Diabetes Mellitus

Dr Hiew Fu Liong
Jabatan Perubatan
Hospital Kajang
 PREVALENCE OF DM
NHMS I (1986) NHMS II NHMS III NHMS III
(1996) (2006) (2006)
Age group ≥35 years ≥30 years ≥18 years ≥30 years
Prevalence 6.3% 8.3% 11.6% 14.9%
Known diabetes 4.5% 6.5% 7.0% 9.5%
Newly diagnosed 1.8% 1.8% 4.5% 5.4%
Impaired Glucose Tolerance
* / Impaired Fasting
4.8% * 4.3% * 4.2% ** 4.7% **
Glucose **

In 2006, there is an estimated 1.5 million Malaysians age 18 years and above living with
diabetes.
 CVD Risk in DM
§
Any CVD event §

Stroke
§
Intermittent claudication †

†
Cardiac failure §
†
CHD ‡

‡
MI §

Angina pectoris Men with diabetes

Sudden death * Women with diabetes
N/A
†
Coronary mortality †

1 2 3 4 5 6
Age-adjusted risk ratio
(1 = risk for individuals without diabetes)

Adapted from Kannel WB et al. Am Heart J 1990; 120: 672–6.

 12
,0
00
29
,0
00
43
,0
00
65

2.4%
,0
00
86
,0
00
14 Overall Prevalence 11.55%
8,
00
0
19
6,
00
23 0
8,
00
22 0
8,
00
0

Burdens
16
0,
00
0
12
8,
00
0
Prevalence

74
,0
00
39
,0
00
19
,0
00
DM management
in ward
 Problems

•
Difficult Control Sugar
•
Diabetes Ketoacidosis
•
Hyperglycemic Hyperosmolar State (HHS)

Hypoglycemia
Medical Nutrition
Therapy
 Medical Nutrition
•
Medical Nutrition Therapy
•
Preventing DM, managing DM and delaying complication
•
Proper diet
•
To attain and maintain blood sugar
•
Blood pressure
•
Lipid profile
•
Educator
•
Doctor,
others Nurse, Diabetic Nurse, Dietician, Pharmacist and
Assess knowledge, skill, attitude, health beliefs others.
 Medical Nutrition

•
Nutrition counselling by a dietician
•
Individualised according to
•
Nutrition needs

•
Severity of disease

•
Cultural preferences

Willingness to change
 What to do?

•
Rujuk dietician.
•
Ingatkan Dr isi borang
•
Order diet yang betul.
•
Semuanya low- Low sugar/salt/cholesterol
•
Check pt’s food.
•
Makanan manis terutamanya
Label “Diabetic Diet”.
Blood Glucose Monitoring
 GM Check
•
Do not require alcohol swab unless patient is
“dirty”
•
Alcohol influence GM reading.
•
Wait till alcohol dry if alcohol swab is used.
•
Use proper GM lancets.
•
DO NOT USE BLOOD TAKING NEEDLE.

Less painful sites.

 GM Monitoring

•
Patient on Insulin and OHA
•
Critically ill patient

Frequency depends on the glucose status,

glucose goals and mode of treatment.
 GM Monitoring

Breakfast Lunch Dinner

Mode of
Treatment Post /
Pre Post Pre Post Pre
Pre-bed

Diet Only √ √ √ √

Oral anti-
diabetic √ √ √ √
agent

Insulin √ √ √ √ √ √

√ Recommended timing of SBGM

√ Optional timing of SBGM
 Target GM

Levels
Glycaemic Control *
Fasting 4.4 – 6.1 mmol/l
Non-fasting 4.4 – 8.0 mmol/l
HbA1c  6.5 %

* Glycaemic target should be individualised to minimise risk of hypoglycaemia.

 GM Monitoring
Basal Bolus Insulin Regimen
 Problems
•
Hypoglycemia
•
Whipple’s triad
•
Symptoms consistent with hypoglycemia, a low plasma
glucose level and relief of symptoms when plasma
glucose is raised
•
Symptoms
Shaking, sweating, palpitation, hunger, reduce
consciousness, coma.
GM @ 7 am 3.5 mmol/L
Apa nak buat ?
 Ask yourself
•
Hypoglycemia - Symptomatic ?
•
Why patient develop hypoglycemia ?
•
Poor oral intake/ overdose insulin/OHA / Liver / Sepsis
•
Shall i give the insulin?
•
Asymptomatic/taking orally - Give insulin
•
How much to give?
•
Actual dose. May 1/2 the dose depends on clinical
judgement
When should i repeat the GM?
If GM high
> 12.0 mmol / L
 Top Up scale
•
Every 4 units sugar above target GM - add 2
unit S/C Insulin
Levels
Glycaemic Control *
Fasting 4.4 – 6.1 mmol/l
Non-fasting 4.4 – 8.0 mmol/l

•
E.g S/C Actrapid 10 unit TDS
•
10 - 13.9 ---- Add 2 unit
•
14 - 17.9 ---- Add 4 unit
18 - 21.9 ---- Add 6 unit
 Sekiranya tak pasti
Panggil Dr In-charge
NB: Jangan “omit” insulin without conclusive reason.
 Insulin Infusion

•
Ordered in DKA/HHS/ill patient/Pending surgery
•
OHA may not be adequate in maintaining euglycemia.
•
Very high sugar that need to be controlled fast
•
Patient kept NBM / poor oral intake
•
S/C Insulin is not suitable

If patient takes orally--- Insulin infusion is not helpful.

 DKA/ HHS
•
Sliding scale Vs Insulin infusion
GM (mmol/L) Insulin (Unit)

>20 6

17-19.9 5

14-16.9 4

11-13.9 3

8-10.9 2

5-7.9 1

Insulin infusion is constant insulin unit throughout

 DKA/ HHS
•
Problems
•
GM > 15 mmol / l -----Normal saline

•
GM < 15 mmol / l -----Dextrose 5%

•
Hourly GM monitoring
•
Sliding scale yang rumit

GM masih tinggi dengan sliding scale.

 HHS

•
Need very close GM monitoring.
•
Sugar falls 5 mmol / hour
•
Patient is very sensitive to insulin

Watch GCS closely

GM chart - Mesti
di-ISO-kan
 Conversion

•
Overlap IV insulin with S/C insulin
•
Inject S/C Actrapid 30 mins before meal.

Insulin infusion off 30 mins after meal for

uninterupted sugar level.
 Insulin Injection

•
Pharmacist
•
DRC
•
Trial of insulin injection in ward
•
Let patient / family inject @ ward

Home glucose monitoring

Thank you