CDA CPGs 2008
Dx Diabetes.ppt

Pt visit
q3mos


wgt/BMI
(normal: 18.5-24.9; overwt: 25-30; obese: >30)
BP (target: ≤130/80)
A1C (target: <7%)
BG records (target: premeal 4-7; 2 h postmeal 5-10)
hypoglycemic episodes:
tob:
EtOH:
diet:
exercise:

Annually


waist circumference (target (cm): male: caucasian ≤ 102; Asian ≤ 90
female: caucasian ≤ 88; asian ≤ 80)
lipids (target: LDL <2.0; TC/HDL <4.0)
ACR (target: M: <2.0; F: <2.8)
10g monofilament:
annual eye exam by ophth or optom:
annual flu:
Pneumovax:

Diagnoses


	FPG	PG 2 hrs post-75g glucose
Normal	≤ 6.0	< 7.8
Impaired fasting glucose	6.1 - 6.9	< 7.8
Impaired glucose tolerance	≤ 6.0	7.8 - 11.0
IFG & IGT	6.1 - 6.9	7.8 - 11.0
Diabetes mellitus	> 6.9	> 11.0

IFG &/or IGT = "pre-diabetes"

DM if:

FPG > 6.9 or
PG 2 hrs post-75g glucose > 11.0 or
random PG > 11.0 & S&S's of DM

Mgt DM2

Insulin sliding scale
Give scheduled insulin subcutaneously (e.g. Regular, NPH)
TID ac meals (NOT qhs due to risk of overnight hypoglycemia)


Blood Glucose mmol/L	Low Insulin Resistance	Intermediate Insulin Resistance		High Insulin Resistance
< 4	Follow Hypoglycemia Protocol
4.1-8	0 units		0 units	0 units
8.1-10	0 units		0 units	2 units
10.1-12	0 units		2 units	4 units
12.1-14	2 units		4 units	6 units
14.1-16	4 units		6 units	8 units
16.1-18	6 units		8 units	10 units
18.1-20	8 units		10 units	12 units
> 20	8 units & call MD		12 units & call MD	14 units & call MD

DKA

ABCs
O2 - IV - Monitor
Chemstrip BG
EKG
CBC, electrolytes, BUN, creatinine, Ca, Mg, PO4
ABG


IV fluids

Normal saline or Ringer’s lactate
Most adult pts have approx 100cc/kg deficit
If mild dehydration: estimated deficit of 3L
1st litre over 1st 30 mins
2nd litre over next 1 hr
3rd litre over next 2 hrs
One more litre over next 4 hrs if necessary

IV insulin
0.1 U/kg/hr short acting insulin
Subcutaneous insulin has erratic absorption in volume-depleted pts
Avoid correction of hypoglycemia b/c risk rebound ketosis
Avoid rapid correction b/c risk edema brain, lungs

Potassium

3-5 meq/kg deficit dt osmotic diuresis, vomiting
Goal: plasma K+ 4.0-5.0 meq/L
If plasma K+ 3.0-4.5 meq/L → 20 meq/hr
If plasma K+ 4.5–6.0 meq/L → 10 meq KCl/hr
If plasma K+ > 6.0 meq/L → withhold KCl b/c profound acidemia; fluids & insulin will lower K+

If K+ > 6.5 mmol/L or dysrhythmia

↓

Ca gluconate 10% 10 ml slowly (preferably via central venous catheter b/c the calcium may cause phlebitis) → ↓ myocardial excitability protecting against life-threatening arrhythmias.

↓

Regular insulin 10-15 u IV along with D50W 50 ml (to prevent hypoglycemia) → shift K+ into cells

↓

NaHCO3 1 amp (45mEq) infused over 5 mins) is effective in cases of metabolic acidosis.

↓

Salbutamol 10-20 mg by nebulizer → shift K+ into cells

↓

Dialysis

If not so severe:
Polystyrene sulfonate (binds K within the intestine)


Calcium resonium 15 g PO TID
Kayexelate 30 g PO
Diuretic (e.g. furosemide, hydrochlorothiazide)

Thyroid Dysfunction

SYMPTOMS OF HYPOTHYROIDISM
• Weight gain
• Lethargy
• Cold intolerance
• Menstrual irregularities
• Depression
• Constipation
• Dry skin


SYMPTOMS OF HYPERTHYROIDISM
• Palpitations/Tachycardia/Atrial fibrillation
• Widened pulse pressure
• Nervousness and tremor
• Heat intolerance
• Weight loss
• Muscular weakness
• Usually goiter is present






Tx Hypothyroidism
Levothyroxine 1.6 mcg/kg PO daily (usual maintenance dose 50 - 200 mcg/day)

For elderly or patients with cardiac disease, consider starting levothyroxine at quarter to half of regular dose and titrate slowly. Monitor for tachycardia and angina.

Titrate dose every 6 - 8 weeks until TSH within normal range. Three to four months after the start of treatment, measure FT4 as well to decide any need for a minor adjustment in the dose. Once target dose reached, may check TSH annually.