Management principles

• Provide detailed and comprehensive patient education, support and reassurance.

• Achieve control of presenting symptoms.

• Achieve blood pressure control (< 140/90 mmHg supine).

• Emphasise the importance of the diet: good nutrition, adequate complex carbohydrates, restricted fats and sugars.

• Promptly diagnose and treat urinary tract infection.

• Treat and prevent life-threatening complications of ketoacidosis or hyperosmolar coma.

• Treat and prevent hypoglycaemia in those having insulin and oral hypoglycaemic agents.

• Organise self-testing techniques, preferably blood glucose monitoring.

• Detect and treat complications of diabetes—neuropathy, nephropathy, retinopathy, vascular disease.

• Beware of the deadly quartet (syndrome X): 5

1. upper truncal obesity

2. dyslipidaemia

■ T triglycerides

■ I HDL cholesterol

3. glucose intolerance, i.e. NIDDM

4. hypertension

These are all risk factors for coronary atherosclerosis. Monitoring techniques

• blood glucose estimation (fasting and postprandial)

• urine glucose (of limited usefulness)

• urine ketones (for type I diabetes)

• glycosylated haemoglobin (HbAIc) (essential to know glycaemic control)

• microalbuminuria (regarded as an early and reversible sign of nephropathy)

• blood pressure

• renal function (serum urea/creatinine)

Control guidelines are summarised in Figure 17.1 and Table 17.3 .

Table 17.3 Suggested guidelines for glycaemic control (plasma glucose mmol/L)

Ideal Acceptable (fair) Suboptimal or unacceptable

After meals (2 hours postprandial) < 7.7 7.7-11 > 11

* HbAIc is an index of the mean plasma glucose levels over the preceding 2-3 months (assume a reference range of 4.5-8%). The reference ranges vary in different laboratories.

higl^

poor blood glucose level mimol/L

poor blood glucose level mimol/L

hypoglycemia low

Fig. 17.1 Control guidelines for diabetic management

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