APPROACH TO A DIABETIC PATIENT

By Dr. Pushpendra Vyas.Guided by Dr. Rakesh Gupta sir.

DIABETESINITIAL MEDICAL EVALUATION

1. Classify diabetes2. Detect complication3. Review previous treatment & risk

factor control in established case4. Assist in formulating a management

plan5. Provide a basis for continuing care

COMPONENT OF MEDICAL EVALUATION

Medical history Physical examination- Weight , Blood

pressure, Foot examination . Lab evaluation- FBG, HbA1c, Lipid

profile, Renal function, Urinalysis, Microalbuminuria

Referrals- Retinopathy, Neuropathy, Nephropathy,

DIABETES MANAGEMENT

WHAT IS OUR AIM :-1. ACHIEVE HBA1C GOAL OR FBS OR OGTT OR PPG GOAL2. PREVENT & DELAY LONGTERM MACRO & MICRO - VASCULAR COMPLICATION3.INCREASE LIFE EXPECTANCY

TWO TYPE OF APPROACH

1. NON PHARMACOLOGICAL .2. PHARMACOLOGICAL .

1. NON-PHARMACOLOGICAL . It contain all action except drugs

therapy1. Diabetes patient education2. Medical nutrition therapy3. Exercise or workout4. Reduce risk factors like smoking,

obesity , alcohol ,sodium (2300mg/day)

DIABETES PATIENT EDUCATION First demonstrated by miller & Goldstein in 1972 Objective is to make patient understand & handle acute &

chronic complication which are 50-80% preventable . It Significantly reduce hypoglycemic event , ketoacidosis , leg amputation & improve diabetes control .

Impossible to manage diabetes without good awareness . No diabetes educators in india . At community level promotion Teaching a teacher - In India even physicians doesn’t receive

education program . There should be a curriculum to train teacher includes nutritional & physical advice , home based method of monitoring blood glucose , injection techniques, all acute & chronic complications .

MEDICAL NUTRITION THERAPYBasic principles are – 1. Decrease in saturated fat2. Decrease in simple carbohydrates3. Substitute with complex carb.4. Increase in dietary fibers.5. limiting alcohol consumption6. 2 gm of protein/kg bw to minimize nitrogen loss7. Consumption of high calorie snacks or sugar rich

beverages should be discontinued .8. Consumption of three main meals a day with 1 or 2

snacks .

BROCA’S INDEX & BMI Ideal body weight of a pt may be

assessed using broca’s index Height in cms -100 = desirable body wt

in kg . Maintaining wt at 90% of desirable wt may be preferred in pt with diabetes .

BMI = (wt in kgs )/(ht in mtr)^2

HOW WE DETERMINE DIET PRESCRIPTION

DETERMINE EXERCISE PRESCRIPTION

Normal prediabetic patient ADA recommond 150min/week aerobic or jogging activity

Diabetes with obesity more than 30 BMI recommondation of 300min/week aerobic with some vigorous exercises .

SMOKING CESSATION One of the most cost effective

interventions in pt with DM . Ask history about duration, frequency &

types of smoking & tobacco . Regardless of patient’s willingness , offer

advice & information about the effects & complications related to smoking .

Once pt prepare for quitting give them a favourable environment .

CONTROL OBESITY BMI should be less than 23 kg/m2 in indians Diet & food based therapy Exercise Behavioral therapy Pharmacotherapy drugs like orlistat(decrease fat

absorption),phenteremine (appetite suppressant) lorcaserin(satiety) ,naltrexone(reduce foodintake) ( USFDA approved ) others are metformin , glp-1 agonist , dpp-4 inhibitors .

Bariatric surgery

OTHERS INCLUDES :- Alcohol cessation Psychological assessment Immunization

2. PHARMACOLOGICAL APPROACH

Type 1 DM Type 2 DM

TYPE 1 DM PHARMACOTHERAPY1. Insulin insulin & insulin . Insulin must be prescribed in basal bolus

regimens There is no other drug use in type 1 dm2. Pramlintide – USFDA approved delayed gastric emptying , blunt

pancreatic secretion of glucagon & enhance satiety . Induce wt loss & lower insulin dose . Only indicated in adult .

TYPE 2 DM PHARMACOTHERAPY These includes OHA in monotherapy or

in combination with other OHA or INSULIN .

THANK YOU