Diabetes: A guide to diagnosis and medical treatment

2021-07-27 11:10 PM

Diabetes mellitus is a chronic state of hyperglycemia, characterized by disturbances of carbohydrate metabolism, accompanied by disturbances of lipid and protein metabolism.

Worldwide, the prevalence of type 2 diabetes is estimated to be 6.4 percent in adults, varying from 3.8 to 10.2 percent by region; Undetected diabetes rates can be as high as 50% in some areas.

Type 2 diabetes accounts for more than 90 percent of patients with diabetes. Due to associated microvascular and macrovascular diseases, at least half of them are associated with complications such as myocardial infarction, stroke, end-stage renal disease, retinopathy, and ulcerative foot disease. . Many other factors also contribute to the impact of diabetes on quality of life and economy. Diabetes is associated with high rates of emotional illness and adversely affects employment, absenteeism, and work productivity.

Recommendations regarding screening of asymptomatic patients for type 2 diabetes. Screening pregnant women for gestational diabetes and evaluating patients for signs and symptoms of diabetes (tears, polyuria, blurred vision, paresthesia, or unexplained weight loss) are discussed separately. In addition, the prevention of type 2 diabetes in patients with impaired glucose tolerance (IGT) is discussed separately.

Diabetes mellitus is a chronic state of hyperglycemia characterized by disturbances of carbohydrate metabolism, accompanied by disturbances of lipid and protein metabolism due to an absolute or relative decrease in the biological effects of insulin and/or insulin secretion.

Classify

Type 1 diabetes: due to autoimmune disease: pancreatic p-cells are destroyed by immune mediators, this destruction can be rapid or slow. Rapid progression is seen in young people < 30 years old, clinical symptoms are intense, thirst, drinking a lot, weight loss, fatigue. Antibodies to islet cell autoantibodies (ICA), autoantibodies to insulin, and autoantibodies to GAD (glutamic acid decarboxylase) appear in 85-90% of cases. The most common acute complication is a ketoacidosis coma. Treatment requires insulin therapy, the incidence is < 10%. The slow-growing form that is common in adults is called latent autoimmune diabetes in adults (LADA).

Type 2 diabetes: Type 2 diabetes was formerly known as non-insulin-dependent diabetes, adult diabetes, and familial disease. Type 2 diabetes is characterized by insulin resistance accompanied by relative insulin deficiency. Age > 30 years old, clinical symptoms are silent, often detected late. The most common acute complication is hyperosmolar coma. May be treated with diet, oral medications, and/or insulin. The incidence is 90-95%.

Gestational diabetes: Gestational diabetes is a disorder of blood sugar tolerance that occurs during pregnancy.

Other specific hyperglycemia conditions: decreased beta-cell function due to genetic defects: MODY 1, MODY 2, MODY 3, mitochondrial diabetes, decreased insulin activity due to gene defects.

Pancreatic diseases: pancreatitis, fibrosis, pancreatic stones, pancreatic cancer,... Some endocrine diseases: enlarged dipoles, Cushing's syndrome,... caused by drugs, chemicals, infections.

Definite diagnosis

As recommended by the American Diabetes Association (ADA) in 2010, based on 1 of 4 criteria 4

(first). HbA1c ≥ 6.5%. Tests must be performed in a laboratory using standard methods.

(2). Fasting blood sugar Go ≥ 7.0 mmol/L (≥ 126 mg/dL).

Fasting blood sugar Go is measured when you have fasted for at least 8 hours.

(3). The 2-hour blood sugar in the G2 glucose tolerance test is ≥ 11.1 mmol/L (≥ 200 mg/dL).

 The glucose tolerance test must be performed according to the WHO model, using 75 grams of glucose.

(4). Any blood sugar ≥ 11.1 mmol/L (≥200 mg/dL) in symptomatic disease of classic diabetes.

Pre-diabetes:

 (first). HbA1c from 5.7 to 6.4%.

(2). Impaired fasting glucose (IFG), with a fasting blood glucose of 5.6 to 6.9 mmol/L (100 to 125 mg/dL) and

(3). Impaired glucose tolerance, RLDNG (impaired glucose tolerance, IGT), 2-hour blood sugar in the G2 glucose tolerance test measured in the range of 7.8 - 11 mmol/L (140 - 199 mg/dL).

Two points to keep in mind in pre-diabetes:

(first). Blood glucose levels are higher than normal, but not enough to diagnose diabetes and

(2) There is already a state of insulin resistance, which means that insulin is no longer effective.

According to the diagnostic criteria of the World Health Organization 1998

Fasting blood glucose (blood glucose - GM) > 1.26g/l = 7.0mmol/l (at least twice).

GM at any time s 2g/l = 11 mmol/l with clinical symptoms or GM after 2 hours of testing for hyperglycemia > 11.1mmol/l.

If 1.1 g/l < GM < 1.26 g/l: need to do a glucose tolerance test to confirm the diagnosis.

Board. Diagnose diabetes or impaired glucose tolerance by capillary or venous glucose

Conclusion

Capillaries

(mmol/L)

Vein

(mmol/L)

 

Diabetes

Hungry

≥ 6,1

≥7,0

After 2 hours

11,1

11,1

Impaired glucose loading

Hungry

<6,1

>7,0

After 2 hours

≥7,8

≥7,8

 

Laboratory testing

Blood sugar: fasting, 2 hours after eating.

HbA1c: first detected and every 3 months.

Blood biochemistry: blood creatinine, cholesterol, triglycerides, HDL-C, LDL-C (at diagnosis and every 3 months).

Urinalysis is done routinely. Microalbuminuria (after > 5 years for type 1 diabetes and at the time of diagnosis for type 2 diabetes).

Electrocardiogram: first detected and every 6 months.

Doppler ultrasound of the carotid and leg vessels: at the time of diagnosis, when there is suspicion of injury.

Cardiopulmonary imaging: at the time of diagnosis and when lung injury is suspected.

Eye exam: at diagnosis and after each year. When there is eye damage: every 3 -6 months.

Treatment

Treatment goals

ADA glycemic control goals, 2010.

HbA1c <7% is considered a common goal for both type 1 and type 2 diabetes.

Fasting blood glucose (GM) should be maintained at 3.9 - 7.2 mmol/l (70 - 130 mg/dl).

2 hours postprandial GM <10mmol/l (<180mg/dl).

Treatment of accompanying risk factors: hypertension, dyslipidemia (refer to the section on treatment of chronic complications of diabetes patients).

Non-drug treatment regimen - hyperglycemia

Diet:

Follow a reasonable and balanced diet with ingredients: glucid 50-60%, protid 15-20%, lipid 20-30% of total calories in the day, should choose foods with a high glycemic index (GI) ) low, high in fiber (vegetables 100 - 200g/meal), abstain from sweets. Type 2 diabetes eats 3 main meals (breakfast, lunch, dinner). Patients who are injecting insulin can divide into 4 -5 meals to prevent hypoglycemia.

Physical activity:

At least 30 minutes, 5 days/week, pay attention to check blood sugar, blood pressure, cardiovascular status before exercise. All types of exercise are walking, swimming, badminton, climbing stairs. But choosing which type must be appropriate to the health situation and complications and comorbidities of each patient (note when 14mmol/l < fasting blood sugar < 5mmol/l without exercise), it is necessary to consult the doctor. Specialist doctors about the form of exercise and how to monitor blood sugar before and after exercise.

Treatment with insulin

Insulin treatment regimen.

Point:

Is mandatory for type 1 diabetes, gestational diabetes.

Type 2 diabetes in the presence of:

Decompensation due to stress, infection, acute wound, hyperglycemia with severe acute hyper ketosis. Uncontrollable weight loss.

Surgical intervention.

Pregnant.

Liver and kidney failure.

Allergy to hypoglycemic drugs.

Failure with hypoglycemic tablets.

Indicated temporarily as soon as there is high blood sugar > 250-300mg/dl (14 - 16.5mmol/l), HbA1c > 11%.

Diabetic coma with ketoacidosis or hyperosmolarity.

Diabetes due to pancreatic disease: chronic pancreatitis, after pancreatectomy...

In some cases, the patient's insulin requirements are high: treat some drugs that cause hyperglycemia (corticoids).

Insulin injection dose:

The insulin dose required in patients with type 1 diabetes is from 0.5 to 1.0 IU/kg body weight. The starting dose is usually 0.4 - 0.5 UI/kg/day. The usual dose is 0.6UI/kg, injected under the skin 1-2 times a day. Then, based on the results of blood sugar, increase or decrease insulin dose from 1 - 2 UI / time.

Insulin dose in patients with type 2 diabetes mellitus: starting from 0.2 UI/kg/day. Usually 0.3 - 0.6UI/kg/day.

Basal insulin dose 0.1 - 0.2UI/kg.

Insulin injection site (see Appendix for insulin injection site map).

Treatment regimens:

There are many different insulin regimens. For type 1 diabetes, a regimen of 2 to 4 doses a day is usually used. For type 2 diabetes in addition to the regimen such as type 1 diabetes, it is possible to use a regimen of 1 insulin injection in combination with pills (Insulatard or Lantus).

Gestational diabetes usually uses a regimen of 1 - 4 doses/day depending on the patient's blood sugar level. Use only biosynthetic insulin (Actrapid, Mixtard, Insulatard).

One-shot insulin regimen: combine diabetes pills with one shot of intermediate- or mixed-acting insulin before dinner or one shot of intermediate-acting insulin or Glargine in the evening before bedtime. Dosage 0.1 - 0.2UI/kg.

2 insulin regimen: usually use 2 injections of intermediate-acting insulin or mixed insulin before breakfast and dinner. Divide dose by 2/3 before breakfast, 1/3 before dinner. When the above treatment regimen fails, the diet and lifestyle are erratic or when it is necessary to closely control blood sugar such as during pregnancy or when there are severe complications that need to be switched to other regimens with multiple injections. insulin.

Multiple insulin regimen: inject 3 times a day: 2 injections of rapid insulin and 1 injection of semi-slow or 2 injections of semi-slow insulin or basal insulin. Inject 4 times a day: 3 shots of rapid-acting insulin before 3 meals and 1 shot of NPH-type basal insulin at bedtime (21-22 hours) or Glargin (Lantus).

Table of Types of insulin by the duration of action

Insulins types

Start to work

(Hour)

Maximum effect

(Hour)

Lasting effect

(Hour)

Apart (Novo Log)

Lispro(Humalog)

10-20 minutes

1

3-4

Regular

0,5-1

2-4

6-8

NPH

Lente

1,5-3

2-4

4-10

7-12

12-2

16-22

Mixtard(NPH/Regular)

(70/30,80/20,40/60)

0,5-1

4-10

10-16

Utralente

4-8

Dose-dependent

18-30

Glargine (Lantus)

1-2

No

24

Treatment with oral drugs

There are the following classes of drugs.

Drugs that stimulate the pancreas to secrete insulin (sulphonylurea):

Sulphonylurea types: gliclazide (Diamicron MR 30mg, Diamicron 80mg, Predian 80mg. Glimepiride (Amaryl 2 -4mg). Glibenclamid (Glibenhexal 3,5mg). Glyburide (1,25/2,5/5mg). Glipizid (Glucotrol 5/1 Omg).

Indications: type 2 diabetes with a moderate or thin body. Combination with metformin, thiazolidinedione (TZD), acarbose, insulin.

Contraindications: type 1 diabetes, renal failure, severe liver failure, diabetic ketoacidosis, pregnancy or allergy to sulfolilurea.

Side effects: hypoglycemia, allergies, weight gain.

Dosage: gliclazide 30-120mg/day orally 15-30 minutes before meals.

+ Glimepiride from 2-8mg/day orally once a day 15-30 minutes before meals (taken once a day).

+ Glibenclamide from 3.5 - 20mg/day divided equally before each main meal 15-30 minutes.

Drugs that increase peripheral insulin sensitivity and reduce insulin resistance:

Metformin, thiazolidinediones. Biguanide: the only drug still in use is metformin.

Mechanism of action: by reducing gluconeogenesis in the liver, inhibiting glucose absorption in the gastrointestinal tract and increasing glucose uptake in skeletal muscle.

Indications: type 2 diabetes, especially in overweight or obese patients.

Contraindications: type 1 diabetes, ketoacidosis, peripheral hypoxia (heart failure, respiratory failure), renal failure, liver dysfunction, pregnancy, low-calorie diet (for weight loss) ), immediately before and after surgery or patients > 70 years old.

Dosage: Glucophage tablets 500, 850,1000mg; Meglucon 850mg tablets. Dose from 500 - 2500mg/day, taken immediately after meals.

Side effects: side effects on the gastrointestinal tract such as anorexia, nausea, vomiting, abdominal bloating, diarrhea... found in 20% of patients. This side effect is dose-related, occurs frequently at the start of treatment, and is usually transient. There are 3-5% of patients who have to stop the drug. Rare side effects, toxicity on the skin, hematology. Metformin does not cause hypoglycemia. Lactic acidosis is not actually a side effect but is often caused by disregarding contraindications such as advanced age, alcoholism, liver failure, kidney failure, heart failure or respiratory failure.

Thiazolidinedione:

Mechanism of action: unclear but the observed effects are increased glucose transporters (GLUT 1 and GLUT 4). Reduces free fatty acids. Decreased gluconeogenesis in the liver. Increases differentiation of pre-fatty acids into fatty acids. Like biguanides, thiazolidinediones (TZDs) do not cause hypoglycemia.

Indications: combination therapy with sulfonylurea or metformin or insulin.

Contraindications: hypersensitivity to the drug and its components, pregnancy and lactation, liver disease (ALT enzyme greater than 2.5 times the upper limit of normal), heart failure.

Dosage: pioglitazone (Pioz 15mg tablet): dose 15-45mg/day. The drug is taken once a day, away from meals, can be taken before breakfast.

Side effects: often causes weight gain, mainly due to increased subcutaneous fat storage and partly due to water retention. Therefore, caution should be exercised when treating TZDs in patients with heart failure or heart disease, hepatitis, or elevated liver enzymes.

Alpha-glucosidase inhibitors reduce glucose absorption:

Mechanism of action: the drug affects glucose absorption: inhibits glucose absorption, reduces postprandial blood sugar.

Indications: slight increase in blood sugar after eating. Monotherapy in combination with diet or in combination with other drugs.

Dosage and Administration:

+ Acarbose (Glucobay 50 and 10Omg tablets): 50 - 200mg x 3 times/day.

+ Voglibose (Basen tablets 0.2 and 0.3mg): 0.2 - 0.3mg x 3 times/day.

+ Miglitol (Gliset tablets 25, 50 and 100mg): 75 - 300mg x 3 times/day.

Take the medicine after the first bite of rice. Start with the lowest dose and increase gradually according to response to treatment or severity of side effects.

Side effects: nausea, bloating (20-30% of patients taking Glucobay). Feeling of needing to go out, diarrhea (3% of patients taking Glucobay).

Glind Team:

Mechanism of action: the drug stimulates pancreatic beta cells to secrete insulin. The effect of the drug is similar to that of a sulfonylurea but shorter and weaker.

Indications: postprandial hyperglycemia. Take the medicine 1-10 minutes before a meal, usually the main one.

Dosage and administration: meglitinide (Starlix), repaglinide (Prandin, Novonorm tablets 1 and 2mg): 0.5 - 4mg/time, taken 15 minutes before meals.

Side effects: low blood sugar.

Drugs that act on the incretin system:

GLP-1 isomers (glucagon-like peptide 1)

Mechanism of action: stimulates insulin secretion when blood glucose levels rise after eating. GLP-1 also reduces glucagon secretion, slows gastric emptying, and reduces appetite. The result is a drop in blood sugar after eating.

Indications: type 2 diabetes, postprandial hyperglycemia.

Dosage and administration: exenatide drug (Byetta pen injection), subcutaneous injection 5 or 10μg, 2 times/day, 60 minutes before meals.

Side effects: nausea occurs in 15 - 30% of patients (usually self-limited), hypoglycemia may occur when used with drugs that stimulate insulin secretion.

DPP IV inhibitors:

Mechanism of action: inhibits GLP-1 degrading enzyme, DPP IV (dipeptidyl peptidase IV), thereby increasing the concentration and effect of endogenous GLP-1.

Indications: type 2 diabetes, postprandial hyperglycemia.

Dosage and administration: sitagliptin (Januvia tablets 25, 50 and 100mg). Dosage adjustment is required in patients with renal impairment.

Side effects: nausea (but less so than with GLP-1 isomers), headache, sore throat.

Amylin isomer:

Mechanism of action: reduce postprandial blood sugar due to inhibition of glucagon secretion, slow gastric emptying, rapid satiety, increase GLP.

Indications: type 1 and type 2 diabetes.

Dosage and administration: pramlintide (Symlin injection pen), injected under the skin 30μg - 120μg, right before the main meals, it is necessary to reduce the insulin dose when starting the combination of 2 drugs.

Side effects: vomiting, nausea, loss of appetite, headache.

Initial drug selection

Monotherapy:

Obesity, dyslipidemia: choose metformin or glitazone, or alpha-glucosidase inhibitors (note contraindications of each drug class).

Fasting blood sugar > 13.7mmol/l, lean: choose sulfonylurea or insulin.

Postprandial hyperglycemia: choose the alpha-glucosidase inhibitor group.

Blood glucose > 16.5 mmol/l and/or HbA1c > 10%: insulin therapy immediately.

Combination of drugs: when monotherapy is not achieved, the following combination can be used:

MET + SU, if postprandial hyperglycemia adds an alpha-glucosidase inhibitor. If the goal is not reached, add insulin before bed (basal insulin or insulin NPH) or switch to insulin 2 - 4 ml/day.

Alpha-glucosidase inhibitor + su + Met.

SU + Met + alpha-glucosidase inhibitor.

Met + SU + alpha - glucosidase inhibitor + insulin.

(SU: Sulphomylurea; Met: Metformin.)

Treating risk factors

Hypertension, dyslipidemia, treatment of complications...

Prevention

Level 1 prevention for people at high risk of diabetes (obesity, hypertension, family history of diabetes, dyslipidemia, women with a history of giving birth to a large baby > 4kg). and < 2.5 kg, smoking): by consulting a reasonable diet, increasing physical activity, examining and doing periodic blood tests.

Level 2 disease prevention: to slow down the progression of complications for those who already have the disease by counseling on a reasonable diet, increasing physical activity, and good adherence to the treatment regimen.