hihfrouvhoreijger9p

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

2. Presentation outline
• Definition
• Epidemiology
• Risk factors
• Clinical features
• Diagnosis
• Treatment
• Complications
• Prevention
6/8/2023 Honelet D 2

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

6. Types of DM
6/8/2023 Honelet D 6

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

13. Diagnostic criteria
6/8/2023 Honelet D 13

14. Treatment
Objectives of treatment
Relieve symptoms
Prevent acute hyperglycemic complications
Prevent/delay chronic complications of diabetes
Prevent treatment-related hypoglycemia
maintain appropriate glycemic targets
Ensure weight reduction in overweight and
obese individuals
6/8/2023 Honelet D 14

15. Non pharmacologic treatment
6/8/2023 Honelet D 15

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

20. Pharmacologic treatment
6/8/2023 Honelet D 20

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

32. 6/8/2023 Honelet D 32
•Complication of DM

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

44. Welcome with your
•Questions? and
•comments
6/8/2023 Honelet D 44

45. Acknowledment
To
• Dr. Kumar
6/8/2023 Honelet D 45

46. Thank you
6/8/2023 Honelet D 46