This document provides guidance on managing patients with diabetes mellitus. It discusses conducting clinical assessments focusing on eyes, hands, blood pressure, feet, and insulin injection sites. Management aims to control blood glucose, lipids, weight, and blood pressure through lifestyle education, medication, monitoring, and documentation. Special situations like surgery, illness, fasting, and religious fasting require modified care. Patients in poor control or with complications should be referred to hospitals.

1. Session 4.2: Basic Management
of Diabetes Mellitus
Module 4: Management of
Patient with Diabetes
Mellitus

2. Learning Objectives
• At the end of this session participants are
expected to be able to:
• Conduct clinical assessment of patients with
diabetes mellitus
• Manage patients with diabetes mellitus
• Document patient management card and
related monitoring tools

3. Learning Objectives (2)
• Provide health education and adherence
counselling to patients and treatment
supporter
• Manage diabetes mellitus in special
situations
• Implement referral pathway for patients
with diabetes mellitus

4. Clinical Assessment of Patients with
Diabetes Mellitus (2)
During the Initial Visit:
• Take a detailed history
• Perform physical examination
• Perform Biochemistry
• Make a proper diagnosis

5. Clinical Assessment of Patients with
Diabetes Mellitus
 When performing clinical assessment
focus on the following areas:
 Eyes (cataracts, visual acuity, fundoscopy)
 Hands (cheiroarthropathy, Dupuytren’s
contracture )
 Blood Pressure
 Insulin Injection sites (Lipodystrophy)
 Feet (sensation, pulses, ulcers)

6. Activity:Buzzing
• What is the management of a patient with
diabetes?

7. Management of Patients with
Diabetes Mellitus (1)
• The aims of management are to:
 Reduce symptoms and improve quality of life
 Detect other risk factors early
 Control blood glucose, lipids, weight and
blood pressure
 Prevent complications including
cardiovascular disease
 Reduce mortality
 Diabetes can be controlled if the patient
follows lifestyle advice (diet and activity) and
all of the recommended drugs

8. Management of Patients with
Diabetes Mellitus (2)
• Management Strategies to always include:
• Giving health education on healthy eating and
lifestyle at each visit
• Reviewing self-care at each visit: self-
monitoring improves therapy
• Determine and agree with the patient on the
correct treatment
• Record keeping is critical: both patient
records and clinic records

9. Activity: Individual Exercises
Chose the appropriate diagnosis from
the following:
 Peter still has pre-diabetes
 Peter has developed diabetes
 What is the next stage in his treatment?
(bear in mind he has already followed
lifestyle advice for one year)

10. Activity: Individual Exercises (2)
 Which medication should you commence him
on?
 How will you advise him about dosing?
 What side effects should you warn him
about?
 How soon should you arrange his next
appointment?

11. Management of Diabetes
• The goal of diabetes treatment is to maintain
the Blood Glucose as close to normal as
possible and avoid Hypoglycemia
• All patients with T1DM require insulin
therapy and early achievement of near
normal HbA1c has been shown to
• preserve residual beta-cell function
• reduce long –term complications

12. Management of Diabetes
• The Diabetes Control and Complications
Trial (DCCT) and its follow-up study have
shown that every 1% reduction in HbA1c
reduces:
• retinopathy by 33%,
• microalbuminuria by 22% and
• neuropathy by 38%

13. Management of Severely ill Patients
 Refer to hospital severely ill patients or if:
• Altered consciousness with too low/high glucose
• Chest pain and/or breathlessness (angina, heart
attack or heart failure)
• Slurred speech, one-sided weakness
(stroke/transient ischaemic attack)
• Severe infection including necrotic or
gangrenous foot ulceration
• Newly diagnosed children or suspected newly
diagnosed type 1 diabetes, especially if
ketonuria and/or vomiting
• Sudden loss of vision

14. Activity:Brainstorming
• What are the tools used in documenting
patient management information

15. Documentation of Patient Management
Card & Related Monitoring Tools
 Every visit, record in a diabetes
management card or register:
 The lifestyle advice given on diabetes
 The blood glucose and other laboratory results
 The drug regimen
 The number of tablets per dose for each drug
or the insulin dosage
 Such records enable better monitoring and
evaluation of chronic conditions like
diabetes

16. Activity: Role Play
 Educating for Patient on Diabetes mellitus
Disease
 REFER to handout 4.2.1 Scripts for a role
play

17.  All patients who have been diagnosed with
diabetes (and associated conditions such as
hypertension) must be educated on:
 Diabetes and its complications
 Need of supervision and support of treatment
 All patients should identify an appropriate
treatment supporter
 The treatment supporter should be educated
on diabetes and how to support treatment
Educating the Patient about Diabetes

18. Educating the Patient about Diabetes (2)
 Ask about their existing knowledge about
diabetes, exploring any misunderstandings
 Through questioning and discussion, find out
the state of mind following diagnosis
 Counsel them, starting from this level of
knowledge
 Give information to suit the personal and
social situation of the patient
 At diagnosis, the patient may be “numb” and
in denial, and not take in very much

19. Activity: Brainstorming
• What are the special situations in
diabetes?

20. Surgery in Diabetes Mellitus
• General measures
 Correct pre-operative management depends
on type of surgery (major or minor), type of
diabetes and recent diabetes control
 Surgery should be delayed if possible if
HbA1C >9% or blood glucose fasting >10
mmol/l or random glucose > 13 mmol/l
 Screen for nephropathy, cardiac disease,
retinopathy and neuropathy and inform
surgical team

21. Surgery in Diabetes Mellitus
• If diabetes is well controlled and surgery
is minor:
 If on diet or oral agent therapy, omit therapy
on morning of surgery and resume therapy
when eating normally
 For T1DM, continue with normal dose of
insulin

22. Surgery in Diabetes Mellitus
• If on insulin therapy or poor glycemic
control or major surgery:
• Use continuous IV insulin infusion
• Start at 8 am and stop when eating normally
• Monitor blood glucose before, during and after
surgery: aim for blood glucose levels of 6–10
mmol/l

23. Surgery in Diabetes Mellitus
• For all major surgery once oral intake is
restricted, start an IV regimen to ensure
availability of insulin to avoid lipolysis and
ketoacidosis
• Add short-acting insulin (16 Units) + KCl
10mmol/L to 500mls of 10% dextrose
• Infuse at 80ml/hr IV
• If obese or initial blood glucose is high
(>14mmo/l) consider higher dose of insulin
(20 Units)
• If very thin or usual insulin dose is very low
consider lower dose (12 Units)

24. Surgery in Diabetes Mellitus
• Monitor blood glucose levels hourly (aim
for 6–10 mmo/l)
• If blood glucose is low or falling reduce dose
by 4 Units
• If blood glucose is high or raising increase
dose by 4 Units

25. Surgery in Diabetes Mellitus
• Patients receiving Multiple Daily Insulin
Therapy (MDIT) should receive preoperative
basal insulin dose without interruption in the
perioperative period
• When oral intake is restricted, regular insulin
may be given every 4–6 hrs to control
hyperglycemia
• When a diet is tolerated, the MDIT regimen
should be resumed

26. Surgery in Diabetes Mellitus
• Post operatively: To 1 litre of 5–10%
dextrose add KCl 20ml + 2/3 of total daily
dose of insulin and infuse over 8hrs: repeat
until able to take orally
• Continue the infusion until 60 minutes after
the first meal
• Resume usual therapy after first meal
• Check electrolytes daily

27. Activity: Buzzing
• What is Sick day management of diabetes
mellitus?

28. Sick Day Management of Diabetes
Mellitus (1)
 Many illnesses especially those associated
with fever, raise blood glucose levels
because of the effect of stress hormones
 The increased resistance to insulin can
increase ketone production
 When vomiting occurs in a child with diabetes, it
should always be considered a sign of insulin
deficiency (impending ketoacidosis) until proven
otherwise

29. Sick Day Management of Diabetes
Mellitus (2)
 Illnesses with gastrointestinal symptoms (e.g.
diarrhoea and vomiting) may lead to lower
blood glucose levels and hypoglycaemia due
to
 decreased food intake
 poor absorption and
 changes in intestinal motility
 Sick day management should be an integral
part of the initial education of the child and
family, and then reinforced at regular intervals

30. • Do not stop insulin during sick days.
Additional insulin is usually necessary to
control blood glucose (unless the illness
causes hypoglycaemia or food intake is
reduced)
• Evaluate and treat the acute illness
• Increase monitoring of blood glucose levels
and ketones
• Supportive care, including ensuring adequate
fluid intake
Sick Day Management of Diabetes
Mellitus (3)

31. • Give additional short or rapid-acting insulin if
blood glucose is elevated:
• With absent or small ketones
 5 - 10% of total daily dose of insulin (or
0.05 - 0.1U/kg)
• With moderate or large ketones
• 10-20% of total daily dose of insulin (or
0.1U/kg)
• Repeat every 2-4 hours
Sick Day Management of Diabetes
Mellitus (4)

32.  Strenuous exercise should be avoided
 Evaluate the patient and consider admission
especially if unable to test blood glucose at
home
Sick Day Management of Diabetes
Mellitus (5)

33. Management of Diabetes During
Religious Fasting
There are several types of fasting:
• Partial fast
• the person abstains from all foods
• can take water for a limited time or abstain from
selected foods and drinks, or omit a certain meal
each of the fasting days
• Total fast
• total abstinence from both food and water
• should not go beyond a maximum of three days
• not recommended for those taking insulin
secretagogues or insulin

34. • Those with very poor glucose control should
be discouraged from fasting
• A total fast is not recommended for anyone
with diabetes
• Adequate hydration is important even during
the period of fasting
• For those on insulin, a partial fast is preferred
to total fasting
Management of Diabetes During
Religious Fasting (2)

35. • Self-blood glucose monitoring is mandatory
for people with diabetes who elect to fast
• Once-a-day is adequate for patients on diet
only or diet with metformin
• At least 3 times a day in patients on insulin
secretagogues
• More frequently if hyperglycemia is marked
and the urine tested for ketones
Management of Diabetes During
Religious Fasting (3)

36.  Consider terminating the fast if frequent
hypoglycemia or intercurrent infections
 Neither insulin injection nor the breaking of
the skin for SBGM will break the fast
 Vigorous activity should be avoided during
period of fast
 Ensure ready access to healthcare providers
during the period of fast
Management of Diabetes During
Religious Fasting (4)

37. • Management of normal fasting for people
treated with oral hypoglycemic agents
 Usual dietary advice should be followed
 Patients on metformin, alpha-glucosidase
inhibitors or thiazolidinediones (glitazones) can
continue taking the usual doses at the usual
times
 Patients on second or third generation
sulphonylurea (glibenclamide, gliclazide,
glipizide, glimepiride) should take them at the
time of breaking the fast and not before dawn
Management of Diabetes During
Religious Fasting (5)

38. • Management of normal fasting for T2DM
patients on insulin
 If on once daily insulin before bed, this can be
given as usual
 If on twice daily short- and intermediate-acting
insulin:
• Before the dawn meal, give the usual
evening dose of short-acting insulin without
any intermediate-acting insulin
• Before the evening meal give the usual
morning dose of short-acting and
intermediate-acting insulin
Management of Diabetes During
Religious Fasting (6)

39. • If on basal bolus regimen:
• Usual doses of the short-acting insulin can
be given before the dawn and evening
meals, and usual doses of the
intermediate-acting insulin can still be
given at 10pm
• Regular SBGM is essential to ensure
prevention of hypoglycemia
• Titration of doses should occur according
to SBGM results
Management of Diabetes During
Religious Fasting (7)

40. Management of other Fasting Types
Treatment regimen
When to take
antidiabetic agents
Fasting
regimen
Diet only Not applicable Total, partial
Metformin,
Thiazolidinediones
With meals Normal or
partial
Insulin secretagogues
Sulphonylureas
Before meals Partial
Daily intermediate or
long-acting insulin
Before first meal Partial
Multiple insulin doses
using intermediate and
short acting insulin
Not applicable Avoid fasting
Long-acting plus bolus
fast acting insulin
Lantus am and
analogue with meals
Avoid fasting
or partial fast

41. Activity: Brainstorming
• What is referral pathway for patients with
diabetes mellitus?

42. Referral Pathway
• Severely ill patients should be referred to
hospital as soon as possible
• REFER to Desk Guide page 39 Patient
Referral

43. Key Points
• Clinical assessment of patients with diabetes
mellitus focuses on
• history taking
• performing physical examination
• laboratory investigations to identify
symptoms and signs of diabetes

44. Key Points
• Management of patients with diabetes
mellitus include:
• Monitoring of glucose, provision of medication
• Documentation in patient management card
and related monitoring tools
• Provision of health education
• Adherence counselling to patients and
treatment supporter
• Managing diabetes mellitus in special
situations and referral of patient for further
management

45. Session Evaluation
• What are the issues to focus on during
patients’ assessment?
• How do you manage a patient with diabetes
mellitus?
• What are the issues to consider for treatment
supporter?