APPROACH TO A
By Dr. Pushpendra Vyas.
Guided by Dr. Rakesh Gupta sir.
INITIAL MEDICAL EVALUATION
1. Classify diabetes
2. Detect complication
3. Review previous treatment & risk factor
control in established case
4. Assist in formulating a management plan
5. Provide a basis for continuing care
COMPONENT OF MEDICAL EVALUATION
Physical examination- Weight , Blood
pressure, Foot examination .
Lab evaluation- FBG, HbA1c, Lipid profile,
Renal function, Urinalysis, Microalbuminuria
Referrals- Retinopathy, Neuropathy,
WHAT IS OUR AIM :-
1. ACHIEVE HBA1C GOAL OR FBS OR
OGTT OR PPG GOAL
2. PREVENT & DELAY LONGTERM
MACRO & MICRO - VASCULAR
3.INCREASE LIFE EXPECTANCY
TWO TYPE OF APPROACH
1. NON PHARMACOLOGICAL .
2. PHARMACOLOGICAL .
1. NON-PHARMACOLOGICAL .
It contain all action except drugs
1. Diabetes patient education
2. Medical nutrition therapy
3. Exercise or workout
4. Reduce risk factors like smoking,
obesity , alcohol ,sodium
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
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 THERAPY
Basic principles are –
1. Decrease in saturated fat
2. Decrease in simple carbohydrates
3. Substitute with complex carb.
4. Increase in dietary fibers.
5. limiting alcohol consumption
6. 2 gm of protein/kg bw to minimize nitrogen loss
7. Consumption of high calorie snacks or sugar rich
beverages should be discontinued .
8. Consumption of three main meals a day with 1 or 2
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
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 .
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 .
BMI should be less than 23 kg/m2 in indians
Diet & food based therapy
Pharmacotherapy drugs like orlistat(decrease
fat absorption),phenteremine (appetite
,naltrexone(reduce foodintake) ( USFDA
approved ) others are metformin , glp-1 agonist ,
dpp-4 inhibitors .
OTHERS INCLUDES :-
2. PHARMACOLOGICAL APPROACH
Type 1 DM
Type 2 DM
TYPE 1 DM PHARMACOTHERAPY
1. Insulin insulin & insulin .
Insulin must be prescribed in basal bolus
There is no other drug use in type 1 dm
2. 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 .