Peripheral neuropathy

There are several nomenclatures which can be confusing. In practice they are not always clearly definable. From the patient's point of view it is important to know if any sensory modality is missing so as to be careful to avoid injury if it hurts or feels peculiar or if a muscle is weak or does not work. The commonest form of neuropathy is loss or blunting of sensation in a 'sock' or sometimes 'glove' distribution. Different modalities may be differently affected. Problems that arise are...

Medication

Oral hypoglycaemic agents and a diabetes diet can control diabetes in many patients. Those who need insulin should be offered biosynthetic human insulin as pork-derived Table 18.2 Dietary restrictions practised by religious and ethnic groups Table 18.2 Dietary restrictions practised by religious and ethnic groups Mostly vegetarian fish rarely eaten no alcohol. Meat must be 'Halal' no shellfish eaten no alcohol. Regular fasting, including Ramadan for 1 month. Meat must be killed by 'one blow to...

Thirst polydipsia and polyuria

The thirst of untreated diabetes is not easily slaked. Unfortunately many people choose sucrose or glucose-rich aerated drinks like lemonade or cola which temporarily relieve the thirst but exacerbate the underlying problem. At night they will have a glass of water on the bedside table. A few people, often elderly, are sufficiently strong-willed to ignore their thirst for fear of increasing their polyuria. This leads to severe dehydration and may precipitate hospital admission. Polyuria is the...

Driving

Form D100 (January 1991) from the Driver and Vehicle Licensing Agency, 'What you need to know about driver licensing,' states If after your licence has been granted, you develop a medical condition or your medical condition worsens, you must inform the Licensing Centre at once You must declare any medical condition which is likely to last more than 3 months and may affect your ability to drive . . . It is essential that you report the following Epilepsy sudden attacks of disabling giddiness or...

Human insulin

Eli Lilly were the first company to use genetic engineering to produce a drug on a large scale. A segment of the DNA of non-pathogenic bacteria (Escherichia coli) is replaced by that coding for the human proinsulin gene. The bacteria are then cultured in vats. As they multiply they produce human proinsulin. The bacteria are destroyed and the proinsulin is converted to insulin, purified, and marketed as the range of Humulin insulins (prb insulin). Novo Nordisk...

Guar gum

This polysaccharide increases gastric transit time, slows carbohydrate absorption, hence lowering postprandial blood glucose rise it also sequesters bile acids. It may reduce LDL cholesterol. It can be used in Type 1 or Type 2 patients to improve blood glucose balance. Its use around the UK is variable. The dose is one 5 g sachet with each meal either sprinkled over the food or stirred into it. The meal must be accompanied by at least 100 ml water or water-based drink. Alternatively it can be...

Monitoring of people on insulin therapy

It is the patient who injects the insulin, not the doctor The doctor prescribing the insulin is not the person who has to inject it and live with what happens thereafter. The insulin regimen must be tailored to the needs of the each person with diabetes. If the patient cannot control their blood glucose on a particular regimen, finds it hard to use, or loses confidence in it, it should be changed. Clearly, it is worth giving each new regimen a few months' proper trial with full education and...

Clinical examination

Factors especially relevant to diabetes are the acute consequences of hyperglycaemia, tissue damage, and evidence of conditions causing secondary diabetes or associated with diabetes. The detailed section below includes some uncommon findings for completeness. Examples of abnormalities which may be found in diabetes are given but there may obviously be many other causes for some signs. The details of diabetic tissue damage are discussed in Chapter 13....

Audit

Several studies have audited diabetes care in general practice as compared with that of similar practices in the local hospital diabetes clinic. The Wolverhampton mini-clinic project was one of the earliest Singh et al. 1984 . Supported by an enthusiastic diabetologist, general practitioners managed patients with Type 1 and Type 2 diabetes. Patients were more likely to attend the mini-clinic default rate 6 per cent , than the hospital 31 per cent , and their glycaemic balance was similar. In...

Diabetic tissue damage

In most people's minds diabetes is sugar trouble. Yet most of the problems of diabetes arise, not from the ups and downs of the glucose concentration but from its many tissue complications. Diabetes is a chronic multisystem disorder of which one manifestation is hyperglycaemia. The tissue complications of diabetes are preventable and while we still have much to learn about the causes of diabetic tissue damage, we can at least work on reducing the damage due to factors we have identified....

St Vincent Declaration

Representatives of Government Health Departments and patients' organizations from all European countries met with diabetes experts under the aegis of the Regional Offices of the World Health Organisation WHO and the International Diabetes Federation IDF in St Vincent, Italy on October 10-12, 1989. They unanimously agreed upon the following recommendations and urged that they should be presented in all countries throughout Europe for implementation. Diabetes mellitus is a major and growing...

How to do a fingerprick blood glucose test

Like all laboratory techniques performed outside the laboratory, finger-prick blood glucose measurement is a waste of time unless it is done properly. Important factors are The finger Should be warm, clean, and dry. Wash with water then dry. Sticky fingers give falsely high blood glucose levels. The sides of the finger are less sensitive than the tip. Some people also use their ear lobe. Making the hole Lancets are for single use only and a fresh one is used each time. They can be used alone...

Insulin pen devices

Novorapid Piston

These devices have an insulin cartridge instead of ink and a double-ended needle instead of a nib. This pierces the bung of the insulin cartridge ready for use. The insulin dose is dialled up or clicked in at the other end of the pen. A plunger pushes the bottom of the cartridge down, ejecting the chosen dose of insulin through the needle. Each device has a slightly different action. The pen does the same job as a syringe and needle but there is no need to draw up the insulin dose from a...

Implantable insulin infusion devices

There have been several implantable insulin pumps with an insulin reservoir which can be filled through the skin. The insulin is pumped either directly into a vein or intraperitoneally. At present they are mainly used as a last resort in people in whom no other method has succeeded in preventing frequent diabetic ketoacidosis. When reliable implantable glucose sensors are widely available there will be further exciting possibilities with implantable systems the aim being to have a fully...

Colleagues at work

People with diabetes on sulphonylureas or insulin should tell their work colleagues that they have diabetes. For insulin-treated patients it is sensible to teach one or two colleagues what to do in the event of hypoglycaemia. Everyone on insulin should carry glucose and a supply at work is essential. Some patients keep a supply of insulin and blood testing kit at work this must be locked away. People who give insulin injections at work should do so openly in a clean environment with...

Drawing up insulin

Drawing Insulin Syringe

Drawing insulin into a syringe to the correct dose with no air requires dexterity, concentration, good vision, and a steady hand. The bottle of insulin should be in date and the top should be clean to clean use 70 per cent alcohol . Bottles of cloudy insulin should be rotated gently between two hands to mix the insulin. The insulin bottle is held vertically bung-down and the needle is inserted vertically so that insulin, not air, is drawn up. It is easier to withdraw insulin if air is injected...

Prandial glucose regulators

Like sulphonylureas, these drugs act by increasing insulin release from the pancreas. The main advantage is rapid absorption and action which means they can be taken before meals whenever they are. Because of the short duration of action these agents MONITORING OF ORAL HYPOGLYCAEMIC THERAPY 73 are unlikely to cause hypoglycaemia, and may be particularly helpful in patients who suffer fasting hypoglycaemia on sulphonylureas. They may be combined with metformin, but not with other...

Factors affecting insulin absorption

These are myriad and tend to be forgotten when the patient and diabetes adviser are poring over the blood glucose diary. The size of the insulin depot and the amount of fat surrounding the depot affects absorption. The rate of entry into the blood stream is determined by the circulation through and from the injection site. Thus cold or other stimuli causing vasoconstriction such as nicotine or drugs will reduce absorption, as will shock from whatever cause. Heat will increase absorption as will...

Diabetic nephropathy

If the microalbumin concentration is raised check for infection midstream urine microscopy and culture . If infection is present treat it and then repeat the microalbumin estimation after the infection has settled. Cardiac failure may also produce microalbuminuria. If the creatinine is raised perform a creatinine clearance test. Note that small people or those with low muscle bulk should have creatinine levels at the lower end of the normal range. Do a creatinine clearance if their creatinine...