Diabetes Care for the Older Patient: A Practical Handbook
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If hyperglycaemia is confirmed, treat the patient accordingly as previously discussed , but send a pre-treatment blood sample to the labo- ratory for blood glucose estimation Pregnancy Many authorities consider that these diagnostic criteria for blood glucose also apply to pregnant women. However, different criteria are sometimes used in pregnancy E p. Retrospective diagnosis of diabetes Occasionally, a doctor is presented with a patient in whom oral hypoglycae- mic treatment for diabetes has already been started without proper confir- mation of the diagnosis. This should not occur if the guidelines are followed.
If the patient is seen within six weeks of starting medication, the finding of a raised HbA1c E p. Sometimes oral hypoglycaemic treatment has to be stopped to allow clarification of the diagnosis. There are 3. The two main types are type 1 previously called insulin-dependent diabetes or juvenile-onset diabetes and type 2 previously called non-insulin-dependent or maturity-onset diabetes.
It can be very difficult to decide what type of diabetes a patient has; treat the patient and the glu- cose and seek specialist advice. The need for insulin treatment does NOT define diabetes type. Time sometimes provides the answer. There are symptoms over weeks or months, with high glucose, high HbA , ketones and islet cell or antiGAD-Ab antibodies present.
Type 1a may also present as late onset autoimmune diabetes LADA in apparent type 2 diabetic patients. Parental diabetes is uncommon.
A Practical Handbook
This is rare and dangerous. Type 2 diabetes Click Here!! Type 2 diabetes is a multi-factorial condition. Multiple genes have been implicated in vari- ous combinations with significant interaction with environmental factors. TCF7L2 shows the strongest association Diabetologia ; —4; doi: Type 2 diabetes is largely a diagnosis made when other forms have been excluded and it includes multiple vari- ants, most with unclear cause.
Most patients have metabolic syndrome. While many can be managed by diet, exercise, and oral hypoglycaemics, many come to need insulin. Type 2 diabetes is usually a combination of relative insulin lack and insulin resistance. Early-onset type 2 diabetes is an unusual variant which starts between 25 and 40 yrs. It is associated with obesity. Insulin is often needed and microvascular complications are common. This affects 30 —60 people in the UK.
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MODY is used here as the familiar term. This usually starts in those under 25 yrs old. MODY is slowly progressive and seldom needs insulin. Seek advice before arranging tests or family screening for suspected MODY.
Diabetic cycle of care
Maternally inherited diabetes and deafness MIDD This mitochondrial disorder in men and women, inherited via the female line, affects up to people in the UK. It is usually diagnosed in middle age, although it can affect any age. Most patients are short and not over- weight.
MIDD can usually be treated with tablets at first avoid metformin although many people need insulin within two years. Patients may also have heart rhythm problems, myopa- thy, kidney and eye disease, and constipation. Seek expert advice about For Best Diabetes Treatment Table 1.
Anyone with any type of diabetes may need insulin treatment. The use of insulin does NOT define the type of diabetes.
Diabetes Care - Diabetes Care - Research Guides at Drake University
Corticosteroids, thiazides, antipsychotics, antiretrovirals Infections, e. We await the WHO classification. Other forms of diabetes Some patients are difficult to classify but can still be treated on clinical and biochemical assessment.
African—Caribbean patients presenting in DKA may have ketosis-prone type 2 diabetes or type 1b diabetes. There is a sub-Saharan variant. Tropical diabetes is rarely seen in the UK. It is associated with pancreatic calculi fibrocalculous and, sometimes, with Those in whom diabetes is part of a complex syndrome may have deafness, early visual problems, and other physical abnormalities. Inheritance of diabetes Click Here!! For Best Diabetes Treatment Much more is known about this complex topic than in the past. Diabetes—a high blood glucose—is the endpoint of thousands of different genetic and environmental interactions.
Genetic studies have identified multiple genes linked in various ways to type 1 and type 2 diabetes. Type 2 diabetes The chance of inheriting type 2 diabetes is harder to assess as some indi- viduals do not develop the disease until they are in their eighties. We now know that many genetic and environmental factors interact to produce type 2 diabetes. MODY is dominantly inherited; i. Miscoding, misclassification, and misdiagnosis of diabetes Classification of diabetes is much more complex than previously believed.
If in doubt about the type of diabetes, explain to the patient that he or she has diabetes but it may take a little time to clarify exactly which type. Glucose-lowering treatment and management of any risk factors or com- plications can continue. Typing is important for optimal management, espe- cially glucose-lowering. If in doubt seek specialist advice.
Misunderstandings may lead to wrong diagnoses being recorded. In particular, insulin treatment in people with type 2 diabetes may be recorded as type 1. Investigation of routinely collected primary care data showed that 2. Diabet Med ; —9. On release into the circulation the insulin and C-peptide separate.
The presence of C-peptide is a sign that the patient is making his or her own insulin. At diag- nosis people with all types of diabetes may be making some insulin—usually much less in type 1 than type 2. As diabetes progresses insulin produc- tion falls. There is increasing evidence that C-peptide measurement may help inform difficult diagnoses or treatment decisions.
Absent or very low C-peptide indicates the need for insulin treatment. After pancreatic transplant or bariatric surgery, patients may be normogly- caemic on no glucose-lowering treatment. They may be told that their dia- betes is cured and be taken off the diabetes register at the GP surgery. But diabetes is not just sugar trouble.
High glucose levels in the years before the procedure may still be driving diabetic tissue damage E pp. For example, although in future years retinopathy may stabilize or improve, it can still worsen in the year or so post-operatively.
Diabetes Care for the Older Patient: A Practical Handbook
Furthermore, if the graft fails or weight is regained, the hyperglycaemia will return. Click Here Emergencies 24 Information needed by the diabetes care team 25 Clinical examination 27 Summary 30 Consider urgent hospital admission. If hypotensive or shocked, iv fluids are required first. For Best Diabetes Treatment Much of this may seem basic information, but items are frequently omit- ted, to the detriment of patient care. This causes extra work and delays.
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Diabetes is a lifelong condition and it has a major impact on social and fam- ily life. Robust and regularly updated information is essential. Much of this information is already available in practice or hospital records. GPs may feel that this information is much too detailed, but because about half of all patients with newly diagnosed type 2 diabetes have complications at diag- nosis, it is important to make a thorough initial assessment.
What does it involve? The diagnosis may have important financial implications. Sulfonamide allergy precludes sulfonylurea use. Most diabetic patients will need antibiotics sometimes. Consider evidence of diabetic tissue damage. Consider hypoglycaemia if on glucose-lowering medication , diabetic ketoacidosis, hyperosmolar hyperglycaemic state, stroke. These will influence impact of diabetes and ability to self-care. Infection common, not excluded by normal temperature.