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DIABETES MELLITUS

CLINICAL MANAGEMENT PROTOCOL

Coordinator:
Prof Dr Zafar Ahmed Latif (BIRDEM)
Members:
Prof Dr Md Faruque Pathan (BIRDEM)
Prof Dr Md Farid Uddin (BSMMU)
Dr S M Ashrafuzzaman (BIRDEM)
Dr Shahjada Selim (BIRDEM)

Management Goal:
Blood glucose Fasting/Premeal < 6 mmol/l
2h- post meal < 8 mmol/l (Breakfast, Lunch or Dinner )
HbA1c < 7 % ( < 8 % for older age)
Blood Lipids CHOL < 200 mg/dl
LDL < 100 mg/dl
TG < 150 mg/dl
HDL > 40 mg/dl
Blood Pressure SBP < 130 mm of Hg
DBP < 80 mm of Hg
Body weight BMI < 23kg/m2 or Waist < 90 cm (Male) and < 80
cm (Female)
Patient Education Diet, Exercise, Monitoring and adjustment of
OAD/insulin, Empowerment
N.B. Less strict control of BG is appropriate for children, old age, repeated hypoglycemia, advanced CKD, CLD, limited
life expectancy etc cases.

Modalities of treatment:
Regimen Item
1 Life style ( Diet+ Exescise)
2 LS± Metformin or other Sensitizer
3 LS± Metformin+ Secretagauge
4 LS+ Insulin ± sensitizer± OAD
5 Other regime(GLP-1, DPP4 i ) ± OAD/Insulin
6 Insulin
LS= Lifestyle OAD= Oral Anti Diabetic Drugs

1
** Guideline for initiation of treatment for uncomplicated and non-pregnant T2DM
Category Blood Glucose Treatment
A FBG<10 mmol/L , RBS <14 mmolL/L Life style ± Metformin
HbA1c < 8%
B FBG 10- 14 mmol/L , RBS 14-17 mmol/L Life style ± Metformin + SU
HbA1c 8 -10% (Sulphonylurea)
C FBG >14 mmol/L, RBS>17 mmol/L Life style + Insulin
HbA1c >10%
N.B. Consider contraindication and side-effect of a drug before selection and also cost
Drugs for diabetes
Oral : Secretagouge (Sulphonylurea): Gliclazide, Glimiperide, Glipizide, Glibanclamide;
Sensitizer: Metformin, Pioglitazone
Injectable: Short acting; Intermediate acting, long acting and Premixed
Type 1 DM and GDM: Start insulin

Who should be tested/ screened for diabetes: (High risk subjects, even asymptomatic)
[Preferably by OGTT]
ƒ Age > 35 years
ƒ Obesity, Sedentary life style, BMI> 23 kg/m2 (Asian)
ƒ Family history of diabetes mellitus or prediabetes
ƒ Bad obstetric history /GDM/ Delivery of large baby >4 Kg
ƒ Hypertension/ Dyslipidemia/ IHD
ƒ PCOS
ƒ Chronic illness

2
Diabetes Management Algorithm

Diabetes Diabeticc Emergency


Suspected
Polyuria,
Polydipsia,
Polyphagia,
Weight loss,
Gen weakness Hypoglycemia Hyperglycemic Crisis (Usually RBS ≥ 24 mmol/L)
+ RBS > RBS <3.5 mmol/L), Sweating,
11.1mmol/L palpitation, restlessness, hunger,
headache, confusion, convulsion,
Or Known abnormal behavior, and coma
diabetes Diabetic Ketoacidosis (DKA): Hyperosmolar hyperglycemic state
Altered consciousness, (HHS)/ HONK:
Dehydration, Tachypnoea, Low Clinical features similar to DKA but
BP, Tachycardia Very high blood more marked hyperglycemia and
glucose, Ketonuria, Low dehydration without ketonuria. Usually
Conscious Unconscious bicarbonate in serum occurs in elderly type 2 DM patients

Start IV Normal saline: 1L


Oral Glucose/ in 1st 1/2 h. Then 1 L in Start IV Normal saline: 1L in 1st
* Sugar/Honey/ Intravenous next 1 h. Then 1 L in next 1/2 h. Then 1 L in next 1 h. Then
1 L in next 2 h and so on. Start
Any Glucose 2 h and so on. Start short
Guid short acting insulin 10 unit IM stat
eline carbohydrate acting insulin: 10 units IM and 6 units IM hourly. More fluid
for stat, followed by 6 units IM is required than DKA.
initiat hourly
ion of
treat
ment
Repeat Follow
RBS up or
after 15 Refer
Refer
mins to Refer
&Follo to secon to
w up second secon
ary or dary
tertiary or dary
centre tertiar or
y tertiar
centre y
centre

Blood pressure, weight and Foot examination … Every visit


Creatinine, SGPT, Lipid profile at diagnosis and according to indication
ECG … Yearly and on demand
Monitor Retinopathy, Nephropathy, Neuropathy.. Yearly

For maintenance therapy of previously diagnosed diabetic patients, follow


** Guideline for initiation of treatment for uncomplicated and non-pregnant T2DM

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