DM

Diabetes
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Dx
---
HbA1C > 6.5 %


Fasting (> 8hr) glucose >7 mmol/L


Random glucose >11 mmol/L

Oral glucose tolerance test >11 mmol/L
(give 75 g oral glucose. measure level after 2 hrs)

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Other exam:
Kidney function (albuminuria & GFR): Random spot urine Albumin/Creat ratio. GFR from Serum Creat.
Heart: ECG, lipogram
Eye: fundoscopy
Foot: foot exam.


(Blood tests to order: glucose, HbA1c, Cr, Lipogram)


Rx
---

Life style - exercise, lose weight, eat vegetable, stop smoking





1. BP control:

ACEI /ARB -> THIAZIDE -> Ca blocker -> Beta blocker  (에이스 두 꺼 비 - ace thi ca be)

(The American Diabetes Association recommends the following step therapy: ACE inhibitor or angiotenin-II receptor blocker as the

initial agent; to add thiazide if not well controlled; then if needed add calcium channel blocker; then if needed add beta-blocker.)

2. lipid control

simvastatin 40mg dly PO

+- 3. antiplatelet

aspirin 75 mg dly PO


Insulin therapy can be initial therapy (i.e. skip oral hypoglycemic trial) when fasting glucose > 16.5 mmol/L or random glucose > 19.5

mmol/L.


2 types of insulin:

1. bolus (ultra fast and fast acting insulin)
2. basal (intermediate and long acting insulin) - given before meal.


insulin type according to duration:

-ultra fast acting -> 방금 먹은 끼니에 작용 (given 5 min before meal or even immediatelty after meals)

-fast acting -> 다음 끼니 혈당을 잡음 (given 30 min before meal - due to slower onset than ultra fast insulin)

-intermediate acting -> 두끼 앞 혈당을 잡음

-long acting 

(ultra-fast & long-acting insulins are more expensive.)

insulin trade name examples:
e.g.) fast : actrapid,   intermediate: protaphane,    biphasic: actraphane (actrpaid + protaphane in 30:70)
        fast : humalin R,    intermediate: humalin N,    biphaisc: humalin  30/70  (humalin R + humalin N in 30:70)
참고: NPH = isophane insulin


4 strategies to give insulin:

1) basal alone (long acting)
2) basal + bolus
3) basal + bolus (intermediate + fasting acting)
4) insulin in combination with oral agent


insulin 의 투여 시기:

-아침, 점심, 저녁, 취침전 - 넷중에 하나
-fast 는 끼니(아침, 점심, 저녁)때에
-Intermediate, long acting 은 아침이나 취침전에 투여




initiation and adjustment of insulin in typeII DM:

---
Step1:

bed time long acting insulin(glargine(Lantus) better than determir(Levemir))
dose: 10 U or 0.2 U/kg

increase dose by 2 U every 3 days until fasting glucose lies in target range.
(increase by 4 U every 3 days if fasting glucose > 10 mmol/L)

If hypoglycemia:
reduce dose by 4 U or 10 % (whichever is greater)

Step2:

check HbA1c in 3 months:
if < 7 -> good. check again in 3 months.

if > 7: then

check glucose at: pre-lunch, pre-dinner, pre-bed time:
--
high pre-lunch glucose
-> add rapid acting insulin at breakfast

high pre-dinner glucose
-> add rapid acting insulin at lunch
OR - add intermediate acting(NPH) at breakfast

high pre-bed time glucose
-> add rapid acting insulin at dinner
< ?? OR - add intermediate acting(NPH) at lunch ? -> not mentioned. Intermediate is not used during lunch?? >

how much to add?
-usually 4 U.
and adjust by 2 U every 3 days until glucose lies within range.
--

---


Type 1 DM


"conventional insulin therapy" : single or two injections per day
"intensive insulin therapy": three or more injections per day (now considered standard therapy for type 1 DM) provides more

physiologic profile of insulin.


total daily insulin dose = 0.2~0.4 U / kg

one half of this total is given as basal insulin using either:
-long acting insulin (either in the morning or at bedtime.)  or
-intermediate acting insulin (two-thirds of the half of the total given in the morning, one third given at night)
(lunch bolus may be omitted if twice daily intermediate acting insulin is used)

remaining half of the total is distributed over 3 meals, using fast acting insulin. (maybe adjusted depending on size of the meal,

glucose level)

storage of insulin
-in cool place. Don't expose to direct sunlight.
-unopend, regrigerated insulin can last until expiry date.
-all types of unopend insulin can be left in room temperature ( < 30 degree C) and still maintain potency for 28 days.
-Once opened, the vials (whether refrigerated or kept at room temperature) should be discarded after 28 days.
-pens and cartridges should be stored at room temperature and discarded within the following periods:
mistures of insulin ( 70/30.. etc) : 10 days
insulin suspensions ( NPH ) : 14 days
Rapid acting insulin (Humalog, etc) : 28 days



Gesetational diabetes
def: glucose intolerance with onset and first recognition during pregnancy.

Dx:

75g oral glucose test after overnight fasting of 8hrs

Fasting level > 5 mmol/L
@ 1 hr level > 10 mmol/L
@ 2 hr level > 8.5. mmol/L

Dx made when any of the above values are exceeded.


Rx:
insulin therapy requires highly individualized titration.

In isolated fasting hyperglycemia:
-Start with 10 U intermediate acting insulin at bed time then titrate.

In post-prandial hyperglycemia:
-Start with follwing:
work out total dose with 0.7 U / kg
give two-thirds of the total in the morning and one-third before supper.
morning dose consists of two-third intermediate acting insulin and one-third fast acting insulin.
evening dose consists of one-half intermediate acting insulin and one-half fast acting insulin.




High glucose in the morning:
-can be either one of the two:
1) Somogyi phenomenon -> hypoglycemia while sleeping -> counter regulatory hormone secretion -> hyperglycemia in the morning
therefore, Somogyi needs decrease in insulin dose.
2) Dawn phenomenon -> increase insulin dose

Somogyi -> 3 am glucose is low
Dawn -> 3 am glucose is high