg per day in patients who are in the later stages of chronic kidney disease.

Artificial sweeteners : Sucralose,Aspartame,Saccharin,Acesulfamec and a few others are non caloric sweeteners.Their consumption should be minimised .The scientific data favouring their safety is scanty hence they can be used in smaller quantities with a caution although the accepted daily intake for Aspartame is 50 mg/kg/day and for Sucralose and saccharin is 5 mg/kg/day.

Vaccination- Pneumococcal vaccine may be recommended for all diabetics.

Life style interventions – The Diabetes Prevention Program found that people at risk of developing type 2 diabetes were able to cut their risk by 58% (it was 74% in subgroup of asians) with moderate physical activity (30 minutes a day) and weight loss (5 to 7% of body weight, or about 15 lb). For people over age 60, the risk was cut by almost 71% .Adopting healthy lifestyle with increasing physical activity and weight reduction is key for achieving success in diabetes management. The effect of physical activity and other life style interventions on glucose and BP is comparable to pharmacological treatment. The goals of the life style interventions should be to achieve at least 5% reduction in body weight in obese. The individuals with high risk should be systematically targeted with lifestyle interventions regardless of their glucose status. Regular daily physical activity of 45 minutes or more is recommended for all diabetics in general. Besides leisure time physical activity, other forms of activity like walking, occupational or daily commuting on foot or bicycle, household chores ,activity at work place is also helpful and should be encouraged. Later the intensity and duration of exercise can be increased according to one's general health and age. To begin with it could be just brisk walk. The aim is to raise and sustain the heart rate for 15-20 minutes to 60-85% of the maximal heart rate for that age. Maximal heart rate is 220 minus age. Exercise should be preceded by an additional 05 minute warmup and followed by a 05 minute cool down. Thorough examination before starting physical activity is mandatory in view of associated comorbidities like CAD, proliferative retinopathy, autonomic neuropathy, arthritis, feet problems etc. Cessation of smoking, tobacco and moderating alcohol intake(only for those who are already taking alcohol, it cannot be recommended in any form for those who are not taking alcohol) should be reemphasised on every clinic visit.

Stress management : Relieving stress by adopting healthy lifestyle or by any other method including the traditional Indian methods is helpful.

Oral drugs : Oral anti diabetic drugs (OADs) have no or very little role in Type -1 diabetes. They can be initiated at the time of detection of diabetes or after a trial of lifestyle measures for 6-8 weeks. Choice of an oral agent depend on many factors like duration of the diabetes, age and weight of the patient, presence of other comorbidities ,lifestyle of the patient ,degree and type of hyperglycemia(fasting /postprandial)and susceptibility to hypoglycemia. Metformin(MF) and Sulphonylureas (SU) alone or in combination should form the base or the first line therapy in most of the OAD requiring diabetics.Sensitisers (like MF , Pioglitazone )and Alpha glucosidase inhibitors (AGI) are useful throughout the lifespan of a diabetic. Secretagogues like SU and Glinides are not very useful in long duration of diabetes and progressively lose their efficacy as their action is dependant on residual beta cell mass which progressively decline in all Type -2 diabetics. Glinides are useful as monotherapy in elderly where a potent long acting SU is relatively contrindicated. DPP-4 inhibitors are not suitable for burnt out or long standing diabetes. As cost is often an issue for choosing an OAD ,DPP-4 inhibitors can be added if mono or dual therapy fails. At present they cannot be recommended as first line therapy. Pioglitazone can be used as mono,dual or tripple therapy.Alpha glucosidase inhibitors are useful adjunct with any of the above mentioned drugs if postprandial hyperglycemia is the main target, though by themselves they are weaker drugs if used alone. Two OADs from a same group should not be used together. If HbA1c is mildly elevated (around 7%) monotherapy may be sufficient. For moderately elevated HbA1c (around 8%)dual drug therapy as seperate or in fixed combination can be initiated. However MF or SU as monotherapy in higher doses may be sufficient even for these patients. For HbA1c of more than 9%, combination therapy is initiated or intensified as dual or tripple therapy or insulin can be added as single bed time dose if fasting hyperglycemia is the main target .Insulin as multiple doses(premixed or split mixed )can be added to the OADs. In some situations where other measures fail, insulin can be used along with a combination of OADs and GLP-1 analogues.

IGT- MF and Acarbose can be used to delay the onset of diabetes.

Side effects of OADs

Sulphonyureas : Hypoglycemia, nausea, constipation, pain abdomen, weight gain, hematological abnormalities, headache, skin disorders. Not very useful with higher doses of insulin,avoided in advanced renal failure.

Glinides : Hypoglycemia,nausea,constipation,pain abdomen, diarrhoea.

Metformin : Pain abdomen, nausea, vomiting, diarrhoea, anorexia, weight loss, flatulence, B-12 defeciency. Contraindicated if serum creatinine is >1.4 in women and >1.5 in males, also contraindicated in CHF, advanced hepatic and respiratory failure.Avoided in periop period.

Alpha glucosidase inhibitors- Flatulence, constipation, pain abdomen, diarrhoea, vomiting. Avoided in serious GI disorders.

DPP-4 inhibitors- constipation, pain abdomen, diarrhoea, swelling ,headache, URI, arthralgia, anorexia. Not very useful in long standing diabetes.

Pioglitazone : fluid retension, anaemia, weight gain, sinusitis, worsening of retinopathy, Fractures in postmenopausal women. Contraindicated in CHF, fluid overload states and in advanced hepatorenal dysfunction. Recent data impicates it in bladder cancer. It has been banned in Germany. A great caution is required in patient selection for its use .

Mechanism of action of OADs

Insulin secretagogues	Sulphonylureas,Glinides
Insulin sensitisers	Pioglitazone,Metformin
Drugs acting locally on gut	Alpha glucosidase inhibitors
Potentiating Incretin axis,glucagon suppression	DPP-4 Inhibitors

When HbA1c is high ,fasting glucose should be the target first and when Its relatively better or towards normal side the postprandial glucose should be targeted first to achieve better glycemic control.

Insulin – Insulin is a potent anabolic hormone .The effects other than glucose lowering are important in many clinical situations where anabolic activity is desired.

Indications

Type -1 DM, pregnancy, severe infections, severe catabolic states, OAD failure,acute stressful situations like acute coronary syndrome, stroke, acute renal or hepatic failure, periop period. Secondary diabetes, post transplant diabetes ,congestive heart failure are also indications for insulin usage. Insulin can be added to existing OADs for short durations (e.g. steroid use in a diabetic on OADs) or long durations.

Animal insulin is no longer preferred as more safe and cheap synthetic human insulin is easily available in abundance.

Basal insulin therapy -if only fasting hyperglycaemia is the concern and patient is already on OADs then basal may be added to OADs.

Shifting to rapid acting analogues or their premixed preparations are preferred in the following situations:

• When good control is not possible with short acting or premixed human insulins,


• Occurrence of frequent hypoglycemia,


• When lifestyle of the patient demands immediate intake of food after insulin injection


• Renal or hepatic failure where more predicted and shorter action of insulin is desired.


• Allergic reactions to human insulin.

Insulin should be injected on anterior abdominal wall as the first preferred site,other sites can be thighs,buttocks and lastly the arms.Injecting repeatedly at one site can cause lipodystrophy and erratic insulin absorption.

Other injectable therapies-GLP-1 analogues- Currently available GLP-1 analogues Exenatide and Liraglutide are a good choice in an obese Type-2 diabetic. They can be used as an adjunct with any OAD except DPP-4 inhibitors for reducing both fasting and postprandial hyperglycemia. Hypoglycemia is uncommon if used alone. Nausea, vomiting, abdominal pain, distension, dyspepsia, diarhoea and headache are the common side effects. Usage should be avoided in patients with associated severe GI disorders like pancreatitis. Exenatide is given twice daily subcutaneously before meals and Liraglutide once daily with disregard to the meals but almost at the same time daily. Weight loss is an advantage with these agents which make them a useful tool for obese diabetics. They are contraindicated in Type-1 DM and acute hyperglycemic complications.

Insulin pump : At present due to its prohibitive cost its usage is very limited. All patients who qualify for insulin pump therapy should be referred to a centre where expertise for a pump is available. Pump therapy requires a lot of motivation and time from both - the patient and the clinician.

Indications

• All Type -1 diabetics who are poorly controlled with basal-bolus therapy.


• Pregnancy


• Frequent hypoglycemia or hypoglycaemic unawareness


• Persistently elevated fasting glucose (Dawn phenomenon)


• Multiple chronic complications with labile glucose requiring fine tuning of glycemic control


• Management of labile diabetes after renal or hepatic transplant


• In situations where insulin requirement is very high a trial of pump therapy can be given.

Hypertesion in diabetics :

Lifestyle measures form the cornerstone of hypertension management. Salt intake should be restricted to less than 6 gm per day. Restriction of salt intake should however be individualised .Care has to observed in elderly and in people who sweat much particularly in summers. The target BP is 130/80 for all diabetics and 120/70 in established nephropathy (creatinine >1.5 or proteinuria >1 gm per day) .BP should be measured at each visit .Measuring postural variation in BP is useful in autonomic dysfunction. Therapy should be individualised based on the associated comorbidities and side effects of drugs. Lifestyle measures and dietry adjustments are essential to attain the desired goals.

ACE (Angiotensin Converting Enzyme )Inhibitors and ARBs (Angiotensin Receptor Blockers) can be used interchangeably as a first line antihypertensive agent in all diabetics. Second line agent could be calcium channel blockers or cardioselective betablockers. Diuretics and alpha blockers can also be used whereever needed. Glucose intolerence due to any of these agents is not clinically significant.

Diabetic dyslipidemia - Classically, DM induces elevation in triglyceride and LDL, and low HDL levels.It should be treated aggressively with a LDLc target of <100 mg/ dl without CAD and <70 mg/ dl with CAD.Goal for triglycerides is <150 mg/dl and for HDLc is > 45 mg/dl. Statins form the cornerstone of lipid lowering therapy.Statins are also useful if microvascular complications like nephropathy and retinopathy are present. Addition of fibrate or ezitimibe is indicated when desired goals are not met.Triglycerides of >400 is an indication for the use of fibrate as a primary therapy. Combination of niacin can be useful if HDL is persistently low. Usually anti lipid therapy is lifelong and doses need adjustments based on periodic lipid profile. Dietary modifications and lifestyle measures can alone be sufficient sometimes. Statins can produce myalgias and rarely myopathy .

Aspirin(ASA) usage in diabetes- Low dose(75-150mg) ASA prophylaxis should be given to all diabetics over 50 years of age with one additional cardivascular risk factor. Watch for adverse events -GI bleed and hemorrhagic stroke .

Management of diabetes in pregnancy- prepregnancy counseling for the desired goals for glucose and blood pressure,lifestyle measures ,nutrition.Shifting to insulin and withdrawl of ACE inhibitors and lipid lowering drugs is required in prepregnancy period.Folic acid 10 mg daily should be started to prevent neural tube defects.

Screening for GDM

Glycemic targets in pregnancy- fasting- 95 mg/dl, 2hours post prandial-<120 and one hour <140

Diabetic Foot : Even a small ulcer should be given full attention .Neglecting small ulcers or trauma can finally become the reason for limb loss.

Diabetic foot results predominantly due to neuropathy ,associated with infection and ischemia.Xray of the foot may expose foreign body or gas and must be done .Shifting these patients to insulin helps in better glycemic control and early healing. Infections of the foot are polymicrobial and require wide spectrum coverage. Limb and life threatening infections must be treated with parenteral antibiotics. Pus collection of any magnitude should be drained out and explored widely. Early surgery is always desired .Iodinated solutions , H2O2 and other strong antiseptics should be avoided for cleaning the wound as they prevent angiogenesis. Planter lesions will heal only with offloading the affected foot.

Referral to a higher center necrotising fascitis, any chronic non healing ulcer, lesion associated with systemic involvement, presence of significant ischemia charcot's joint, requirement of advanced imaging and customised footwear or orthotic support.

Targets

BMI	21-25
Fasting glucose	80-120
2 hours postprandial glucose	130-160
HbA1c	6.5-7.0
BP	140 / 80
Total Cholesterol	<150
LDLc	<100
Triglycerides	<150
HDLc	>40 for males, > 50 for females

Hospitalised patient -periop period

Targets-Preprandial glucose- <110

2 hours Postprandial glucose-<180

Critically ill patients- 140-180

Most of these patients will be on insulin which preferably should be given as bolus -basal therapy i.e.3-4 boluses of short acting insulin and a bedtime dose of NPH or long acting insulin. Stable patients who are eating well can be managed with 2-3 time insulin (premixed or split mixed)In all hemodynamically compromised situations, acute myocardial infarction, stroke, high dose steroid therapy, immediate post op period of major cardiac surgery, severe sepsis, very high glucose levels ,patients on ventilator. IV infusion of short acting insulin with glucose monitoring every 1-2 hours is preferred. Basal insulin requirement must be assessed for all patients to prevent fasting and inter prandial glucose peaks. Patients who are nil by mouth may also need some basal insulin. Overlap between subcutaneous and IV insulin for 30-60 minutes should be done to prevent sudden hyperglycemia relapse when shifting from IV to subcutaneous insulin.

Hypoglycemia : more common in following situations

Patients who are older, have renal or liver disease

Have a long duration of diabetes, autonomic neuropathy, hypopituitarism

Regularly miss meals, erratic meal pattern

unusual exercise

Take greater than the prescribed dose of their medication

Concomitant medication – Levofloxacin*, beta blockers,

* hyperglycemia is more common with Levofloxacin though rarely hypoglycemia can occur.

Diabetes Education : Educating the patient for lifestyle modifications, hypoglycemia, insulin therapy, foot care, benefits of quitting smoking and tobacco, reducing alcohol helps in achieving the targets of therapy.

Sick day guidelines : The objective of these guidelines is to avoid hospitalisation during situations like acute diarrhoea, vomiting febrile illness. And if at all it is required the patient is able to prevent DKA or other diabetes related acute complications. All diabetics should be taught these simple rules or a handout may be given mentioning- In any febrile illness or whenever there is poor intake of food and water due to any illness dehydration and ketosis must be avoided .Never omit your medication -insulin or OAD. Infact sometimes a higher dose is required when we are sick even when we are not eating. Blood glucose and urine ketones must be checked frequently -every 4-6 hourly. Type 1 diabetics may require monitoring 2-4 hourly. Try to eat small amounts of carbohydrates every 2-4 hourly ,soft food or liquids are easier to take .!00-120ml of fluid every hour (carbohydrate free if glucose is >250 and with carbohydrates if glucose is less than 250. Fluids and carbohydrates are required to maintain hydration and calorie requirement and preventing hypoglycemia. Dehydration and worsening ketosis are ominous signs . Physician must be consulted if nausea or vomiting persists with ketosis .If blood glucose is persisting more than 300 on two consecutive times .If breathing becomes rapid or laboured, fever >100 degree F persisting more than 24 hours, persisting diarrhoea or vomiting or pain abdomen. Inability to take fluids for more than 4 hours due to vomiting drowsiness or altered sensorium or anyother unexplained symptoms. Drug treatment adjustments during sickdays- stop metformin, and preferably other OADs except sulphonylureas, increase or decrease sulphonylureas according to the glucose readings. Addition of short acting insulin may be required to OADs.In situations where patient is already on insulin, long acting or intermediate insulin should be continued in the same doses. Dose of short acting insulin can be adjusted by measuring sugars 4-6 hourly.Premixed insulins should be supplimented by short acting insulins usually 20-25 %extra or more dose of insulin is required in addition to the usual dose of insulin.However if vomiting or diarrhoea persists hypoglycemia can occur.

Prevention of diabetes : Identify the high risk population .Fasting glucose and OGTT should be used for identifying IFG and IGT.No drug is recommended for the prevention of diabetes.MF and Acarbose can be used in IGT and IFG.Lifestyle measures mentioned in section 2.3 should be persued for prevention of diabetes.

Referral to a tertiary center /Endocrinologist : In the following situations a referral to a tertiary center where endocrinologist is available should be done at least once or more in a year. Diabetes in a neonate or an infant, all Type -1 diabetics with polyendocrinopathy, Coeliac disease or with growth hormone defeciency. Diabetes with complications, brittle diabetes, pregnancy with diabetes, diabetes with endocrine tumors like pheochromocytoma, pituitary tumor, rare varieties of diabetes like diabetes with lipodystrophies or rare syndromes, requirement of CGM or insulin pump. Diabetes after liver or renal transplant. In any other situation where glycemic control is not achieved despite of all efforts.

Referral to a nephrologist : serum creatinine >1.5 ,proteinuria more than >1 gm/day,nephropathy in absence of retinopathy ,suspicion of a nondiabetic renal disease.

Referral to a retinal surgeon : when early NPDR is progressing ,CSME,advanced retinopathy.

Referral to a neurologist : severe neuropathic symptoms not responding to the standard treatment, suspicion of non diabetic neuropathy, amyotrophy, stroke, mononeuropathy.

Referral to a cardiologist : angina or its equivalent ,diabetic cardiomyopathy,peripheral vascular disease requiring further workup

Who does what

Doctor- history taking, physical examination, ordering investigations, prescrbing treatment.

Nurse- patient education -like explaining the basics of diabetes and its complications, foot care, exercises, hypoglycemia, self monitoring of glucose, insulin injection devices and techniques.

Dietician- calorie calculation, explaining the concept of carbohydrate counting, food exchanges, glycemic index, modifications in diet during special situations like pregnancy, renal impairment.

Technician- drawing blood ,doing ECG, installing CGMS, insulin pump installation and its management except the insulin dose calculation and its modifications . Biothesiometry and use of other gadgets for foot care.

Guidelines by The Ministry of Health and Family Welfare :

Dr Sailesh Lodha Fortis Escorts Jaipur