4.Chronic dis.qxp:STM5 7/4/10 9:38 PM Page 253 Diabetes
Common – Type 2 diabetes, gestational diabetesLess common – Type 1 diabetes, pancreatic insufficiency/disease Type 2 diabetes – initially increased insulin levels but body doesn’t use
it properly. Later less insulin made – often need insulin injections late
In Indigenous people diabetes more common, more severe, happens at a
Heart attack at a young age a major cause of death. May happen with
no chest pain, or with symptoms like tiredness or problems breathing Diabetes is important
People with diabetes are very likely to develop other health problems, eg
High BP, heart attacks, strokes
Kidney disease, kidney failure
Eye damage, loss of vision
Nerve damage (neuropathy) to feet causing ulcers, amputations
Serious infections
Dental/oral disease, tooth loss
Risk factors for diabetes
Family history of diabetes
Overweight or obese – BMI more than 25
Waist circumference – women more than 80cm, men more than 94cm
Women – history of gestational diabetes or polycystic ovarian disease
Impaired glucose tolerance
Healthy diet, physical activity, good oral hygiene, not smoking andweight loss if overweight/obese lessen the chance of getting diabetes andslow progress of the disease. (Messages for health p220, Tobacco p224,Brief interventions p216). Diagnosis
Usually no symptoms until late in disease when complications develop.
See Testing for diabetes (p234) for how to diagnose.
Early diagnosis through screening may prevent complications
Adult Health Check (p212) is very important 4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 254 Diabetes
Also check for diabetes if someone has any of these symptoms
Frequent infections, eg boils, UTIsTirednessPassing urine too often, especially at nightWeight changeEyesight problemsOften thirsty If person sick with anything else at time of diagnosis, BGL of more
than 20mmol/L, ketones in urine – may need to send to hospital Ketones in urine can mean person has not eaten, or may have undiagnosed Type 1 diabetes (needs insulin). Medical consult
Impaired glucose tolerance or impaired HbA1c
Do cardiovascular risk assessment (p229)
Medical review
Management plan including yearly BGL, HbA1c, follow-up schedule
Give advice about diet, physical activity, losing weight to lessen risk of
diabetes (Messages for health p220) Think about starting metformin, talk with physician
Gestational diabetes
See WBM (p121)
Yearly BGL, HbA1c
Type 2 diabetes
See Combined checks (p238) – monthly checks for first 3 months then
Give advice about diet, physical activity, losing weight and quitting
smoking (Messages for health p 220, Tobacco p224) Pre-pregnancy counselling (WBM p79)
Good diabetes care looks after the whole person, not just blood glucose
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 255 Diabetes
Medicines for best diabetes control
Usually a combination of medicines to control blood glucose, BP,
blood fats (lipids) and cardiovascular risk.

Blood glucose control
Aim for
Random or after meal BGL 4–8mmol/LHbA1c less than or equal to 7% (good average blood glucose over last 3 months)– Any decrease in HbA1c is good and lessens risk of complications– High HbA1c levels increase person’s risk of heart attack, kidney Review weekly for 1 month when changing treatment
BGL self-monitoring helps person to understand and manage their
diabetes. Most useful for younger people, person on insulin, during
changes in drug treatment, or if unstable
If person on insulin can’t self monitor – do in clinic
Offer enough medicine to achieve best control (Flowchart 4.2 p257)
to lessen risk of heart attack, kidney failure, foot amputation, blindness You should get better glucose control by adding a second medicine
rather than using a maximum dose of one medicine alone 4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 256 Diabetes
Table 4.19: Oral medicines for glucose control
Gliclazide Gliclazide Glimepiride Pioglitazone
daily with daily with daily with dailyfood Maximum 2g daily often
3g daily maximum
– can give 1.5gtwice a day (bd)with food Metformin XR
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 257 Diabetes
Flowchart 4.2: Blood glucose control
Diagnosis of diabetes (p234)
Diet and exercise AND metformin (if no contraindications)
Add sulfonylurea
Regular check-ups afterHbA1c controlled at lessthan or equal to 7% Add glitazone or insulin
Add a fourth medicine or increase insulin
Specialist consult
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 258 Diabetes
Insulin treatment is needed by most people with diabetes after 6–10
years due to decreased ability of pancreas to produce insulin.
Think about starting insulin if
Person is taking maximum tolerated oral medicines
2 or more HbA1c results more than 7% OR BGL always more than 8–
Symptoms of high blood glucose (p254)
Starting insulin needs time for education about insulin, injecting and
monitoring, thinking it over, and talking with another person who is on
Get help from diabetes educator (could be by phone) (p410)
Discuss practical ways to store insulin, monitor BGL
There are many easy-to-use injecting devices available
Clinic staff need to be positive and supportive about using insulin
Start with daily insulin – keep adjusting doses until good BGL control.
Change to twice a day insulin if
Not controlled with maximum daily insulin AND oral medicines
Able to manage a more complex treatment plan
Eating regular meals – as higher risk of low blood glucose with mixed
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 259 Diabetes
Table 4.20: Insulin treatment
Twice a day
Glargine – same time each
Novomix 30 OR
Humalog Mix 2575 OR
OR Protophane – bedtime
Mixtard 3070
1/ 2
Starting dose
Maximum dose
When good BGL control –may be more than 50 units,often up to 100 units Adjusting dose
BGL less than 4mmol/L
BGL 4–6mmol/L – use
BGL 6–8mmol/L – increase
BGL more than 8mmol/L –
BGL aim
Oral medicines continue unchanged
Eye disease
Includes diabetic retinopathy, cataract. Any change in vision should be
assessed straight away by ophthalmologist, especially if sudden onset.
Risk of blindness is less with
Regular screening (fundoscopy or retinal camera) (Combined checks
4.Chronic dis.qxp:STM5 2/3/10 11:05 PM Page 260 Diabetes
If diabetic eye damage – more frequent eye specialist examination
Laser treatment, if needed
Good BP control (p264) and blood glucose control (p255)
Foot problems
Foot problems are the most common complication of nerve damage
(peripheral neuropathy) – may lead to infection, foot ulcers, amputation.
Do regular foot checks (Combined checks p238, CRANACPM p121)
Foot ulcers and infections
Every new ulcer or infection is serious
• Medical consult – may need to send to hospital
If infected – swelling, red, warmth, pain (may be very little pain). Give
Amoxicillin-clavulanate (doses p394)
OR Cephalexin (doses p397) AND metronidazole oral (doses p401)
High risk feet
Person with identified high risk feet will need
More frequent foot checks
Management plan
Education about foot care, foot protection
See CRANACPM (p121, p124)
Dental problems
Person with Type 2 diabetes has higher risk of more frequent and severe
dental/oral disease. Risk increased by poor dental hygiene, smoking, poor
control of diabetes. Dental/oral disease makes it harder to control
Problems include infections, bone and tooth loss, loose and painful teeth.
Encourage and support
Good oral hygieneStopping smoking (Tobacco p224) Make sure of regular visits to dentist (as often as every 3 months if


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ASTHMA ACTION PLAN (To be updated at least annually and as needed) For children in childcare, kindergarten and family day care Instructions 1. To be completed by parents in consultation with their child’s doctor. 2. Parents should inform their child’s childcare service, kindergarten or family day care immediately if there are any changes 3. Please tick the appropriate bo

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Pergunta: Acabo de ser diagnosticado com pré-leucemia, já quase leucemia mesmo. O senhor poderia me indicar uma terapia alternativa? Resposta: Falando de um modo genérico, a leucemia é uma doença do sistema imunológico. Ou talvez melhor dito, um câncer do sistema imunológico. Então achei que esta seria uma boa oportunidade para apresentar uma terapia pela qual me interessei recentemente.

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