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DM F.pptx
1. COLLEGE OF MEDICINE AND HEALTH
SCIENCES, SCHOOL OF NURSING AND
MIDWIFERY
DEPARTMENT OF ADULT HEALTH NURSING
Presentation On Diabetes Mellitus
By Honelet Debebe
DESSIE ETHIOPIA
APRIL 2023
6/8/2023 Honelet D 1
3. Definition
• DM is metabolic disorder of multiple etiology
characterized by chronic hyperglycemia with
disturbances of carbohydrate, fat and protein
metabolism resulting from
defects in insulin secretion, insulin action, or
both.
The effects of diabetes mellitus include long-
term damage, dysfunction and failure of various
organs.
6/8/2023 Honelet D 3
4. Epidemiology of DM
• The number of people with diabetes rose from 108
million in 1980 to 422 million in 2014.
• Prevalence has been rising more rapidly in low- and
middle-income countries than in high-income
countries.
• Diabetes is a major cause of blindness, kidney
failure, heart attacks, stroke and lower limb
amputation.
• Between 2000 and 2019, there was a 3% increase in
diabetes mortality rates.
• In 2019, diabetes and kidney disease due to
diabetes caused an estimated 2 million deaths.
6/8/2023 Honelet D 4
5. Risk factors
• Having prediabetes
• Overweight
• Age >45
• Genetics
• Physical inactivity(<3times/wk)
• Gestational state
6/8/2023 Honelet D 5
7. 1. Type 1
• Type 1 indicates the processes of beta–cell
destruction that may ultimately lead to
diabetes mellitus
• An individual with a Type 1 process may be
metabolically normal before the disease is
clinically manifest, but the process of beta–
cell destruction can be detected.
• Type 1 is usually characterized by the
presence of anti–GAD (glutamic acid
decarboxylase), islet cell or insulin antibodies
which identify the autoimmune processes that
lead to beta–cell destruction.
6/8/2023 Honelet D 7
8. 2. Type 2
• Type 2 is the most common form of diabetes
and is characterized by disorders of insulin
action and insulin secretion, or both
• By definition, the specific reasons for the
development of these abnormalities are not
yet known.
6/8/2023 Honelet D 8
9. 3. Gestational Hyperglycemia and Diabetes
• Gestational diabetes is carbohydrate
intolerance resulting in hyperglycemia with
onset or first recognition during pregnancy.
• It does not exclude the possibility that the
glucose intolerance may antedate pregnancy
but has been previously unrecognized.
• The definition applies irrespective of whether
or not insulin is used for treatment or the
condition persists after pregnancy.
6/8/2023 Honelet D 9
10. 4. Other specific types
• Other specific types are currently less
common causes of diabetes mellitus, but are
those in which the underlying defect or
disease process can be identified in a
relatively specific manner.
• for example, fibrocalculous pancreatopathy,
• a form of diabetes which was formerly
classified as one type of malnutrition–related
diabetes mellitus.
6/8/2023 Honelet D 10
11. Clinical features
• Type 1 diabetic patients tend to be much more
symptomatic than type 2 diabetic patients
• polyphagia, polyuria, polydipsia
• Fatigue
• Unexplained weight loss
• Blurred vision
• Recurrent skin infections
• Recurrent itching of the vulva (candida infections)
• Numbness, Foot abnormalities (ulcer, ischemia,
deformity) if complicated.
6/8/2023 Honelet D 11
12. Investigations and diagnosis
For New diagnosis
• Clinical features
FBS/RBS, glycated hemoglobin (HbA1c)
Urine ketones, Urine albumin, Blood urea and creatinine
Fasting lipid profile
In diagnosed patients, follow up investigations
Glycemic control: HbA1c, FBS/RBS
Screening for complications: Urine albumin/protein,
retinal screening by ophthalmologist, serum creatinine
and urea.
Other cardiovascular risk screening: Lipid profile.
6/8/2023 Honelet D 12
16. A. Medical Nutrition Therapy (MNT): general guidance
1. Principles of nutritional therapy
Focus on supporting the patient on choosing
healthy eating behaviors
Consider the literacy of the individual, access to
food, and willingness
Try to maintain the pleasure of eating as much as
possible
Respect and address the individual preferences,
cultural, and religious choices.
Be nonjudgmental / decision is left for the pt.
6/8/2023 Honelet D 16
17. Be practical
Limit food choices when only supported by
scientific evidences
Help overweight and obese individuals to
decrease body weight
Help to attain individualized glycemic, blood
pressure, and lipid goals.
6/8/2023 Honelet D 17
18. 2. General advice
• Avoid refined sugars: soft drinks with sugar, or
adding sugar/honey to teas/other drinks.
• Carbohydrate - Reduce overall carbohydrate intake
• Proffered whole grains, non-starchy vegetables,
fruits, and dairy products
• Reduce saturated fat (animal fat) intake: butter,
fatty cuts of meat
• Mono-saturated and polyunsaturated vegetable
oils are preferred
• Protein - Should be left to the individual choice.
• When there is chronic kidney disease, reduction
(not stopping) protein intake.
6/8/2023 Honelet D 18
19. B. Exercise
• Regular moderate-intensity aerobic physical activity : for
at least 30 minutes at least 5 days a week (at least 150
min/week)
• Encourage resistance training three times per week.
C. Weight management
• For obese and overweight individuals - Eating plans
(focusing on reduction of overall carbohydrate intake)
and exercise
D. Stop smoking
E. Moderation of alcohol intake
F. Self-blood glucose monitoring (SBGM)
G. Screening for micro and macro vascular complications
6/8/2023 Honelet D 19
21. Management of blood sugar
A. Target blood glucose
Target should be individualized
In young patients with recent diagnosis, without
significant chronic complications, tight glycemic control
should be encouraged.
History of severe hypoglycemia
The elderly and those limited life expectancy
Established cardiovascular disease
Advanced micro vascular disease e.g. chronic kidney
disease
comorbid conditions e.g. liver disease, malignancy
Long duration of diabetes
6/8/2023 Honelet D 21
22. B. Target in most non-pregnant adults without
significant comorbidities:
6/8/2023 Honelet D 22
23. C. Blood glucose lowering medicines
First line:
• Metformin Initial dose 500mg to 1000mg/day daily or
in two divided doses with meals.
• Titrate dose every two weeks depending on the fasting
blood sugar Maximum dose = 2000mg/day (1000mg
BID) –
• The major side effects of metformin are
gastrointestinal intolerance: bloating, abdominal
discomfort, and diarrhea.
Metformin is contraindicated in patients with advanced
chronic kidney disease
6/8/2023 Honelet D 23
24. 2. Alternative to Metformin
If Metformin is contraindicated a sulfonylurea
can be started
Basal insulin can also be started as an alternative(
see for indications for starting insulin in type 2
diabetes)
3. Add on to Metformin
If glycemic target is not achieved by metformin
alone after three months, add either of the
following. oSulfonylureas : Glibenclamide,
Glimepiride, Gliclazide OR o Basal insulin
6/8/2023 Honelet D 24
25. 4. Sulfonylureas
• Glibenclamide (Glyburide)
Starting dose is 2.5-5mg/day, 30 minutes before breakfast.
Titrate dose slowly to maximum of 20mg/day - When 10mg/day
is needed, divide the total dose into two, with the larger dose in
the morning.
Avoid in the elderly and patients with renal impairment.
• Glimepiride
Starting dose is 1-2 mg/day, 30 minutes before breakfast.
Titrate dose slowly to maximum of 8mg/day
• Gliclazide,
Starting dose 30mg/day
Titrate the dose slowly to a maximum dose 120mg/day
• The major side of sulfonylureas is hypoglycemia.
• - Individuals should be educated about the risk, manifestations,
prevention and treatment of hypoglycemia.
6/8/2023 Honelet D 25
26. 5. Insulin therapy in type 2 diabetes
Indications for insulin therapy
Failure to control blood glucose with oral medicines
Temporary use for major stress, e.g. surgery, medical
illness
Severe kidney or liver failure
Pregnancy
In patients difficult to distinguish type 1 from type 2
diabetes
Ketonuria
Unexplained weight loss accompanied by poorly
controlled blood sugar
Initial therapy for a patients presenting with very high
blood sugar o HbA1C >10% or fasting blood glucose >250
mg/dl or random glucose consistently >300 mg/d
6/8/2023 Honelet D 26
27. • Dosing basal insulin in type 2 diabetes
If started on as an add on therapy to Metformin
Starting dose = NPH 10 units at bed time
A higher dose might be started for higher blood
glucose ▪ Dose increment 2-4 units in 3-7 days with
self-monitoring of blood sugar
If started as a replacement for oral agents ▪ Starting
dose = NPH 15 -20 units at bed time
A higher dose might be started for higher blood
glucose
For doses above 20units divided in two ( about 2/3
in the morning and 1/3 in the evening)
Dose increment 2- 4 units in 3-7 days with self-
monitoring
6/8/2023 Honelet D 27
28. • Addition of prandial regular insulin
Indications to start regular insulin before meal
If FBS is well controlled but HbA1c is above target
If HbA1c is above target despite increasing basal
insulin to >0.5 unit/Kg/day
• Dosing prandial regular insulin
Starting dose of prandial insulin : Regular insulin
4units
Preferred time : before the largest meal of the day
Dose increment 1-2 units in 2-3 days with self-
monitoring of the next pre-meal blood glucose
6/8/2023 Honelet D 28
29. D. Management of other
cardiovascular(CV)risks
1. Cardiovascular risk calculation
All patients 10 year cardiovascular risk factor
needs to be calculated
2. Blood pressure management
3. Lipid lowering therapy
4. Antiplatelet therapy
6/8/2023 Honelet D 29
30. Treatment of Type 1 Diabetes Mellitus
Non pharmacologic treatment
Similar to that of management type 2
Diabetes
6/8/2023 Honelet D 30
31. Pharmacologic
• Insulin is the main stay of treatment in type 1 diabetes
• Conventional insulin therapy
It encompasses simpler non-physiologic insulin regimens.
These include single daily injections, or two injections per
day
• Intensive insulin therapy
It describes treatment with >3 injections/day or
continuous insulin infusion
• Designing insulin therapy
Total insulin dose per day Initiation, 0.2 to 0.4 units/kg/day
Maintenance – highly variable roughly 0.6 to 0.7
units/kg/day
6/8/2023 Honelet D 31
33. Acute Complication of DM
• Diabetic ketoacidosis (DKA)
• hyperglycemic hyperosmolar state (HHS)
6/8/2023 Honelet D 33
34. • Diabetic ketoacidosis (DKA) is a condition in
which there is a severe deficiency of insulin
resulting in very high blood glucose.
Fat is broken down as an alternative source of
energy with ketones/ketoacids as a byproduct.
This state of severe hyperglycemia and ketone
body production results in severe metabolic, fluid
and electrolyte abnormalities.
DKA often occurs in type 1 diabetes patients but
may also occur in type 2 diabetes.
The most common settings in which DKA occurs
include:
6/8/2023 Honelet D 34
35. • Clinical features Symptoms
Excessive urination
Excessive thirst and drinking of water
Nausea, vomiting
Abdominal pain
Symptoms of infection or other precipitants Signs
Deep and fast breathing
Low blood pressure
Fast and weak pulse
Alteration in sensorium or collapse
Dehydration with dry skin, reduced skin turgor or sunken
eyes
Fruity' breath (smell of acetone) in DKA
Evidence of infection, recent surgery, stroke etc.
6/8/2023 Honelet D 35
36. Diagnosis
• Diagnosis of DKA or HHS is made with the presence of
severe hyperglycemia, clinical features and ketone in the
urine (in case of DKA)
• Investigations
Random blood glucose : usually >300mg/dl)
Urine glucose (usually >3+)
Urine ketones (usually >2+)
BUN and Creatinine
Serum electrolytes, particularly serum potassium
Investigations for precipitants: CBC, blood film for malaria
parasites and others based on the suspected precipitating
factors
6/8/2023 Honelet D 36
37. Treatment
• Objectives of treatment
Replace fluid losses
Replace electrolyte losses and restore acid-
base balance
Replace deficient insulin
Seek the precipitating cause and treat
appropriately
6/8/2023 Honelet D 37
38. • Replace fluids
Individualize fluid needs based on the patient
hydration status
• Administer short-acting insulin Regular Insulin
10units IV and 10 units IM, stat,
Then If there is perfuser: 0.1units/kg per hour by
continuous IV infusion.
If there is no perfuser: 5 units, I.M, every hour.
• Potassium
All patients with DKA have potassium depletion
irrespective of the serum K+ level.
If the initial serum K+ is 5.3 mmol/l, do not
supplement K until the level reaches < 5.3.
6/8/2023 Honelet D 38
39. Precipitant identification and treatment
Noncompliance, infection, trauma, infarction.
Initiate appropriate workup for precipitating event
(cultures, CXR, ECG)
Follow up of response
Blood glucose every 1–2hrs o Urine ketones every
4hr o Electrolytes (especially K+) every 6 h for first
24 h.
• Continuation of treatment
The above treatment should continue until the
patient is stable, clinically acidosis improves, and
patient is able to take oral feeding.
6/8/2023 Honelet D 39
40. • Transition
Once the patient is able to take oral feeding
and clinically the acidosis improved.
Reduce regular insulin : 2-3 units hourly (5
units every 2 hour) or for continuous infusion
by 0.05/kg per hour
Overlap regular insulin with subcutaneous
NPH insulin for 2-3 hours
6/8/2023 Honelet D 40
41. Chronic complication of DM
• Microvascular
Diabetic kidney disease,
retinopathy and nephropathy
• Macrovascular
coronary artery disease, stroke and peripheral
vascular disease
• Diabetic foot disease is also a major complication
which results from multifactorial causes
6/8/2023 Honelet D 41
42. • Prevention of these complications can be
achieved through optimal glycemic control,
optimal blood pressure management, lipid
control, quitting smoking and maintaining a
healthy life style.
6/8/2023 Honelet D 42
43. References
• Brunner and Suddarth
• STG 2020
• Harrisons principle of internal medicine
6/8/2023 Honelet D 43