Diabetes Management: Clinical Assessment and Treatment

Posted on Jan 13, 2025 in Medicine

Diabetes History Taking

Type and Duration of Diabetes

Current Hypoglycemia

Polyuria, polydipsia, nocturia, weight loss, blurred vision, recurrent cutaneous sepsis, urinary tract infections, balanitis, pruritus vulvae

Control

Home blood glucose monitoring, HbA1C, clinic visits advice

Admissions

DKA, HHS, Hypoglycemia

Current Treatment

Insulin

Duration, type of insulin, storage, who administers, where administered, what’s used to administer, dosage, skin problems related to injection sites.

Oral Hypoglycemic Agents

Metformin (bloating, diarrhea), Sulphonylurea (weight gain, hypoglycemia)

Diet advice? Are you following? Structured exercise?

Hypoglycemic episodes, symptoms, how often do they occur, too much insulin, not eating enough, skipping meals, hypoglycemic unawareness, does the patient need assistance from another person to recover from these episodes, living alone?

Complications

Cardiovascular

Chest pain, breathlessness, orthopnea, paroxysmal nocturnal dyspnea, ankle edema, PCI or CABG previously

Peripheral Vascular Disease

Cold extremities, claudication, bypass surgery

Cerebrovascular Accident

Visual disturbance, neurological deficits, TIA or stroke

Retinal

Deterioration of vision, eye check-up? Laser, injections

Neuropathy

Arms and legs, walking on cotton wool, burning sensation in legs and arms

Nephropathy

Protein in urine? Frothy urine? Acute kidney injury?

Autonomic Neuropathy

Gustatory sweating, erectile dysfunction, fullness, constipation/diarrhea

Feet

Ulcers, lesions, foot care advice, always wear shoes.

Hypertension? Control on treatment

Hyperlipidemia, cholesterol levels? On treatment?

Past Medical History and Family History

Gestational diabetes, family history, recurrent stillbirth

Pancreatitis, cystic fibrosis, hemochromatosis

Cushing’s syndrome, acromegaly, pheochromocytoma (palpitations, sweating, hypertension), organ transplantation (tacrolimus – post-transplant diabetes)

Drugs

Steroids, OCP, HCT, atypical antipsychotics, tacrolimus, HIV drugs

Beta-blockers? Can impair adrenergic hypoglycemic awareness. Carvedilol as a second line is safe. Metoprolol is not recommended.

Social History

Smoking, finances, alcohol

Any daily work disability (vision, amputation, time for insulin injection, hypoglycemia)

Heavy vehicle use, driving

Childbearing, family planning.

Mood

Plan

I want to optimize hyperglycemia to prevent microvascular and macrovascular complications of diabetes

Lifestyle (diet and exercise), and drug compliance, monitoring and follow-up.

Look into insulin dosing, problems.

Monitor for blood glucose, blood pressure, urine albumin, retinal screening, blood lipids.

Educate on diet, exercise, foot care, hypoglycemic awareness, insulin storage and injection.

Oral Hypoglycemics

  • Metformin Initial Dose: 500 mg twice daily (b.d.) or 850 mg once daily (mane) with meals. Maintenance Dose: 1500–2000 mg per day in divided doses. Maximum Dose: 2550 mg per day. Administration Timing: Typically given twice daily (b.d.), with morning (mane) and evening (nocte) meals to reduce gastrointestinal side effects.

  • Glibenclamide (also known as Glyburide) Initial Dose: 2.5–5 mg once daily (mane) with breakfast. Maintenance Dose: 1.25–20 mg per day in one or two divided doses. Maximum Dose: 20 mg per day. Administration Timing: Once or twice daily (mane and sometimes nocte).

  • Gliclazide Immediate-Release: Initial Dose: 40–80 mg once daily (mane). Maintenance Dose: 40–320 mg per day in one or two divided doses. Maximum Dose: 320 mg per day. Administration Timing: Once or twice daily (mane and nocte). Modified-Release: Initial Dose: 30 mg once daily (mane). Maintenance Dose: 30–120 mg once daily. Maximum Dose: 120 mg per day. Administration Timing: Once daily (mane) with breakfast.

  • Sitagliptin Standard Dose: 100 mg once daily (mane). Maximum Dose: 100 mg per day. Administration Timing: Once daily (mane) with or without food.

  • Empagliflozin Initial Dose: 10 mg once daily (mane). Maintenance Dose: 10–25 mg once daily. Maximum Dose: 25 mg per day. Administration Timing: Once daily (mane) in the morning, with or without food.

  • Pioglitazone Initial Dose: 15–30 mg once daily (mane). Maintenance Dose: 15–45 mg once daily. Maximum Dose: 45 mg per day. Administration Timing: Once daily (mane), with or without food.

Side Effects

Metformin

  • Gastrointestinal Symptoms: Nausea, vomiting, diarrhea, abdominal pain, and loss of appetite.
  • Lactic Acidosis: A rare but serious side effect, particularly in patients with renal impairment, liver disease, or conditions predisposing to hypoxia.
  • Vitamin B12 Deficiency: Long-term use may lead to decreased absorption of vitamin B12.

Glibenclamide (Glyburide)

  • Hypoglycemia: The most common side effect, especially in elderly patients or those with renal impairment.
  • Weight Gain: Can contribute to an increase in body weight.
  • Gastrointestinal Symptoms: Nausea, heartburn, and a feeling of fullness.
  • Allergic Skin Reactions: Rash, pruritus, and erythema.

Gliclazide

  • Hypoglycemia: Common, especially with inappropriate dosing or missed meals.
  • Weight Gain: May cause moderate weight gain.
  • Gastrointestinal Symptoms: Nausea, vomiting, diarrhea, and constipation.
  • Allergic Reactions: Skin reactions such as rash, itching, or urticaria.

Pioglitazone

  • Weight Gain: Common side effect, often due to fluid retention.
  • Edema: Swelling due to fluid retention, which can exacerbate or lead to heart failure.
  • Increased Risk of Bone Fractures: Particularly in women.
  • Bladder Cancer: Long-term use has been associated with an increased risk.
  • Hepatotoxicity: Liver enzyme elevations; rare cases of liver failure.

Empagliflozin

  • Genital Infections: Increased risk of fungal infections, particularly in the genital area.
  • Urinary Tract Infections: Higher incidence of UTIs.
  • Dehydration and Hypotension: Due to increased urination, leading to volume depletion.
  • Ketoacidosis: Rare but serious risk of diabetic ketoacidosis, even with normal blood glucose levels.
  • Increased Risk of Lower Limb Amputation: Observed in some studies, though not universally accepted.

Sitagliptin

  • Nasopharyngitis: Common cold-like symptoms such as sore throat and runny nose.
  • Upper Respiratory Tract Infections: Increased susceptibility to respiratory infections.
  • Headache: Frequent mild to moderate headaches.
  • Hypoglycemia: Generally low risk when used alone but can occur when combined with other diabetes medications, particularly insulin or sulfonylureas.
  • Pancreatitis: Rare but serious risk of acute pancreatitis.
  • Allergic Reactions: Hypersensitivity reactions, including anaphylaxis, angioedema, and severe skin reactions such as Stevens-Johnson syndrome.
  • Renal Function Changes: Worsening of renal function in some patients, particularly those with pre-existing renal impairment.

Hypoglycemia Treatment

Mild to Moderate Hypoglycemia (conscious and able to swallow)

Oral glucose: 15-20 grams of fast-acting carbohydrate (e.g., glucose tablets or gel).

Severe Hypoglycemia

Dextrose 50% (D50W): Administer 25-50 mL (which provides 12.5-25 grams of dextrose) intravenously (IV) as a bolus. Follow with a continuous infusion of 5-10% dextrose solution (D5W or D10W)

Pediatric (Children)

Mild to Moderate Hypoglycemia

Oral glucose (if conscious and able to swallow): 0.3 grams/kg of fast-acting carbohydrate.

Severe Hypoglycemia

Dextrose 10% (D10W): Administer 2-5 mL/kg IV as a bolus. Alternatively, Dextrose 25% (D25W): Administer 2-4 mL/kg IV as a bolus.

Glucagon

1mg IM, IV, subcutaneously. Intranasally 3mg

Children less than 25kg – 0.5mg

Diabetic Ketoacidosis (DKA) Management

  • Fluid Resuscitation: Normal saline initially, then adjust based on hydration and electrolyte status. 0.9% NS, 1 liter bolus over 1 hour. Replace 4-6L over 24 hours. Add 20mmol of K+ from the second NS drip.
  • VBG for pH, K+, and Na+ levels
  • Insulin Infusion: 0.1 units/kg/hour IV. (1unit/mL in normal saline: add 50 units to 50mL N/S)
  • Dextrose Addition: When blood glucose < 200mg/dL, add 10% dextrose to fluids.
  • Electrolyte Monitoring: Regularly check and replace potassium and other electrolytes.
  • Transition to Subcutaneous Insulin: Overlap IV and subcutaneous insulin to ensure stable blood glucose levels.
  • Diagnosis >3.0mmol/L, ketonuria, +2
  • Blood glucose >11.0mmol/L
  • Bicarb <15mmol/L pH <7.3
  • Resolution >7.3 pH
  • >15mmol bicarb
  • <0.6mmol/L ketones
  • Look for a focus of sepsis (septic screen), coronary event (ECG, trop I) pregnancy?
  • Absolute need for insulin if not already on.

Hyperosmolar Hyperglycemic State (HHS)

Hydrate 4-6 L in 24h NS (Na level >160, 0.45% saline)

Insulin 0.05U/kg/hour

Stop infusion at 250mg/dL – cerebral edema

Septic screen and ECG, stroke, GI bleed, trauma

>600mg/dL plasma glucose

Plasma osmolality = 2Na + glucose mmol/L + urea mmol/L (>320mOsm/L)

No ketoacidosis

Watch for cerebral edema, pulmonary edema, DVT, stroke/MI, osmotic demyelination, hyponatremia, hypokalemia

Insulin Dosing

Basal Insulin (Long-Acting Insulin)

  • Insulin Glargine (Lantus, Basaglar): Initial dose is 10 units once daily. Maintenance dose is 0.2 to 0.5 units/kg/day, adjusted based on blood glucose levels and individual needs.
  • Insulin Detemir (Levemir): Initial dose is 10 units once or twice daily. Maintenance dose is 0.2 to 0.5 units/kg/day, adjusted as needed.
  • Insulin Degludec (Tresiba): Initial dose is 10 units once daily. Maintenance dose is 0.2 to 0.5 units/kg/day, adjusted based on individual requirements.

Bolus Insulin (Rapid-Acting Insulin)

  • Insulin Lispro (Humalog): Typical dose is 1 to 2 units with meals, adjusted based on carbohydrate intake and blood glucose levels. Dosage can range from 4 to 10 units per meal, depending on the individual’s needs and insulin sensitivity.
  • Insulin Aspart (Novolog): Typical dose is 1 to 2 units with meals, similar to Insulin Lispro. Can range from 4 to 10 units per meal.
  • Insulin Glulisine (Apidra): Typical dose is 1 to 2 units with meals, adjusted based on the individual’s needs. Can vary from 4 to 10 units per meal.

Mixed Insulin (Combination of Basal and Bolus)

  • Insulin 70/30 (70% NPH/30% Regular): Typical dose is 10 to 30 units twice daily, adjusted based on blood glucose levels and individual requirements.
  • Insulin 75/25 (75% Lispro Protamine/25% Lispro): Typical dose is 10 to 30 units twice daily with breakfast and dinner.
  • Insulin 50/50 (50% NPH/50% Regular): Typical dose is 10 to 30 units twice daily.