Diabetes Mellitus

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Clinical Description

The diagnosis of diabetes is based on 2 abnormal blood sugar measurements {FBS > 7 mmol/L (126 mg/dl) or RBS >11.1mmol/L (200 mg/dl) or HbA1C >6.5%} in an asymptomatic patient or 1 abnormal measurement if the patient has symptoms of hyperglycinemia.

Forms of diabetes:

  • Type 1 diabetes (can be early onset or late onset)
  • Type 2 diabetes (usually late onset but can be early onset (MODY - mature onset diabetes of the young)
  • Gestational diabetes
  • Secondary diabetes (related to medication use (e.g. steroids), endocrine or pancreatic disease etc.)

Causes:

  • Autoimmune disorder (Type 1 diabetes)
  • Idiopathic (Type 1 diabetes)
  • Genetic factors causing a defect in the action or secretion of insulin (Type 2 diabetes)
  • Environmental factors e.g., excessive calorie intake and lack of physical activity (Type 2 diabetes)
  • Pregnancy (Gestational diabetes)
  • Secondary diabetes: Medication e.g., corticosteroid use or abuse,  
  • Pancreatic disease or pancreatectomy, Endocrine disorders e.g., Cushing’s syndrome, acromegaly etc.

Clinical Features 

SIGNS AND SYMPTOMS

  • Polyuria, Polydipsia, Burning sensation/pins and needles (feet), Blurred vision, Foot ulcers, Family history of diabetes (type 2 diabetes)
  • Obesity (some type 2 diabetes patients)
  • Erectile dysfunction in men
  • Recurrent skin boils
  • Recurrent vulvovaginal candidiasis in women
  • Big baby (gestational diabetes)

Complications of Diabetes

  • Retinopathy and nephropathy, Hypertension, Myocardial infarction, heart failure, Stroke, Diabetic foot, peripheral neuropathy, erectile dysfunction, Peripheral vascular disease, Recurrent infections: skin, UTI, candidiasis, Pregnancy and Birth complications

INVESTIGATIONS

  • Random or fasting blood sugar, HBA1c, FBC, urea, creatinine, and electrolytes, urine dipstick: assess glucosuria, ketonuria, proteinuria, fasting lipogram, fundoscopy: screening for diabetes retinopathy, HIV test

Treatment

Treatment objectives

  • Establish treatment aims: some patients require strict glycaemic control with near normal glucose values targeted, for others symptom control and avoiding severe side effects of treatment may be the maximum achievable
  • Check BP regularly and aim for BP <130/80 mmHg
  • Advise to stop smoking
  • Educate about foot care and screen annually for foot problems (neuropathy or peripheral vascular disease}
  • Screen annually for decrease in visual acuities, look for cataracts
  • Educate on appropriate dietary measures and manageable exercises according to individual patient

NON-PHARMACOLOGICAL

  • Measures mentioned above

PHARMACOLOGICAL

  • Give Aspirin 75mg (to 81mg) daily to hypertensive diabetics aged over 50
  • If a diabetic is admitted unconscious always consider the possibility of hypoglycaemia- administer 100ml 20% or 50ml 50% Dextrose/Glucose IV even if a blood glucose measurement is not available.

Do not rush to refer the unconscious Diabetic mellitus patient before you consider managing hypoglycemia. Hypoglycaemia is more likely to cause sudden death than hyperglycaemia.

 

DIABETES TYPE 1

Clinical Description

  • Insulin production absent because of autoimmune pancreatic beta-cell destruction
  • Most children will have type 1 diabetes.
  • Children with diabetes should be referred for proper management and treatment.
  • Consider hydration while waiting for transport for referral
  • These children need to be followed up every 3 months to monitor blood sugars and long-term complications of diabetes.

Clinical Features

SIGNS AND SYMPTOMS

  • As above for Diabetes Mellitus

INVESTIGATIONS

  • As above for Diabetes Mellitus

Adults with no ketoacidosis or other acute Complication and have type 1 diabetes

TreatmentPHARMACOLOGICAL 

  • Give NPH insulin Lente/Protaphane Insulin 2 doses daily

For proper management of diabetes mellitus refer to Clinical handbooks of QECH College of Medicine and KCH Intern Logbook as well as Pediatric handbook

  • To decide the starting dose of Insulin:
    • The total daily number of Insulin units will be approximately half the patients body weight, e.g., for a 60 Kg person give 30 units Insulin/day divided into 2 doses
    • Then give 2/3 daily dose half an hour before breakfast, give 1/3 daily dose half an hour before evening meal, preferably 12 hours apart
    • Adjust Insulin dose according to fasting blood sugar (FBS} or 2 hours postprandial blood sugar; or symptoms of hypo or hyperglycaemia

Insulin requirements can go up when a patient is acutely ill, even if they are not eating. NEVER stop Insulin in a type 1 diabetic.

Diet

  • Increase fiber intake
  • Reduce refined sugar intake
  • Insulin treated patients require 3 meals a day containing complex carbohydrate to avoid risk of hypoglycaemia
  • Advise patients to eat more before unaccustomed exercise

REFERRAL CRITERIA FOR SPECIALIST OPINION IF:

  • Pregnant diabetic
  • Acutely ill diabetic, particularly if vomiting or decreased Glasgow Coma Score (GCS}
  • Treatable complications e.g., cataracts

 

Children with Diabetic Ketoacidosis

SIGNS AND SYMPTOMS

  • Vomiting, polyuria, dehydration, ketonuria and acidosis. The blood sugar will be high >15mmol/l

Treatment

  • Address airway and breathing
  • IV fluids are the most important resuscitation measure
  • Give Normal Saline or Ringers Lactate
  • Give 10mls/kg bolus and repeat to a maximum of 30mls/kg to correct shock if present
  • Ongoing fluid requirement = (Maintenance} plus (Deficit} minus (shock bolus}
  • CORRECT OVER 48HRS TO AVOID CEREBRAL OEDEMA

Child is usually approx. 7.5 to 10 % dehydrated. Deficit is calculated as % body weight loss.

Maintenance is calculated as per shown below;

  • First 10 kg body weight 100mls /kg /day
  • Next 10 kg body weight 50mls/kg/day
  • Each kg thereafter 20mls/kg /day.

For example:

  • Comatose child weighing 20kg on admission in shock in DKA X 10ml/kg bolus needed to correct shock = 2 X 200 = 400mls
  • Maintenance is 1.5L/ day {1000mls + 500mls}
  • Deficit= 20kg X 7.5% = 1.5L (one litre weighs1kg}
  • Requirement over 48 hours
  • Maintenance (1.5 + 1.5L} + deficit (1.5L} minus bolus (400} 4.1L +/48hours = 85ml/hr
  • Add Potassium Chloride to IV fluids when patient urinates, and peripheral circulation has improved
  • Change to oral K+ supplements when patient is able to feed
  • ECG monitoring if potassium is <2.8 or >6mmol/L

Give Insulin

  • Should be short acting, soluble
  • Start insulin one hour after starting IV fluids
  • start with small subcut dose of 0.1u/kg. Recheck blood glucose after an hour.
  • If glucose is unchanged or increased, repeat subcut dose of 0.1u/kg. Repeat hourly until blood glucose starts falling.

Sliding Scale:

  • Blood glucose (mmol/L}
  • >20kg: 0.5u/kg
  • 15 - 19.9kg: 0.4u/kg
  • 10 - 14.9 kg: 0.3u/kg
  • 5 - 9.9kg: 0.2u/kg
  • 2- 4.9kg: 0.1u/kg only if on a glucose drip
  • <2: omit Insulin and give Dextrose or food

Ongoing Management:

  • Change IV fluid to 1/2 strength Darrow’s or 5 % Dextrose if blood glucose <15mmol/L
  • IV fluids must be continued until child is drinking well, tolerating oral feeds and has ketone free urine
  • Monitor level of consciousness. Deteriorating neurological state may indicate cerebral oedema. Ensure airway is protected
  • Consider NGT on free drainage if child is unconscious
  • Check each urine passed for glucose and ketones as a guide to recovery
  • Maintenance Insulin requirements
    • Once child is drinking and eating
    • Calculate total daily dose of insulin once the child is stable. This is usually 0.5 to 1u/kg/day but should be based on the Insulin requirement of the previous 24hours
    • If only short acting Insulin is available:
      • Continue TDS regime prior to meals according to requirement
    • If long acting is available:
      • BD regime, 2/3 of the total dose should be given before breakfast and 1/3 before dinner
      • Proportion for long acting and short acting should be about 2:1 to 3:1
    • Educate patient and family on diet:
      • Importance of regular meals
  • Avoid refined sugars e.g., SOBO, bananas, cakes and biscuits
  • Encourage complex carbohydrates e.g. cereals and a high fiber diet
  • Educate patient and family on Insulin:
    • Keep in a cool place e.g., clay pot if no refrigerator
    • Rotation of injection sites
    • How to give injections

 

HYPOGLYCEMIA IN ADULTS

Clinical Description

Low blood sugar level below 70mg/dl (3.9mmol/L). Severe hypoglycemia (blood sugar <2.2mmol/l)

Causes/risk factors:

  • Overdose of anti-diabetic medications (oral or insulin)
  • Anti-diabetic drugs in renal impairment
  • Elderly
  • Omitted meals or inadequate meals
  • Excessive unaccustomed physical activity
  • Excessive alcohol intake
  • Liver failure

Clinical Features

SIGNS AND SYMPTOMS

  • Sweating
  • Excessive hunger
  • Trembling
  • Tachycardia
  • Drowsiness
  • Confusion
  • Loss of consciousness, seizures, and irreversible brain damage if severe hypoglycaemia

INVESTIGATIONS

  • Random blood sugar (urgently done using glucometer)
  • urea and creatinine (exclude renal impairment)
  • Liver function test

Treatment

Treatment objectives

  • Treat hypoglycemia urgently if suspected even without knowing blood sugar level (if glucometer not available)
  • Establish causes and treat appropriately
  • Re-educate patient on meals and medications dose

NON-PHARMACOLOGICAL

  • Appropriate advice on medications dosing and meals

PHARMACOLOGICAL 

Adults: 

  • IV dextrose 50% solution 25-50 ml over 1-3 minutes through a large vein Then 510% solution 500ml 4 hourly until the patient is able to eat normally
  • Glucose in form of refined sugars in a conscious patient for adults e.g., SOBO, soft drink, sweets

 

HYPOGLYCAEMIA IN CHILDREN

Clinical Description

Serum glucose level less than 2.5mmol/L (3mmol/L if malnourished).

Causes 

  • Infection
  • Drugs; insulin, metformin, glibenclamide
  • Toxins
  • Malnutrition
  • Liver failure
  • Endocrine: hyper-insulinism, growth hormone deficiency, hypothyroidism, hypopituitarism, adrenal insufficiency, Congenital Adrenal hyperplasia
  • Inborn errors of metabolism

Clinical Features

SIGNS AND SYMPTOMS

  • Sweating, seizures, tachycardia, drowsiness, confusion, poor concentration, blurred vision, irritability and nausea 

INVESTIGATIONS

  • Serum glucose, blood gas, urea, electrolytes and creatinine, serum ketones, toxin screen
  • Identify underlying cause
  • 100

Treatment

PHARMACOLOGICAL 

  • 5ml/kg 10% Dextrose IV if neonate give 2ml/kg or via NGT if there is no IV access.
  • Follow up with regular feeds or continuous Intravenous fluid containing dextrose
  • Treat underlying cause

Complications 

  • Seizures
  • Neurocognitive impairment

REFERRAL 

  • Persistent hypoglycaemia

 

DIABETES TYPE 2

Clinical Description

  • Type 2 diabetes (usually late onset but can be early onset (MODY-mature onset diabetes of the young)
  • Family history of diabetes (genetic predisposition)
  • Obesity also a risk factor
  • Screen for secondary causes (e.g., endocrine disorders, steroids etc. as described above on Diabetes Mellitus)

Clinical Features

SIGNS AND SYMPTOMS

  • As above on Diabetes Mellitus

INVESTIGATIONS

  • As above on Diabetes Mellitus

Treatment 

NON-PHARMACOLOGICAL

  • Adjustment of diet and/or weight reduction (if obese} and increased exercise may control blood glucose without the need for drug therapy
  • Wherever possible (when sugar is mild high) give a 4–6-week trial of diet before introducing oral hypoglycaemic agents

If the above is unsuccessful, then:

PHARMACOLOGICAL 

  • Give Metformin 500mg twice daily, increased to a maximum of 2500mg in divided doses.

Metformin is the drug of choice in type 2 diabetes, particularly in obese patients. It is contraindicated in significant renal insufficiency, and severe respiratory and cardiac disease due to risk of lactic acidosis.

  • If glycaemic control still poor, add Glibenclamide 5mg daily, increasing to a maximum of 10 mg q12h.

20% of type 2 diabetics eventually require Insulin treatment - use principles as in type 1 diabetes to initiate treatment. Use Lente/NPH insulin 0.3U/kg bodyweight to start with at breakfast and dinner and titrate over time according to blood glucose levels.

  • General follow up plan for diabetic patients:
    • Attend monthly clinics at hospital- blood glucose and/or urine should be checked
    • Check injection sites
    • Ask about nocturia
    • HbA1c can be measured
    • Diabetic patients should have the following annually: fundoscopy, urine microalbuminuria and thyroid function tests if available.