Amr and and PeN protocol

1. DIABETES MELLITUS – Screening & Diagnosis Symptomatic patients
Symptoms of DM
Acute (Classic symptoms): polydipsia, polyuria, unplanned weight loss, polyphagia, tiredness, dry mouth
Chronic: Recurrent UTIs, recurrent candida infections, slow healing foot cuts or wounds, peripheral neuropathy
Abdominal pain in children
FBS (preferred), or RBS on handheld (glucometer) device
FBS ≥ 7.0 mmol/L or
RBS ≥ 11.1 mmol/L
FBS < 7.0 mmol/L, or
RBS < 11.1 mmol/L
Diagnosis of DM
*DM type 1? OR
Advanced type 2 DM?
(see below)
No DM. Look
for other
causes of the
symptoms
*Consider diagnosis of T1DM:
• Acute classic symptoms
and or
• Children, adolescent and
age below 30 and or
• Ketonuria and or
• BMI < 25
* Consider diagnosis of T2DM:
• Chronic symptoms
• BMI > 25
• Age > 25

2. 2
Screen high risk patients
• First degree (Parents and/or Siblings) family history of DM
• Age (Above 40 years)
• History of gestational DM
• Hypertension
• HIV Positive
• Active TB
• Obesity (BMI ≥ 30 kg/m²)
• Cardiovascular disease (CVD): stroke, ischaemic heart disease, heart failure, peripheral artery disease
• Chronic Kidney Disease (CKD): CrCl < 60 ml/min)
FBS < 7.0*
RBS < 11.1
FBS ≥ 7.0
RBS > 11.1
Repeat FBS within 1 week at
facility
Follow
management
cascade for
confirmed T2DM
FBS ≥ 7.0
Diabetes
confirmed
No DM
Screening & Diagnosis of Asymptomatic Patients
FBS or RBS on handheld device (glucometer) in mmol/L
FBS
6.1 to 6.9
FBS
3.9 to 6.0
Impaired
FBS
• Dietary &
lifestyle
counseling
• Re-screen after
6 months
Refer to
District
Hospital
• Dietary &
lifestyle
counseling
• Re-screen
after 1 year
Discrepancy
between
1st and 2nd test
3/6/2024

3. FBS >/= 7mmol/l to < 18mmol/l FBS> 18mmol/l
Counsel on diet and physical activity
Start metformin 500mg po bd
Review in 1 month
Test for urine ketones
If ketones >/+ 2+ If ketones < 2+
Refer to hospital
Check hydration status
Dehydration
present
Dehydration
absent
 Give IV fluids
 Start metformin 500mg po bb
 Glibenclamide 5mg po od
 Counsel on hypoglycemia
 Start metformin 500mg po bb
 Glibenclamide 5mg po od
 Counsel on hypoglycemia
Re assess in 3 to 5 days
If no improvement. Refer to Hospital If improved. Continue medication.
Counsel on lifestyle
Review after a month
TREATMENT CASCADES FOR DIABETES MELLITUS
Target not met from self
monitoring or FBS> 7,
RBS> 11.1
Target met from self
monitoring or FBS < 7, RBS<
11.1
 Check adherence
 Reinforce lifestyle changes
 Increase metformin to 1g bd
 Review in a month
 Continue with treatment
 Encourage self care
 Lifestyle counselling
 If target is met then continue with current medication
 If target id not met then add glibenclamide 5mg po od
 Review after a month
If target is not met then refer to hospital

4. Systolic BP ≥140 or
Diastolic BP ≥ 90
Stage 1 HTN
SBP 140-159 or DBP 90-99 on 3 separate
measurements over 2 weeks
Stage 2 HTN
SBP 160-179 or DBP 100-109
on 3 separate measurements over 1 week
Stage 3 HTN
SBP ≥ 180 or DBP
≥ 110
Hypertension patient education
and counseling,
Lab tests
Begin medication
Continue to monitor, adjust/add
medication and follow up per
protocol
Prescribe diet
and lifestyle
management.
Start treatment
Patient education
and counseling.
Hypertension Diagnostic and Screening Cascade
See diagnostic
cascade for
stage 3 HTN
3/6/2024
4
HTN only
Begin
medication
AND REFER
With: Stroke
Heart Failure,
Coronary artery
disease
persistent
proteinuria
High cholesterol
With: DM or
high *CVD
Risk (2 or
more of:
smoking,
obesity,
sedentary
lifestyle,
high
cholesterol)
With: DM or
high *CVD
Risk (2 or
more of:
smoking,
obesity,
sedentary
lifestyle,
high
cholesterol)
With: Stroke
Heart Failure,
Coronary artery
disease
persistent
proteinuria
High cholesterol
Begin
medication
AND REFER
←

5. BP still above
target(140/90) despite
good adherence:
add Amlodipine 5 mg OD
and manage according to
Stage 2 hypertension flow
chart
START HCT 25 mg OD
Reinforce lifestyle changes
Review in 4 weeks
BP ≥ 140/90 mmHg and <160/100mmHg
• No diabetes mellitus
• No cor-mobidities
• Program Target: BP < 140/90 for ALL PATIENTS
STAGE 1 HTN TREATMENT CASCADE
Patients with HTN-only
Preferred practice if resources permit
• Offer counselling on Lifestyle(Diet and exercise)
including:
• Low salt diet
• Regular exercises (minimum 30 min/day for 5-7
days per week of moderate intensity exercises)
• No smoking
• Aim for weight reduction to achieve BMI < 25
• Reduce alcohol intake
• Low fat intake
3/6/2024

6. If BP still above target: confirm adherence and add AMLODIPINE 5 mg OD.
Review in 4 weeks
START Enalapril 10mg OD and refer.
Review in 4 weeks
6
If BP still above target : confirm adherence and increase AMLODIPINE to 10 mg
OD. Review in 4 weeks
STAGE 1 HTN TREATMENT CASCADE
PATIENTS WITH DM OR HIGH CVD RISK
Refer
BP ≥ 140/90 mmHg AND < 160/100
• Ideal target BP for DM-HTN: <130/80mmHg
3/6/2024
If BP still above target, Increase Enalapril to 20mg BD
Review in 4 weeks
• Offer counselling, educational session and prescribe lifestyle
management including:
• Low salt diet
• Regular exercises (minimum 30 min/day for 5-7 days per week of
moderate intensity exercises)
• Stop smoking
• Aim for weight reduction to chive BMI < 25
• Reduce alcohol
• Reduce fat

7. If BP still above target despite adherence: increase AMLODIPINE to 10 mg OD. Review in 2 – 4 weeks
If BP still above target: confirm adherence and add ENALAPRIL 10
mg OD. Review in 4 weeks
If BP still above target: confirm adherence and increase
ENALAPRIL to 20 mg OD or 20 mg OD. Review in 4 weeks
If BP still above target : confirm adherence and consider start of
SPIRONOLACTONE or ATENOLOL
START HCT 25 mg OD AND Amlodipine 5 mg OD
Review in 2 – 4 weeks
7
BP ≥ 160-179/100 -109 mmHg AND < 180/110
• Start treatment
• Target: BP < 140/90 FOR ALL PATIENTS
SECONDARY
CARE
LEVEL
STAGE 2 HTN TREATMENT CASCADE
If BP still above target: confirm adherence and increase
ENALAPRIL to 40 mg OD Review in 4 weeks
If BP still above target despite adherence: Refer

8. 8
HTN Stage 3
SBP ≥ 180 and/or
DBP ≥ 110
Known hypertensive: Reinstitute/
intensify oral medication
and Refer
Hypertensive emergency:
Marked confirmed elevated BP with symptoms and
signs indicative of impairment of one or more organ
systems (brain, eyes, heart, aorta, or kidneys)
Start HCT 25 mg and Amlodipine 5 mg
and refer
urgently to hospital
Hypertensive urgency:
Marked confirmed elevated BP but no damage to
the body's organs (stable patient)
New hypertensive:
Start HCT 25 mg and
Amlodipine 5 mg
and Refer
Signs & symptoms: pale &
cool skin, sweating, fatigue,
very fast or very slow pulse,
SOB, headache, confusion,
acute chest pain, seizure,
body swelling
Target organ damage
Signs & symptoms? New/progressive/
worsening?
STAGE 3 HTN TREATMENT CASCADE
NO YES
Review patients after 3 days. If follow up BP < 180/110 titrate medication upwards and encourage review with the doctor. If
persistently high, emphasize need for referral!
3/6/2024

9. Referal criteria
• BP >180/>110 mm Hg (urgent referral)
• BP ≥140 or ≥ 90 mmHg in people < 30 yrs (to exclude secondary hypertension)
• Known heart disease, stroke, transient ischemic attack, DM, kidney disease (for assessment, if this
has not been done)
• New chest pain or change in severity of angina or symptoms of stroke
• Raised BP ≥140/90 ( in DM above 130/ 80mmHg) while on treatment with 2 medications
• Any proteinuria
• Newly diagnosed DM with urine ketones 2+ or in lean persons of <30 years
• DM with poor control despite maximal metformin with sulphonylurea
• DM with severe infection and/or foot ulcers
• DM patients with glucometer reading above 18mmol/l
• DM with recent deterioration of vision or no eye exam in 2 years
• High cardiovascular risk

10. SEVERE HYPOGLYCAEMIA OR SIGNS
(plasma glucose < 2.8 mmol/L)
 If conscious, give a sugar-sweetened drink
 If unconscious, give 20–50 ml of 50% glucose
(dextrose) IV over 1–3 minutes
SEVERE HYPERGLYCAEMIA OR SIGNS AND
SYMPTOMS
(plasma glucose > 18 mmol/L and urine ketone 2+)
 Set up intravenous drip 0.9% NaCl 1 litre in 2 hours;
continue at 1 litre every 4 hours
 REFER to hospital
MANAGEMENT OF ACUTE COMPLICATIONS