Abc do diabetes

Abc do diabetes

(Parte 5 de 19)

•Dry tongue

Ketoacidosis • Drowsiness

• Dehydration

• Overbreathing

•Breath smelling of acetone

Della Robbia panel from the Ospedale del Ceppo, Pistoia, 1514

Blood glucose concentration • Any

Other indications

•When tablets have failed during pregnancy

•When diet has failed during intercurrent illness

•In patients who have undergone pancreatomy

•Ill patients need admission •Others may start insulin at home

•If there is any doubt use insulin

Clinical presentation: why is diabetes so often missed?

The personal story of Mrs B-J’s diabetes

Mrs B-J was born in 1922 and developed Type 1 diabetes at the age of 10 years in 1932. She saw Dr RD Lawrence at diagnosis and in 1989 wrote an account of her own diabetes which will be presented over several chapters in this book.

Presentation and diagnosis I was always a lively, energetic child so nobody was particularly surprised when I seemed to be growing tall and thin at the end of the summer of 1932. Because of my weight loss, my mother took me to our family doctor who thought I might have TB. He told her to put me to bed for one week, then take me back to him with a urine specimen. Up till then I was perfectly fit and well, but being in bed without exercise, I soon lost my appetite and only wanted oranges and drinks. At night, my mother put water in several quart milk bottles by my bed, but I had drunk it all— about ten pints—before my parents came up to bed. This meant dozens of trips to the toilet each night as a chamber pot could not cope with it.

After about three days, my mother went back to the doctor with a specimen and he said that I had diabetes and must go into hospital the next day. My mother was upset but also relieved, as she had a deep fear of TB.

That night a neighbour called to see how I was. My mother did not realise that I could hear their conversation and told her what was wrong.

In a loud, shocked voice this lady asked, “Is she going to die?” I was immediately interested, and hearing my mother say that I wouldn’t if I did not eat sweets, cake, biscuits, etc. for the rest of my life, I resolved there and then that I would do just that. I never wanted again to feel as awful as I did just then. I think that eavesdropping probably affected me for the rest of my life, and since then I have had no desire for sweet things except as part of my diet, or for warding off hypos. The next morning my parents took me by taxi to King’s College Hospital.

The first illustration is from Geyelin, HR, Marrop, C. JMed Res1922;2:767-9. The figure showing presence of retinopathy according to years since diagnosis is adapted from Diab Care1992;15:815-21 with permission of American Diabetes Association. The table showing presenting symptoms of diabetes is adapted from Malins J. Clinical diabetes mellitus. London:Eyre and Spottiswoode, 1968, and the box showing Type 2 diabetes presentation uses data from UKPDS. Diabetes Med1998;5:154-9.

Diabetes is easy to diagnose, but can be managed with negligent ease by those inclined to do soRB Tattersall, 1990

The first concerns in treating diabetic patients are to save life, alleviate symptoms, and enhance the quality of an independent life. Thereafter treatment aims to minimise the long-term complications and reduce early mortality.

Aims of treatment

Alleviation of symptoms and improvement in quality of life This is achieved by reducing hyperglycaemia; patients who need insulin immediately (those with Type 1 diabetes) were described in the previous chapter. All others normally begin on diet alone, moving to diet and oral hypoglycaemic agents, or diet and insulin as indicated. All treatments must be adjusted to ensure that patients are symptom-free. Education of patients plays an important role in enhancing the quality of life, and needs to be maintained over many years.

Maintainenance of health by reduction of risk factors and preventing the development of diabetic complications The needs here are for:

•achievement of optimal blood glucose control •detection and control of hypertension

•assessment and control of hyperlipidaemia

•assessment of the need for antiplatelet medication

•cessation of smoking

•regular complications screening procedures (described on page45).

Management of long-term diabetic complications

Management of other medical problems affecting the patient

The aims of controlling diabetes

Once diabetes treatment has been established, there is a need to agree the level of control to be achieved in each individual patient. Once symptoms have been eliminated, targets for optimal control (shown in the table) should be discussed and agreed, but it is not always possible to reach ideal goals and pragmatic decisions have to be made. The following criteria need consideration:

•ensure that symptoms have been eliminated •lean patients should gain weight

•obese patients should lose weight

•children should grow normally

•prevention of long-term diabetic complications.

Healthy lifestyle

People with diabetes can help themselves considerably by attention to healthy eating, appropriate exercise levels and weight reduction, and cessation of smoking. These measures

3Aims of treatment: a healthy lifestyle

Treatment aims

•Save life •Alleviate symptoms

•Prevent long-term complications

•Reduce risk factors: smoking hypertension obesity hyperlipidaemia •Educate patients and encourage self-management

•Achieve goals of St Vincent declaration (see page 82)

Targets for control of diabetes

VeryLess than good* Acceptable ideal

Blood glucose in Type 2 diabetes† (mmol/l):

(Parte 5 de 19)