August 99
Always consult your doctor before taking any advice from these pages.
Diabetes
Defined as too much of the sugar glucose ( made from dietary sugar sucrose) in the blood but often not enough in the cells themselves. The more common kind is where the patient is overweight and it can be reversed by losing weight . The main symptoms are tiredness , thirst and often recurrent infections .
It can be diagnosed by checking the blood sugar after an overnight fast of 10 hours -only water being allowed . If the sugar level is greater than 7mmol ( 9 in the elderly) per liter in a patient with thirst and polyuria then diabetes is confirmed . Non symptomatic patients need two tests
These patients can be tried for three months on a weight loss program of 2 pounds - one kilo a month to get their body mass index (weight in kg divided by height squared in meteres) below 27 . Excercise helps a lot by burning off some of the sugar and smoking should be stopped .
They are encouraged by the dietician to take 50% of the diet as high complex starches eg bread , potatoes, rice, chapatis , pasta , 35% or less as fat eg olive oil and to cut out the solid -highly saturated fats, the rest as protein -pulses , beans, fruits etc . A moderate amount of sugar in cakes etc . can be eaten . Special diabetic foods are not necessary . Meals are taken three times a day with snacks of fruit or biscuit at mid morning and mid afternoon to prevent hypos . Alcohol is limited to 21 units a week for men or 14 for women.
Those who at the end of three months still remain above 7 or have ketones in the urine can be tried on oral drugs after checking kidney and liver function tests .Those with FBS more than 15 may be tried earlier . Meformin is used in the overweight at a starting dose of 500 daily with food .It increases glucose uptake in the muscles and cuts appetite. Glicazide in the normal weight , it increases insulin output from the pancreas and can be combined with metformin . Insulin is a hormone which promotes sugar movement from blood to the cells . Both drugs may be combined . Those who cant tolerate these may take acarabose ( glucobay) 50mg daily as well which cuts down on glucose absorption in the gut but can lead to wind. All drugs can be increased at 2 monthly intervals until control is achieved.
Asians are five times more prone to diabetes and need to excercise 20 mintues three times a week hard enough to cause sweating and to cut down on ghee and other animal fats . It is most important for diabetics to have normal blood pressure and ace inhibitor drugs even it is thought in those with normal pressure are very useful and prolong life .
Patients with a fasting blood sugar between 6 and 7 are treated with diet and rechecked at 3 months . A 2hr post meal sugar if higher than 11 indicates that they may need oral drugs .
Those with FBS of over 6 and below 7 may need yearly glucose tolerance tests where the P is given 75g of glucose to drink after an overnight fast and 2 hr blood sugar should be less than 7.8 . These patients should modify their diets to prevent diabetic complications. Those whose fasting blood sugar ( FBS) is still not controlled or complain of lethargy or have ketones in the urine are put by the hospital on insulin injections - human or rarely pork or beef . They are started on intermediate ( cloudy) insulin 10 units twice a day given 15 minutes before a meal ,starting at 0.25u/kg/per day , increased by 2 units every 3 days till control is good usualy 1u/kg/dya max . If the 2hr sugar level after a meal stays high above 10 , soluble( clear) insulin which has an osnet at half hour and peak action 2 hs is added until good control is achieved throughout the day - less than 7.8 at bedtime . Usually 60% of the total dose is taken in the morning . A premixed 30%soluble and 70% intermediate can be used also as a single doseat night . Some patients may need premixed in the evening and soluble insulin before each meal . Nightmares may be due to nocturna hypoglycaemia and need reduction of the evening dose ie in poor control adjust the just prior insulin dose eg if luch time high sugar adjust the morning dose .Metformin can be used in obese patients in addition to orevent wt gain . After injecting air in the bottle draw up the soluble clear insulin first and inject subcutaneous just under the skin .
a few elderly patients can be managed on very long acting lente insulin once a day . The British guidelines recommend that the following values not be exceeded in good control..
FBS 8 , 2hr 10 , Hba1c 7.5 (this gives a measure of glucose control over the previous 60 days so can be done after evry three months ) , glycosuria 0.5% , total cholestrol 6.5 , LDL 4.1 , triglycerides 2.2 , BMI 27 . HDL should be more than 1.
It is very important to keep yearly checks on the eyesight . If it starts to get cloudy or blurred it may mean macular problems and the sharpness acuity (checked by Snellen -the top number is the distance to the P , the bottom number is the line on the chart the P can read eg 6/9 means he can read the 9 line at 6m or 18ft or if less than 6/18 use 3m chart or finger or hand movements at 1m -corrected by glasses or pin hole if necessary ) drops more than 2 units in the Snellen charts then the doctor can examine the back of the eye with an opthalmoscope . First he will examine the optic disc where the blood vessels come into the eyeball , then the nose and temple sides and the macula which is 2 optic disc width lateral to the disc and finally the state of the blood vessels and background .
Features to look for are hard bright yellow exudates due to lipoprotein leakage from the capillaries . Bleeding can cause soft fluffy ones due to blood leakage especially at the macula where the eye sees the sharpest , can be seen by the P (patient ) looking directly at the opthalmoscope . The blood vessels also need to be checked for lots of new tiny wiggly ones -called proliferative which tend to grow in to the front of the retina and pull it away from the back or for dilatations called microaneurysms or for red dark bleeding into the background . All these may need urgent laser treatment . Blood vessels are seen better by the green light .
Cataracts is clouding of the lens and can be spotted by defects in the red reflex. Detachment of the film -retina lining the back of the eye is also more common and can be reported by the P as dark curtain areas and need urgent treatment.
Damage to the kidneys is signified by leak of protein so the urine has to be checked yearly for albuminuria and those who have more than one plus need to have ace inhibitors . Microalbuminuria has to be detected by special dipsticks or by cratinine/albumin ratio of more than 3.5 in the urine and is an early sign of damage . Once the creatinine rises above 200 damage can proceed fast and the patient may need a translplant . Blood pressure must be kept below 140/90 with aceinhibitors preferably or by alpha blockers or calcium antagonists.
Diabetic neuropathy may be of the larger nerves -sensory in the legs causing pain and numbness and tingling which may need aspirin or codeine or of the autonomic nerves causing dizziness on standing up -postural hypotension , night time diarrhea , sweating after meals , impotence etc. and may need tighter control of sugar levels .
Problems with nerves and blood supply tends to make the feet warm ,dry , thin skinned and prone to ulcers ( which may need Scotchcast boots ) and P may have numbness , tingling and infections may spread rapidly .Chiropodic care is essential . Doppler may be needed to study blood flow and antibiotics are used early . Checks include 128c vibration test , fine touch and pin prick and knee and ankle eflexes
Fat build up in the large arteries may cause strokes ( doppler often shows more than 70% blockage) , silent ischaemic heart disease and legs - pain in the calves on walking .
Diabetics need to keep their total cholestrol below 6.5 with the good cholestrol - HDL which is raised by excercise above 1.0 . After a heart attack a level close to 4.8 is advised . After checking for low thyroid , drugs such as thiazide, betablocker use , kidney damage and excess alcohol Statins are used for raised cholestrol and fibrates for isolated raised triglycerides above 4.5 .
Infections of the kidney or lung can cause rapid rise in glucose and dehydration. If the blood glucose is above 20 or there are ketones in the urine then hospital care is advised . Otherwise extra soluble insulin 6 units or so , antibiotics and encouraging maximal sweetened fluid -often ORT -oral rehydration therapy -8 spoons of sugar , one of salt in a litre of boiled water -uptake is advised . Insulin should never be stopped as cells can die if glucose cant get into them .
Low blood sugar which can cause aggressiveness , confusion and collapse is a danger in those who are too tightly controlled . A blood sugar test on fingerprick can be done but in doubtful cases it doesnt hurt to give a sweetened drink of cola , orange juice or two spoons of sugar or jam and then a long term sugar source like bread or a full meal . In emergency cases glucagon 1mg im or 20mls of 50% dextrose iv is used . Glucose may have to be run at a higher level of 7-11.
Ps may report not being able to get or maintain an erection. Normally this is caused by release of nitric oxide in the venous spaces of the penis and this maintains smooth muscle relaxation allowing blood to build up . Lack of testosterone or very rarely pituatary tumor can cause it but mainly its due to nerve damage or lack of blood flow . Smoking should be stopped .
A vacuum pump followed by a constricting elastic band can help or the instillation of a drug called alprostadil which stops the breakdown of nitric acid products or oral Sildenafil tablets . Penile prosthetic implants are also used.
Indo-asians are at high risk of diabetes and need to eat less ghee and butter and sugary foods and to quit smoking and excercise more and reduce weight . Early use of Insulin and metformin may help .
Before getting pregnant diabetic women need to get glucose levels under strict control with insulin , pre meal 6 and post meal 8 max and take folic acid . Non diabetic women who are obese or have had large babies or have glucose in the urine more than once during pregnancy need to be tested for fasting blood sugar at 28 weeks and sent to special diabetic and obstetric clinics . Diet is used to keep blood sugar below 8.
Children often contract the insulin dependent type of diabetes which needs injection and this presents with thirst and weight loss but also often with ketoacidosis - vomiting ,abdominal pain , dehydration,fast breathing and ketones in the urine and needs hospital admission.
After excercise Ps may go hypoglycaemic and need sugary drinks . For long games over half an hour they should have complex carbohydrates like rice , bread , potato beforehand . Excercise 20 minutes three times a week enough to make one sweat -eg treadmill , squash , very fast walk is good . Travellers may need extra soluble insulin with the extra meals .
Those on insulin need to inform the DVLA , carry snacks in cars for hypos and are barred from the Police and armed forces and HGV driving .
Notes- The young insulin dependent type -IDDM is often due to a viral attack on the beta cells of the pancreas -these produce insulin and one method being experimented is beta cell transplants . The older diabetes non insulin dependent -NIDDM - os often due to insulin insensitivity of the body cells which can often be reversed with weight loss. Newly diagnosed older diabetics need a 3 month trial of weight loss with a calorie controlled diet and excercise before starting oral drugs . FBS is checked after the first week and then every 2 weeks . if the FBS stays above 15 after one week .Long acting drugs like glibenclamide are best avoided in the elderly and tolbutamide is preferable as there is less risk fo prolonged hypoglycaemia and confusion . Lack of response to oral drugs may mean poor beta cell reserve and may need insulin . Metformin is preferable in obese Ps which may be combined with insulin or acarbose They also need blood tests for lipids , electrolytes for kidney damage , check on blood vessels , eyes , recognition of hypos etc. Lethargy and ketones in the urine may indicate a need for insulin . Atorvastatin is useful if total cholsetrol is more than 6.5 and LDL/HDL ratio is more than 5 Nightmares and headaches may be due to hypoglyacaeima and need 3am blood checks . Insulin doses should not exceed 1u/kg/day or a cause must be found eg low thyroxine.
Women with IDDM should be controlled well before conception . There is a 5% risk of perinatal mortality -five times higher than normal and an increased risk of the child being a diabetic .
Diabetic Ps need regular clinic checks from a checklist for BP, foot problems, weight , peripheral pulses , urine for protein , examine injection sites , visual acuity , lipids , smoking , fundii etc.
ps should consult their doctors if the finger prick blood sugar stays above 20 for 4 days .
Oin prick and vibrations senses should be tested as they are the first to go .Acei do not work so well in afrocarribeab=ns bb can mask hypos.acei need renal function checking after two weeks in case there is renala artery stenosis .
asians are especially at risk of Coronary disease if they have NIDDM , low HDL , insulin resistance , hypertension and high triglycerides
Hypos require 20g of glucose to correct and alos a toast or cereal bowl for longer term . Excercise hpos can occur for 122 hrs , tight control can lessen sensitivty to hypo symptoms and patients on glibencalmide and chlorpropamide are at risk for yupto 48hrs .
During illness temp high sugars maybe acceptable but over 20mmol for greater than 24 hours will need insulin .
Diabetic Ps are checked yearly at least for complications and monitoring needs. Although intensive control - Hba1c of 7 or less , multiple daily injections and monitoring reduces the incidence of damage to eyes and kidneys markedly ,it also increases the risk of hypos and may not be sutiable in the elderly , children or those with severe disease effects.
The follwoing usually need urgent referral ketoacidosis , vomiting and dehydration , prolonged hypo , visuala loss . Also new foot ulcers or retinal changes . Pregnant women pre conception or at 5 weeks .