Diabetes mellitus in District

Hospital

AP Dr. Khin Swe Ei

MBBS MMedSc.(Anaes)
Dip.STD/AIDS(BKK)
Prevalence
The National Health & Morbidity Survey 2011 (NHMS) reported
diabetes prevalence figures of 15.2% and 20.8% for adults above the age of
18 and 30 years respectively in Malaysia.
Among adults above the age of 18 years old, the prevalence was
highest in the Indians (24.9%) followed by Malays (16.9%) and Chinese
(13.8%).

Of concern, 52% of those with diabetes above the age of 18 years were
unaware of their diagnosis.
In terms of diabetes control, only 23.8% of patients in primary care and
12.7% in tertiary institutions were able to achieve their specified glycemic
targets.
*** next survey in 2015: no data yet.
Symptoms of Diabetes
Majority are asymptomatic.

Common symptoms include polyuria, polydipsia, lethargy, blurring of vision, increased risk of
infection and weight loss.

Complications
Acute Complications
a) Hypoglycaemia
b) Hyperglycaemia

Chronic Complications

a) Macrovascular
(e.g. cardiovascular, cerebrovascular, peripheral vascular diseases)

b)Microvascular (e.g.nephropathy, neuropathy and retinopathy)

 Screening for Diabetes
To detect pre-diabetes and diabetes among the general population and in specific high-risk population groups and to ensure
timely and appropriate intervention.

Any individual who has symptoms suggestive of diabetes (tiredness, lethargy, polyuria, polydipsia, polyphagia, weight loss,
pruritus vulvae, balanitis) must be screened.
Testing should be considered in all adults who are overweight or obese (BMI 23 kg/m2 or waist circumference 80 cm for
women and 90 cm for men), and have one or more additional risk factors for diabetes:
First degree relative with diabetes
History of cardiovascular disease (CVD)
Hypertension (BP 140/90 mmHg or on therapy for hypertension)
Impaired glucose tolerance (IGT)or impaired fasting glucose (IFG)on previous testing
High density lipoprotein (HDL)cholesterol<0.9 mmol/L or triglycerides (TG)>2.8mmol/L
Physical inactivity
Other clinical conditions associated with insulin resistance (e.g. severe obesity and acanthosis nigricans)
Women who delivered a baby weighing >4 kg or were diagnosed with gestational diabetes mellitus (GDM)
Women with polycystic ovarian syndrome (PCOS)
Patients with schizophrenia or Bipolar disorder

In those without these risk factors, testing should begin at age 30 years. If tests are normal, screening should
be done annually.
Schedule Screening should be done annually.
Screen every two years starting at the age of 10 years old or at onset of puberty if puberty occurs at a
younger age.
Screening Test
Screening can be done by measuring either venous or capillary blood using glucometer. Tests that can be
performed are A1c, oral glucose tolerance test (OGTT), fasting blood glucose or random blood glucose
 *IFG=impaired fasting glucose FPG 110 and <126mg/dl
*IGT= impaired glucose tolerance 2-h PG140 and <200mg/dl
**Diagnosis must be confirmed by measurement of venous plasma glucose.
Venous sample for plasma glucose should be taken prior to initiating therapy.

Table 2: Diagnostic Value for T2DM based on Venous Plasma Glucose

FASTING RANDOM
Venous plasma glucose 7.0mmol/L 11.1mmol/L

In symptomatic individual, one abnormal glucose value is diagnostic.

In asymptomatic individual, 2 abnormal glucose values are required.
Management
In principle, all patients with diabetes should undergo lifestyle modification, which consists of
dietary therapy and increased physical activity.
The need for oral medications or insulin therapy depends on the
symptomatology,
state of glycemic control and the presence of any complications.

History
A. patients experience: symptoms. How does he interpret them
weight and his perception of ideal weight
B. If previously diagnosed; date of Dx, Medical Nutrition Rx(MNT),self management education, self
monitoring of blood glucose SMBG training, Diabetic medication
C.Past medical history concerning : acute complications, infections(Skin, vaginitis, balanitis), chronic
complications, CAD risk factors, medications (drugs which increase blood glucose-thiazides,
niiacin,steroids)
D. Health habits: tobacco,alcohol.sexual,exercise and diet history
E. Family history-genogram esp.Dm and Cardiovascular disease
F. Psychosocial history: fears about Dm,barriers to care, support systems??
Physical Exam
Height, weight, BMI,vital signs
Opthalmoscpy and visual acuity
Oral exam: periodontal disease???
Thyroid exam
CVS exam, evaluation of ALL pulses
Foot exam(using standard procedures like Carville foot screen)
Skin exam
Neurologic exam esp. peripheral sensation
Lab evaluation
-FBS, A1c
-Fasting lipid Profile
-Serum Creatinine
-Urinalysis
-Urine for microalbuminemia if urinalysis negative for protein
-Thyroid function tests
-ECG
Management plan Plan together with patient
Patient goals
Written goals for weight, Exercise and diet
Self management education
SMBG(Self-monitoring of blood glucose)
Medications
Immunizations
Agreement on follow-up plan including scheduling for next visit
Follow-up visits
Contact frequency:
daily for initiation of insulin, weekly for initiation or change of ODAs
Routine diabetic visits: quarterly for those not meeting their goals, semiannually for others
On each visit:
Assess patient perspectives of feelings, fears, ideas and questions about care, functions, expectations for the visit and care
plan
Assess treatment regime-result log of SMBG,hypogly.episodes,symptoms of complications, adjustment of regime, lifestyle
changes, medications
Physical exam
Lab evaluation
Renegotiation of treatment plan if needed
Referrals
Physical Examination

Investigation
The Team Approach in management
Important team members in the multi-disciplinary management of diabetes:
1. Primary care practitioner

2 Diabetes educator
3 Dietitian

4. Physician/endocrinologist/diabetologist

5. Pharmacist
6. Ophthalmologist and optometrist
7. Oral health professional For dental and periodontal problems
 Antidiabetic Medications
1.Oral Antidiabetic agents (OADs)
Sulphonyl ureas,
biguanides
Meglitinides
-glucosidase inhibitors
Thiazolidinediones
DPP4 inhibitors
sodium glucose transporter 2 inhibitors
glucagon like peptide 1receptor agonists
OADs can be used alone or in combinations.
Metformin is the preferred choice as first line treatment.
When indicated, start with a minimal dose, emphasize on diet and physical activity
 Diabetes medication Summary
Acarbose metformin Sulphonyl ureas Troglitazone insulin
MOA -glucodase Glucose Insulin secretion insulin sensitivity Insulin level
inhibition; decreased utilization Hepatic glucose Hepatic glucose Hepatic glucose
C/H absorption Hepatic glucose production production production
production
Indication Early stage to prevent Overweight Early stage with Individuals with Adequate control not
post prandial glucose individuals with residual insulin poor control on obtained with MNT
and oral agents
elevations insulin resistance secretion high doses of Late stage with
insulin decreased insulin
secretion
Risk weight low low moderate moderate high
gain
Risk low Low moderate low high
hypoglycemia
Cost $$$ $$$ $-$$ $$$$$$ $$
Comments Frequent GI Lactic !!Sulfa Risk of liver Requires patient
intolerance Flatulence, acidosis(life- allergy,renal/hepa damage- monitor education and
pain, threatening) tic disease LFT support
diarrhoea Renal Cost-effective Hypogly.risk
insufficiency choice in Weight gain
GI intolerance combination with
insulin
 Management of acute complications
1. Hypoglycemia

******
Symptoms of Hypoglycemia

Severity of Hypoglycemia
2. Diabetic ketoacidosis
Principles of Management
3.Hyperglycemic Hyperosmolar State(HHS)
CVRF= Cardiovascular risk factors
 CVRF
Modifiable
Hypertension (high blood pressure)
Tobacco use
Raised blood glucose (diabetes)
Physical inactivity
Unhealthy diet
Cholesterol/lipids
Overweight and obesity (Target 10% of their
baseline weight)
Non-modifiable
Age- with advancing age
Gender- More CHD in males>females.. But risk of stroke
=
Family historyfirst degree relative who has had
coronary heart disease or stroke before the age of 55
years (for a male relative) or 65 years (for a female
relative), the risk increases.
Five key behaviors to help patients becomes successful diabetes
self managers

1. Know your metabolic targets(A1C,BP and lipids)

2. Know how to achieve your targets
3. Stop smoking and alcohol
4. Take your prescribed medications
5. Be certain your HCPs understand how to successfully and intensively
manage diabetes.