糖尿病管理英文

DiabetesMellitusDr.RashaSalamaPhDPublicHealth,SuezCanalUniversity,EgyptDiabetesMSc,CardiffUniversity,UnitedKingdomDiabetesmellitus(DM)isagroupofdiseasescharacterizedbyhighlevelsofbloodglucoseresultingfromdefectsininsulinproduction,insulinaction,orboth.Thetermdiabetesmellitusdescribesametabolicdisorderofmultipleaetiologycharacterizedbychronichyperglycaemiawithdisturbancesofcarbohydrate,fatandproteinmetabolismresultingfromdefectsininsulinsecretion,insulinaction,orboth.Theeffectsofdiabetesmellitusincludelong–termdamage,dysfunctionandfailureofvariousorgans.Whatisdiabetes?

Diabetesmellitusmaypresentwithcharacteristicsymptomssuchasthirst,polyuria,blurringofvision,andweightloss.Initsmostsevereforms,ketoacidosisoranon–ketotic

hyperosmolarstatemaydevelopandleadtostupor,comaand,inabsenceofeffectivetreatment,death.Oftensymptomsarenotsevere,ormaybeabsent,andconsequentlyhyperglycaemiasufficienttocausepathologicalandfunctionalchangesmaybepresentforalongtimebeforethediagnosisismade.DiabetesThelong–termeffectsofdiabetesmellitusincludeprogressivedevelopmentofthespecificcomplicationsofretinopathywithpotentialblindness,nephropathythatmayleadtorenalfailure,and/orneuropathywithriskoffootulcers,amputation,Charcotjoints,andfeaturesofautonomicdysfunction,includingsexualdysfunction.Peoplewithdiabetesareatincreasedriskofcardiovascular,peripheralvascularandcerebrovasculardisease.DiabetesLong-termEffectsThedevelopmentofdiabetesisprojectedtoreachpandemicproportionsoverthenext10-20years.InternationalDiabetesFederation(IDF)dataindicatethatbytheyear2025,thenumberofpeopleaffectedwillreach333million–90%ofthesepeoplewillhaveType2diabetes.InmostWesternsocieties,theoverallprevalencehasreached4-6%,andisashighas10-12%among60-70-year-oldpeople.Theannualhealthcostscausedbydiabetesanditscomplicationsaccountforaround6-12%ofallhealth-careexpenditure.BurdenofDiabetesType1DiabetesMellitusType2DiabetesMellitusGestationalDiabetesOthertypes:LADA(MODY(maturity-onsetdiabetesofyouth)SecondaryDiabetesMellitusTypesofDiabetes

Waspreviouslycalledinsulin-dependentdiabetesmellitus(IDDM)orjuvenile-onsetdiabetes.Type1diabetesdevelopswhenthebody’simmunesystemdestroyspancreaticbetacells,theonlycellsinthebodythatmakethehormoneinsulinthatregulatesbloodglucose.Thisformofdiabetesusuallystrikeschildrenandyoungadults,althoughdiseaseonsetcanoccuratanyage.Type1diabetesmayaccountfor5%to10%ofalldiagnosedcasesofdiabetes.Riskfactorsfortype1diabetesmayincludeautoimmune,genetic,andenvironmentalfactors.Type1diabetesWaspreviouslycallednon-insulin-dependentdiabetesmellitus(NIDDM)oradult-onsetdiabetes.Type2diabetesmayaccountforabout90%to95%ofalldiagnosedcasesofdiabetes.Itusuallybeginsasinsulinresistance,adisorderinwhichthecellsdonotuseinsulinproperly.Astheneedforinsulinrises,thepancreasgraduallylosesitsabilitytoproduceinsulin.Type2diabetesisassociatedwitholderage,obesity,familyhistoryofdiabetes,historyofgestationaldiabetes,impairedglucosemetabolism,physicalinactivity,andrace/ethnicity.AfricanAmericans,Hispanic/LatinoAmericans,AmericanIndians,andsomeAsianAmericansandNativeHawaiiansorOtherPacificIslandersareatparticularlyhighriskfortype2diabetes.Type2diabetesisincreasinglybeingdiagnosedinchildrenandadolescents.Type2diabetesAformofglucoseintolerancethatisdiagnosedinsomewomenduringpregnancy.GestationaldiabetesoccursmorefrequentlyamongAfricanAmericans,Hispanic/LatinoAmericans,andAmericanIndians.Itisalsomorecommonamongobesewomenandwomenwithafamilyhistoryofdiabetes.Duringpregnancy,gestationaldiabetesrequirestreatmenttonormalizematernalbloodglucoselevelstoavoidcomplicationsintheinfant.Afterpregnancy,5%to10%ofwomenwithgestationaldiabetesarefoundtohavetype2diabetes.Womenwhohavehadgestationaldiabeteshavea20%to50%chanceofdevelopingdiabetesinthenext5-10years.GestationaldiabetesOtherspecifictypesofdiabetesresultfromspecificgeneticconditions(suchasmaturity-onsetdiabetesofyouth),surgery,drugs,malnutrition,infections,andotherillnesses.Suchtypesofdiabetesmayaccountfor1%to5%ofalldiagnosedcasesofdiabetes.OthertypesofDMLatentAutoimmuneDiabetesinAdults(LADA)isaformofautoimmune(type

1diabetes)whichisdiagnosedinindividualswhoareolderthantheusualageofonsetoftype1diabetes.Alternatetermsthathavebeenusedfor"LADA"includeLate-onsetAutoimmuneDiabetesofAdulthood,"SlowOnsetType1"diabetes,andsometimesalso"Type1.5Often,patientswithLADAaremistakenlythoughttohavetype

2diabetes,basedontheirageatthetimeofdiagnosis.LADALADA(cont.)About80%ofadultsapparentlywithrecentlydiagnosedType2diabetesbutwithGADauto-antibodies(i.e.LADA)progresstoinsulinrequirementwithin6years.Thepotentialvalueofidentifyingthisgroupathighriskofprogressiontoinsulindependenceincludes:theavoidanceofusingmetformintreatmenttheearlyintroductionofinsulintherapyLADA(cont.)MODYMODY(cont.)MODY(cont.)SecondarycausesofDiabetesmellitusinclude:Acromegaly,Cushingsyndrome,Thyrotoxicosis,PheochromocytomaChronicpancreatitis,CancerDruginducedhyperglycemia:AtypicalAntipsychotics-Alterreceptorbindingcharacteristics,leadingtoincreasedinsulinresistance.Beta-blockers-Inhibitinsulinsecretion.CalciumChannelBlockers-Inhibitssecretionofinsulinbyinterferingwithcytosoliccalciumrelease.Corticosteroids-Causeperipheralinsulinresistanceandgluconeogensis.Fluoroquinolones-InhibitsinsulinsecretionbyblockingATPsensitivepotassiumchannels.Naicin-Theycauseincreasedinsulinresistanceduetoincreasedfreefattyacidmobilization.Phenothiazines-Inhibitinsulinsecretion.ProteaseInhibitors-Inhibittheconversionofproinsulintoinsulin.ThiazideDiuretics-Inhibitinsulinsecretionduetohypokalemia.Theyalsocauseincreasedinsulinresistanceduetoincreasedfreefattyacidmobilization.SecondaryDMPrediabetes:Impairedglucosetoleranceandimpairedfastingglucose

Progressiontodiabetesamongthosewithprediabetesisnotinevitable.Studiessuggestthatweightlossandincreasedphysicalactivityamongpeoplewithprediabetespreventordelaydiabetesandmayreturnbloodglucoselevelstonormal.Peoplewithprediabetesarealreadyatincreasedriskforotheradversehealthoutcomessuchasheartdiseaseandstroke.Prediabetes:Impairedglucosetoleranceandimpairedfastingglucose(cont.)DiagnosisofDiabetesMellitusValuesofDiagnosisofDiabetesMellitusResearchstudieshavefoundthatlifestylechangescanpreventordelaytheonsetoftype2diabetesamonghigh-riskadults.ThesestudiesincludedpeoplewithIGTandotherhigh-riskcharacteristicsfordevelopingdiabetes.Lifestyleinterventionsincludeddietandmoderate-intensityphysicalactivity(suchaswalkingfor21/2hourseachweek).IntheDiabetesPreventionProgram,alargepreventionstudyofpeopleathighriskfordiabetes,thedevelopmentofdiabeteswasreduced58%over3years.Preventionordelayofdiabetes:

Lifestylemodification

Studieshaveshownthatmedicationshavebeensuccessfulinpreventingdiabetesinsomepopulationgroups.IntheDiabetesPreventionProgram,peopletreatedwiththedrugmetforminreducedtheirriskofdevelopingdiabetesby31%over3years.Treatmentwithmetforminwasmosteffectiveamongyounger,heavierpeople(those25-40yearsofagewhowere50to80poundsoverweight)andlesseffectiveamongolderpeopleandpeoplewhowerenotasoverweight.Similarly,intheSTOP-NIDDMTrial,treatmentofpeoplewithIGTwiththedrugacarbosereducedtheriskofdevelopingdiabetesby25%over3years.Othermedicationstudiesareongoing.InadditiontopreventingprogressionfromIGTtodiabetes,bothlifestylechangesandmedicationhavealsobeenshowntoincreasetheprobabilityofrevertingfromIGTtonormalglucosetolerance.Preventionordelayofdiabetes:MedicationsManagementofDiabetesMellitusThemajorcomponentsofthetreatmentofdiabetesare:ManagementofDMADietandExerciseBOralhypoglycaemictherapyCInsulinTherapyDietisabasicpartofmanagementineverycase.Treatmentcannotbeeffectiveunlessadequateattentionisgiventoensuringappropriatenutrition.Dietarytreatmentshouldaimat:ensuringweightcontrolprovidingnutritionalrequirementsallowinggoodglycaemiccontrolwithbloodglucoselevelsasclosetonormalaspossiblecorrectinganyassociatedbloodlipidabnormalitiesA.DietThefollowingprinciplesarerecommendedasdietaryguidelinesforpeoplewithdiabetes:Dietaryfatshouldprovide25-35%oftotalintakeofcaloriesbutsaturatedfatintakeshouldnotexceed10%oftotalenergy.Cholesterolconsumptionshouldberestrictedandlimitedto300mgorlessdaily.Proteinintakecanrangebetween10-15%totalenergy(0.8-1g/kgofdesirablebodyweight).Requirementsincreaseforchildrenandduringpregnancy.Proteinshouldbederivedfrombothanimalandvegetablesources.Carbohydratesprovide50-60%oftotalcaloriccontentofthediet.Carbohydratesshouldbecomplexandhighinfibre.Excessivesaltintakeistobeavoided.Itshouldbeparticularlyrestrictedinpeoplewithhypertensionandthosewithnephropathy.A.Diet(cont.)Physicalactivitypromotesweightreductionandimprovesinsulinsensitivity,thusloweringbloodglucoselevels.Togetherwithdietarytreatment,aprogrammeofregularphysicalactivityandexerciseshouldbeconsideredforeachperson.Suchaprogrammemustbetailoredtotheindividual’shealthstatusandfitness.Peopleshould,however,beeducatedaboutthepotentialriskofhypoglycaemiaandhowtoavoidit.ExerciseTherearecurrentlyfourclassesoforalanti-diabeticagents:i.Biguanidesii.InsulinSecretagogues–Sulphonylureasiii.InsulinSecretagogues–Non-sulphonylureasiv.α-glucosidaseinhibitorsv.Thiazolidinediones(TZDs)B.OralAnti-DiabeticAgents

Ifglycaemiccontrolisnotachieved(HbA1c>6.5%and/or;FPG>7.0mmol/Lor;RPG>11.0mmol/L)withlifestylemodificationwithin1–3months,ORALANTI-DIABETICAGENTshouldbeinitiated.Inthepresenceofmarkedhyperglycaemiainnewlydiagnosedsymptomatictype2diabetes(HbA1c>8%,FPG>11.1mmol/L,orRPG>14mmol/L),oralanti-diabeticagentscanbeconsideredattheoutsettogetherwithlifestylemodification.B.1OralAgentMonotherapy

Asfirstlinetherapy:Obesetype2patients,consideruseofmetformin,acarbose

orTZD.Non-obesetype2patients,considertheuseofmetforminorinsulinsecretagoguesMetforministhedrugofchoiceinoverweight/obesepatients.TZDsandacarboseareacceptablealternativesinthosewhoareintoleranttometformin.Ifmonotherapyfails,acombinationofTZDs,acarboseandmetforminisrecommended.Iftargetsarestillnotachieved,insulinsecretagoguesmaybeaddedB.1OralAgentMonotherapy(cont.)Combinationoralagentsisindicatedin:NewlydiagnosedsymptomaticpatientswithHbA1c>10Patientswhoarenotreachingtargetsafter3monthsonmonotherapyB.2CombinationOralAgents

Iftargetshavenotbeenreachedafteroptimaldoseofcombinationtherapyfor3months,consideraddingintermediate-acting/long-actinginsulin(BIDS).Combinationofinsulin+oralanti-diabeticagents(BIDS)hasbeenshowntoimproveglycaemiccontrolinthosenotachievingtargetdespitemaximalcombinationoralanti-diabeticagents.Combininginsulinandthefollowingoralanti-diabeticagentshasbeenshowntobeeffectiveinpeoplewithtype2diabetes:Biguanide(metformin)Insulinsecretagogues(sulphonylureas)Insulinsensitizers(TZDs)(thecombinationofaTZDplusinsulinisnotanapprovedindication)α-glucosidaseinhibitor(acarbose)InsulindosecanbeincreaseduntiltargetFPGisachieved.B.3CombinationOralAgentsandInsulin

DiabetesManagementAlgorithmOralHypoglycaemicMedicationsInelderlynon-obesepatients,shortactinginsulinsecretagoguescanbestartedbutlongactingSulphonylureasaretobeavoided.Renalfunctionshouldbemonitored.Oralanti-diabeticagentsarenotrecommendedfordiabetesinpregnancyOralanti-diabeticagentsareusuallynotthefirstlinetherapyindiabetesdiagnosedduringstress,suchasinfections.InsulintherapyisrecommendedforboththeaboveTargetsforcontrolareapplicableforallagegroups.However,inpatientswithco-morbidities,targetsareindividualizedWhenindicated,startwithaminimaldoseoforalanti-diabeticagent,whilereemphasizingdietandphysicalactivity.Anappropriatedurationoftime(2-16weeksdependingonagentsused)betweenincrementsshouldbegiventoallowachievementofsteadystatebloodglucosecontrolGeneralGuidelinesforUseofOralAnti-DiabeticAgentinDiabetes

Short-termuse:Acuteillness,surgery,stressandemergenciesPregnancyBreast-feedingInsulinmaybeusedasinitialtherapyintype2diabetesinmarkedhyperglycaemiaSeveremetabolicdecompensation(diabeticketoacidosis,hyperosmolar

nonketotic

coma,lacticacidosis,severehypertriglyceridaemia)Long-termuse:IftargetshavenotbeenreachedafteroptimaldoseofcombinationtherapyorBIDS,considerchangetomulti-doseinsulintherapy.Wheninitiatingthis,insulin

secretagoguesshouldbestoppedandinsulinsensitiserse.g.MetforminorTZDs,canbecontinued.C.InsulinTherapy

Themajorityofpatientswillrequiremorethanonedailyinjectionifgoodglycaemiccontrolistobeachieved.However,aonce-dailyinjectionofanintermediateactingpreparationmaybeeffectivelyusedinsomepatients.Twice-dailymixturesofshort-andintermediate-acting