Blood glucose concentration

Hypoglycaemia is usually defined as a blood glucose below 2.2 mmol l. Most people counter-regulate in some way at these glucose concentrations. At low blood glucose levels blood glucose testing strips may be difficult to read accurately by eye. A meter is better. It is safest to tell patients that if their blood glucose is below 4 mmol l they should stop what they are doing and eat a snack or a meal. They should check their glucose again soon. In a potentially dangerous situation or where rapid...

Contraception

Barrier methods, preferably sheath and spermicide, are the best option, but only if properly used. Condoms protect both partners from infection, protect the cervix from sperm and have no effect on blood glucose. They are also easily bought in a wide variety of shops, supermarkets, and garages. A diaphragm requires gynaecological assessment for fitting and there may be an increased risk of vaginal and urinary infection. However, barrier methods are useless if not used properly planned conception...

Diagnosis

Diabetes may go undetected until the patient attends their doctor for another reason. It may be difficult for any patient to accept that he or she has a disease and should therefore modify his lifestyle and diet, or take medication when he or she does not feel unwell. A community nurse with a special interest in diabetes in Asian people spent one day a week at a day centre. Within a couple of months she had discovered previously unrecognized diabetes in 20 people. When specifying a fasting...

Do they need immunization or prophylactic treatment

People with diabetes should have all the relevant immunizations and their tetanus immunization should always be up-to-date. These may temporarily upset blood glucose balance. Patients must also take antimalarials if appropriate. Advice about food and water hygiene is essential gastroenteritis abroad can be a disaster for someone with diabetes every year several such cases arrive at our airports. Antiemetics, motion-sickness pills, and anti-diarrhoeals, with a course of antibiotics (for example,...

Eating disorders in diabetes

Perhaps because of the constant emphasis on food and diet in diabetes, eating disorders are more common than is realized. Eating disorders associated with diabetes range from restriction of carbohydrate or omitting meals to reduce the blood glucose to a more sinister severe carbohydrate restriction to reduce the insulin dose and reduce weight. Some anorexic patients deliberately induce insulin deficiency and hypergly-caemia to lose weight. They tend to be admitted in biochemical chaos and...

Fatherhood

The diabetic father is under many of the same pressures as the diabetic mother he may be the one looking after the children. In many cases, he may be the breadwinner. They may worry that their diabetes is going to stop them working and make them let their family down. As with working women, they may be working so hard, that they neglect themselves and their diabetes. They may ignore check-ups because they do not wish to take time off work. It may be difficult to contact them but they may be...

Home circumstances

For optimal care, it is essential that people with diabetes live in accommodation in which they can readily maintain a high standard of personal hygiene, where they can keep their medication and equipment secure and where they are not exposed to extremes of temperature, or infection due, for example, to poor food storage or infestation. Every person with diabetes must have a telephone or be able to summon help if taken ill at home, 24 hours a day. If financial difficulties are endangering the...

Insulin injection sites

The most commonly used sites are the thighs, upper buttocks, abdomen, and upper arms. A few patients use their calves and forearms. The conventional wisdom is that patients should rotate their injection sites e.g. left arm Monday morning, left abdomen Monday evening, left thigh Tuesday morning, right thigh Tuesday evening, etc. This is to avoid overuse of a particular site. However, insulin absorption varies with each injection site. It is most rapid from the abdomen, then the arms, thighs, and...

Laser photocoagulation

The aim is to induce regression of new vessels and sometimes to seal leaking new vessels. It is also used to treat maculopathy. Laser treatment prevents severe visual impairment in the majority of patients although the results for maculopathy are less predictable because treatment is close to the macula. Patients should understand that laser treatment may not improve vision but it should stop major deterioration. The treatment is usually given in one or more 30-60 minute sessions as an...

Other problems

If they cannot feel pain, even those who can see or smell a problem may not treat it with the seriousness it deserves 'If it doesn't hurt it can't be too bad'. 'It can't be happening to me.' Those who are aware of the seriousness may be so frightened of losing their foot or leg that they conceal the problems. Partially sighted patients may not be able to see trouble developing on their feet. Marion was a 60-year-old woman with long-standing Type 1 diabetes. She attended diabetic clinic between...

Patients treated with oral hypoglycaemic drugs

Patients may find that there are differences in employment for those on metformin only, as compared with those taking sulphonylureas. There is little risk of hypogly-caemia for people taking metformin alone, and if this controls the diabetes, changing to metformin may help a patient's employment prospects. Patients with tablet-treated diabetes are not usually permitted to join the police, armed services, or fire brigade, or to pilot aircraft. People already working in the police and fire...

Responsibility

Major efforts must be made to prevent hypoglycaemia. These include repeated patient and professional education. People with diabetes clearly have a choice about whether or not to accept medical advice. However, doctors and other health care professionals must ensure that patients understand that hypoglycaemia may not only cause them to injure themselves, but may cause injury to others, for example while driving a car or operating machinery, or requiring the rescue services, perhaps risking the...

Screeningautonomic neuropathy symptomatic patients

Apart from blood pressure, tests for autonomic neuropathy are usually reserved for symptomatic patients. Some are complex. The following can be done with a sphygmomanometer and an ECG machine 1 Lying and standing systolic blood pressure. Normal fall < 10 mmHg abnormal fall > 30 mmHg. 2 Heart rate during and after Valsalva manoeuvre. Find pulse, ask patient to breathe in, then to try to push the breath out hard against a closed glottis for as long as they can. Count the pulse once they've...

Shift work

This can prove difficult for patients on insulin, and sometimes for those on sulphony-lureas. They need to balance the timing of food intake, exertion, and insulin. One regimen is to have evenly spaced meals and snacks when awake, including one before going to sleep. An injection of medium-acting insulin is given before sleeping, and short-or very short-acting insulin is given before meals with an insulin pen. Encourage patients to discuss their work pattern with their doctor many do not do so...

Sick days and missed tablets

If the patient misses a tablet he should not take double next time Discuss each case individually. If the error is realized within two hours of the correct time take the missed dose immediately. In someone on once daily breakfast-time therapy, the missed dose could be taken within four hours of the correct time. If the patient has a vomiting illness or severe diarrhoea not only will he be unable to keep his tablets down (or fail to absorb them) but the illness is likely to push his blood...

Staff

However, some facets of diabetes care do not need to be carried out by a doctor, and some are better done by other health professionals (for example, dietetics, chiropodists). Many surgeries now have a practice nurse. People with diabetes should have regular access to a dietitian and chiropodist, and benefit greatly from the help of a specialist diabetes nurse. It may be possible to share these personnel with the hospital, other practices, or the community...

Sulphonylureas

The drugs, their dosage and approximate duration of action are shown in Table 8.3. Start with a small dose which can be increased every few days according to blood glucose concentrations. Increase chlorpropamide at weekly intervals or longer because of its long half-life. Hypoglycaemia may occur. All sulphonylureas can cause allergic rashes, gastrointestinal disturbances (usually mild) such as anorexia, nausea, and vomiting, and, rarely, reduction in platelets, white cells, or aplastic anaemia....

The businessman or woman

Some of the hazards of the traditional business life are smoking, alcohol, and rich food. As smoking in the work place becomes less acceptable, patients should hopefully find it easier to give up, and to ask that meetings are smoke free. People with diabetes can drink in moderation (21 units a week for men and 14 units a week for women) but must never drink on an empty stomach. To reduce intake alcohol can be alternated with non-alcoholic drinks or diluted. Eating out may place a strain on the...

The diagnosis of hypoglycaemia

A person on glucose-lowering treatment (whether insulin or tablets) who seems unusual or behaves oddly in any way is hypoglycaemic until proved otherwise. It is important for both patient and carers to have a high index of suspicion. This can lead to friction one of my patients pointed out that he can no longer be angry or impatient. Any hint of this is regarded as hypoglycaemia and he is offered glucose. While he understands his family's concern he is fed up with not being allowed to express...

The targets

The aim of diabetes care is to return the patient to as close a non-diabetic state as is safe and practical for that particular person. The targets are set out in Appendix A. Please note that they apply to adults. Children also need careful diabetes care, aiming for safe, near normalization of parameters, but this has particular risks in children. They should be cared for by specialist teams. I have deliberately chosen the most stringent targets available from current literature, recognizing...

Time

Diabetes consultations are not quick. It can take 30 to 60 minutes for a doctor to assess a new diabetic patient thoroughly. Annual reviews take 20 minutes for the doctor's review and 30 minutes for the nurse's review. Add receptionist's and clerical time and the total is about one hour per patient. Visits for glucose balance usually take 10 to 20 minutes. Elderly patients and those with communication problems take longer. Education sessions may take 15 to 60 minutes and as several topics need...

Travel at home and abroad

People with diabetes can travel wherever they wish. However, it is prudent to plan the journey and to ensure that their diabetes and their bodies are in a fit state to travel that they are well supplied with diabetes management drugs and equipment and that they have considered what to do if things go wrong. Diabetes UK issues a series of travel guides for most parts of the world. Clearly, the degree of preparation depends on where the patient is going, for how long, and how remote or...

Vascular disease

Atheroma is common in diabetes, affecting not only large vessels but smaller ones, for example those supplying the legs and feet in which calcification may be seen on X-ray. Poor circulation causes symptoms of its own intermittent claudication, rest pain, and finally gangrene. In addition it worsens other problems by depriving injured or infected areas of oxygen, slowing healing, and allowing anaerobic bacteria to flourish. Antibiotics may not reach the areas of infection in sufficient...

What is hyperglycaemia

Hyperglycaemia may be defined as the blood glucose level above the target zone for an individual patient. However, most patients have 'one-off' levels above their target zone from time to time. Action is required only if hyperglycaemia persists. This may mean for two days in a patient in whom you are aiming for strict normoglycaemia (e.g. a pregnant woman with diabetes), or for three to five days in others. It is important not to cause hypoglycaemia by overzealous normalization of the blood...

When counterregulatory hormones are released

As the blood glucose falls, it stimulates release of adrenaline, noradrenaline, glucagon, cortisol, and growth hormone. Adrenaline causes tachycardia with palpitations and tremor. Glucagon released from the pancreatic islet cells stimulates glucose release from the liver. However, in people with diabetes the glucagon response may be blunted or absent and excess insulin inhibits liver glucose release. The 'emergency' hormonal response to hypoglycaemia is called counter-regulation. Hypoglycaemia...

Patients with complicated diabetes

Insulin has been used in patients with severe painful diabetic neuropathy, even if their glycaemic balance approximates to normal on oral therapy. The rationale is that aggressive normalization of the blood glucose with insulin may relieve the symptoms. Patients with other tissue damage may benefit. Patients with severe hypertriglyceridaemia (i.e. 10 mmol l or more) and diabetes may need very good control and therefore are usually treated with insulin to achieve normoglycaemia and...

A low blood glucosehypoglycaemia

Some patients may feel that health care professionals are more concerned about normalization of blood glucose concentration than the occasional hypoglycaemic episode. But for the person who has diabetes, hypoglycaemia can be a terrifying experience to be avoided at all costs. To this end the person may aim for persistent hyperglycaemia, preferring the absence of hypoglycaemia now to the vague and distant threat of long-term tissue damage. Many older patients still cling to the old advice to...

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...

Autonomic neuropathy

Two in five patients with diabetes have some evidence of autonomic neuropathy when tested in detail, but symptoms are uncommon. If the patient does have symptoms these may be unpleasant and the prognosis is poor. One in two patients with symptomatic autonomic neuropathy will be dead within 5 years. Symptoms include postural hypotension impotence altered sweating ankle swelling gastroparesis loss of hypoglycaemia warning diarrhoea or constipation sudden death All patients with evidence of...

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...

Complication Check

Diabeticare Hillingdon Hospital

gt Dipstick protein ABSENT but raised microalbumin creatinine ratio on 3 occasions Creatinine above normal range Blue White Foot ischaemia Lisinopril 2.5 mg od adjust dose until BP lt 125 75 Refer to Diabeticare Foot Service Out of Hours contact on-call Medical Reg If severe no response to treatment in 2 days Diabetes in Hillingdon Referral letter Date of appointment Date of referral T 01895 279265 F 01895 279521 T F Date of birth NHS number Hospital number Symptoms thirst polyuria weight loss...

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...

Guidelines for doctors

Sunset Foot Ischaemia

Examine every diabetic patient's feet on diagnosis and annually. On examination check Skin colour, ulcers, rubs, blisters, corns, calluses, etc. Foot and toe shape hammer or claw toes, bunions, missing toes, surgery, deformities Fig. 14.1 The diabetic foot warning signs during exami- Infection nation Pulses dorsalis pedis and posterior tibial Sensation light touch, Monofilament, vibration, position Colour change Red foot infection or 'sunset' ischaemic foot white no circulation blue black...

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...