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Diabetes mind map 2- management - Coggle Diagram
Diabetes mind map 2- management
Type 1
Assessment
Treatment targets, SMBG, sick day rules, hypoglycaemia,
target hba1c 48% to reduce complications, check every 3-6months
SBMG (qds) targets- 5-7mmol/l on waking, 4-7mmol/l before meals and 5-9mmols/l at least 90mins after meals
Hospital admission- immediate risk of DKA, moderate ketonuria (+2) or ketonaemia (1.5-2.9) with or without hypoglycaemia,. Underlying condition is unclear, patient is dehyrated, vomiting persists after 2 hours, BG levels unable to be maintained above 3.5mmol/l.
Sick day rules- Do not stop insulin-dose adjustment may be required.Increase frequency of SMBG Consider ketone monitoring. CHO drinks if intake of meals reduced. 3l fluids per day to prevent dehydration.
T1 &T2
Contact number diabetic specialist team
Lifestyle issues-diet,exercise, alcohol, smoking, driving
Structured Education Programme e.g DAFNE
Diabetes support group- Diabetes UK
Individual Care Plan
Assessment and risk assessment of Renal disease, cardiovascular disease and neuropathy
Information on DKA and hypoglycaemia
Risk monitoring T1&T2 -annually
Foot screening
moderate risk 3-6 months
high risk -1-2months
low risk-annually
CV
Smoking status, weight, BMI, BP, blood glucose control, FHx CVD, Waist circumference, Lipid profile-HDL,LDL and triglycerides
Renal
early morning urine ACR
people with ACR greater than 3mg/mmol, should be considered at greater CVD risk
serum creatinine
eGFR of less than 60 mL/min/1.73 m2 is associated with a higher risk for complications of CKD.
always take MSU to rule out raise due to infection
Retinal screening
annual screening
Other: risk of autoimmune disease e.g. thyroid, coeliac, addisons, pernicous anaemia, and complications like erectile dysfunction and gastroparesis
Management T1 &T2
Lipid modification therapy
Lifestyle advice-smoking, diet, exercise,alcohol, liver, thyroid and kidney disease
check suitability- LFTs, U&Es, non fasting lipid profile and if muscle pain Creatinine Kinase
Rx - no established CVD- atorvastatin 20 mg for the primary prevention of CVD. Established CVD- Atorvastatin 80mg for secondary prevention
Antiplatelet treatment
Antihypertensive therapy
albuminuria, or 2 or more features of the metabolic syndrome, BP ≥ 130/80mmhg
no albuminuria or features of the metabolic syndrome, BP ≥ 135/85mmhg
Rx- ACE inhibitor, if not tolerated offer AIIRA,
low dose titrate up by doubling dose every1-2weeks
other antihypertensive drugs may be used to manage control
Target range- systolic below 125 and diastolic below 80mmhg
Neuropathy
optimum blood glucose control
paracetamol or NSAIDS, and bed cradle
Offer a choice of amitriptyline, duloxetine, gabapentin, or pregabalin
evaluate hx of drug abuse before px pregablin or gabapentin
Consider capsaicin 0.075% cream (Axsain®) for people with localized neuropathic pain who wish to avoid, or cannot tolerate, oral treatments.
consider referral to pain clinic
Referral
CKD &T1DM Arrange an urgent 2-week wait referral if a urological cancer is suspected
Refer to a nephrologist for specialist assessment (unless already appropriately managed)
Hospital admission- immediate risk of DKA, moderate ketonuria (+2) or ketonaemia (1.5-2.9) with or without hypoglycaemia,. Underlying condition is unclear, patient is dehyrated, vomiting persists after 2 hours, BG levels unable to be maintained above 3.5mmol/l.
Type 2
Assessment
Treatment target-Hba1c 48%, unless treatment with drug assosciated with hypoglycaemia e.g. sulphonylurea- 53%
Check HbA1c initially 3-6 monthly, then 6 monthly
if Hba1c rise to 58mmol/l or higher- reinforce diabetic diet, aim for 53, and intensify antidiabetic drug treatment
SMBG only if on insulin, hypoglycaemic episodes, drugs which may increase risk of hypoglycaemia (sulphonylureas), pregnancy, treatment with corticosteroids
Sick day rules- as T1
Type 2 Treatment
if ist line treatment offer dual Tx metformin with gliptin, pioglitazone, sulfonylurea, SGLT-2i
if metformin CI
A gliptin plus pioglitazone, or A gliptin plus a sulfonylurea, or Pioglitazone plus a sulfonylurea or An SGLT-2i instead of a gliptin if a sulfonylurea or pioglitazone is not appropriate
if metformin not tolerated or contraindicated consider- a gliptin, pioglitazone, sulfonylurea, SGLT-2i
if second line treatment not effective consider triple therapy
Standard release metformin. If GI upset, offer modified release metformin. Monitor renal function.