DIABETES MELLITUS Treatment Prime objectives of treatment of
DIABETES MELLITUS: Treatment
Prime objectives of treatment of a diabetes (1985) Conservation of a life of the patient and elimination of symptoms of disease; n The possibility of a full social life; n Achievement and maintenance of the good metabolic control; n Prevention of progress of sharp and recent complications of a diabetes; n Reduction of death rate; n Treatment of accompanying infringements n
Compensation criteria of carbohydrate metabolism in DM type 1 Parameters Compensation Hb. AIc(%) Glucose control in the capillary blood mmol/l Subcompensation Decompensation 6, 0 -7, 0 5, 0 -6, 0 7, 1 -7, 5 6, 1 -6, 5 >7, 5 > 6, 5 Glycemia in 2 hours after meal 7, 5 -8, 0 8, 1 -9, 0 > 9, 0 Glycemia before going to bed 6, 0 -7, 0 7, 1 -7, 5 > 7, 5 Glycemia on an empty stomach
Compensation criteria of carbohydrate metabolism in DM type 2 Parameters Compensation Hb. AIc(%) Glucose control in the capillary blood mmol/l Subcompensation Decompensation 6, 0 -6, 5 5, 0 -5, 5 6, 6 -7, 0 5, 6 -6, 5 >7, 0 > 6, 5 Glycemia in 2 hours after meal <7, 5 7, 7 -9, 0 > 9, 0 Glycemia before going to bed 6, 0 -7, 0 7, 1 -7, 5 > 7, 5 Glycemia on an empty stomach
Treatment of diabetes mellitus Diet n Physical activities n Oral hypoglycemic agents n Insulin therapy n
Algorithm of treatment DM 2 types Hb. A 1 c Diet, load, training PSM, Metformin Combination Insulin Normoglycemia Insulin/insulin
Effective treatment DM is possible only at strict observance of a diet Maintaining an ideal body weight n Exclusion from the diet of sugar and, if possible, easily digestible (refined) carbohydrates n The content of the protein in the diet is not more than 16% of the total energy value food n Reducing alcohol consumption n
Main principle of a modern diet sick of a diabetes n The maximum closer to the physiological regulatory compliance power supply healthy, To ensure the normal way of life
n Diet, which contains 60% carbohydrates, 24% Fats and 16% protein is the "foundation" diabetes.
You are in danger of "complete freedom" patient for diabetes? The increase in body size n Inability to provide normoglycemia n Decompensation of diabetes n Progression of diabetic angiopathy. n
Coarse-fibered carbohydrates in the diet of patients with diabetes Do not are sucked toward the blood n Are not an energy source n Facilitated the rapid saturation n Stimulates peristalsis n Reduce suction cholesterol and fatty acids n
Recommendations on a diet № 9
Meal should be a regular, 5 -6 times a day. n Culinary processing: all dishes prepare in a boiled type, on pair or are baked in an oven. n It is necessary to avoid plentiful reception peep especially for the night. n
Recommended soups vegetarian (vegetables, cereals), cabbage soup vegetarian Borscht. n Meat of low-fat grades - a beef, the hen in a boiled and stewed type. n Doctor's sausage, low-fat sausages, a fish in a boiled and stewed type (up to 200 gram a day). n Cottage cheese low-fat (150 -200 гр. ) or products from it. n
n n n Eggs in the form of omelettes or 1 egg 2 -3 times a week. Fats are not more than 40 gr per day (butter and vegetable oil). Porridge of various grits (c sour cream, oatmeal base, barley, betterment). Being Prepared on the water or cut in half with milk 200 gr. Fruit: apples, pears, citrus fruit for 1 -2 pieces, the berries are not more than 1 cup per day. Sugar substitutes: cukli, sucrazit, sorbitol.
It is forbidden: Digestible carbohydrates: sugar, honey, chocolate, sweets, pastries, crispy pastry products, ice cream, lemonade, Fanta, Coca-Cola and others. n Sweet fruit: a melon, bananas, grapes, pineapples, sundries: a fig, raisin, dates, a persimmon. n
Use of alcohol when diabetes mellitus potentiate the hypoglycemic effect of sulfa drugs n Depleted glycogen reserves n contributes to decompensation of diabetes n stimulates ketogenesis n
The factors influencing a choice of a preparation for treatment of a diabetes of type 2 Efficiency n Decrease in risk of progress of complications connected with a diabetes n The combination of other drugs n Conformity to principles of demonstrative medicine n
Antidiabetic oral drugs Stimulators of insulin secretion: -drugs sulfonylureas (1, 2 and 3 generation) n acyl derivatives of amino-alkyl benzoate (meglitinide, repaglinide or novonorm) n
n potentiates the action of insulin - a biguanide (metformin, Siofor, Glucophage). - Glitazones (Actos) n inhibitors of intestinal enzyme alphaglucosidase - acarbose (glyukobay)
MANINIL 1. 75/3. 5/5 n The strongest and most lasting hypoglycemic effect n Micronized doses - treatment of choice for newly diagnosed type 2 diabetes, a tendency to hypoglycemia in the elderly
Diabeton MR Diabeton 80 n n n Restores physiological profile insulin secretion build. Optimal control glucose management and low frequency of the secondary conductivity. A favorable effect on the ground the body. A favorable the vascular effect. Do not worsen kidney function. A one-time admission to continuously for days.
AMARYL 1/2/3/4/6 n For uncomplicated falciparum malaria in patients LED type 2 with BMI < 28 kg/m². - In combination with метформином patients LED type 2 with BMI >28 kg/m². - a one-time admission per day.
Biguanides (metformin – Siofor, Glucofaj) n Diabetes mellitus type 2 and sindromokompleksy, associated with insulin resistance (glucose intolerance, metabolic syndrome, etc. )
Insulin Therapy n n n Normal adult human pancreas secretes 35 -50 UNITS of insulin per day, which is 0. 6 u -1. 2 1 kg of body weight per day. This secretion is divided into food and basal. Basal insulin secretion provides the optimal level of glycemia and anabolism in the intervals between meals and at bedtime. Basal insulin is secreted at a rate of approximately 1 u/h with prolonged physical exertion or prolonged fasting it is reduced to ½ units/h.
n The food the insulin at least 50 -60% of daily insulin production, basal-40 -50%. Secretion of insulin is affected by daily variations: the need for insulin rises in the early hours of the morning, starting at 4 pm, and then gradually falls during the day. Maximum sensitivity to insulin is between 2 and 3 hours of the night. Breakfast at 1 HYE -2. 5 1. 5 u insulin is secreted, at lunch, 1 -1, 2 u, at supper – 1 PCs.
To that to appoint insulin? n n n 1. Patients with diabetes mellitus type 2; 2. Newly diagnosed DIABETES patients with ketosis glukozurii and loss expressed a significant percentage of body weight; 3. pregnant women suffering from DIABETES MELLITUS type 1 or 2; 4. Patients requiring major surgical interventions; 5. Patients suffering from sereznymi infectious diseases; 6. patients who have monodietoterapiâ no effect, with the poor or the existence of contraindications to drugs sulfonylureas.
The intensive mind interaction possible while applying insulin most to physiological endocrine disrupting insulin. Its basic principles: 1. The demand for the insulin, appropriating it базальной secretions, is provided with 2 injections n ИСД (in the morning and in the evening) which total doze should not exceed half of all entered doze of insulin for a day (a daily doze). n
n 2. Food, bolus injections of insulin secretion is replaced by ICD before each meal. This dose ICD is calculated based on the number of carbohydrates, which is supposed to be used during the upcoming meal, and the existing level of blood glucose, the patient is determined by the meter (at least) before each injection of insulin
Daily demand for insulin at onset - 0. 5 U / kg. n honeymoon - less than 0. 5 U / kg. prepubescent -0, 6 -1, 0 U / kg. n puberty (14 -18 years) - 2. 1 U / kg. n with long-term diabetes - 0. 7 -0. 8 U / kg. n decompensated diabetes -1. 5 U / kg. n
Hyperglycemic coma
Prevalence n Had the highest incidence of acute endocrine diseases. Mortality when it reaches 6 -10 %, and in children with type 1 diabetes is the most frequent cause of death.
Pathogenesis n n Insulin deficiency leads to hyperglycemia with an osmotic diuresis. As a result of developing dehydration and lost electrolytes. The decrease in extracellular fluid decreases renal blood flow and glucose to the delay. Increases glycogenolysis and gluconeogenesis, lipolysis is activated to form free fatty acids and glycerol, which promote the development of insulin resistance. The increase in glucose production decreased its recycling fabrics.
Free fatty acids in the liver, where they produce ketone bodies (ketogenesis). This leads to ketonemii and then to ketonurii, which is accompanied by loss of cations, i. e. electrolytes. n Uncontrolled production of ketone bodies causes depletion alkaline reserve, spendable at their neutralization, which is acidosis. n
n Tissue energy starvation by activating adrenaline, cortisol and STH – suppress indirect insulin glucose disposal muscles, increase lipolysis and inhibit residual insulin secretion
Stage of development of ketoacidosis and coma ketoatsidoticescoy n Weakness, fatigue, drowsiness, loss of appetite, nausea, polydipsia, polyuria, dry mouth, mild severe pain in the abdomen, a slight odor of acetone, hyperglycemia, and 20 mmol / L, ketonemiya to 5. 2 mmol / l.
Decompensated stage? ketoacidosis (precoma) Loss of appetite, nausea, vomiting, severe weakness (until prostration), rubeosis person retardation consciousness (stupor). n Deep noisy breathing (Kussmaul breathing), the smell of acetone breath, abdominal pain, sometimes pain in the heart. Unquenchable thirst, frequent urination, dry skin and visible mucous membranes, the presence of brown fur. n
3. Stage coma valuables n lack of awareness, lack or loss of tendon reflexes, deep noisy breathing Kussmaul, the sharp smell of acetone, dry and pale skin, sharp features, the retraction of the eyeballs, thready pulse, blood pressure decreased, oligouriya, anuria
Rehydration n 0. 9% sodium chloride solution (at the level of plasma sodium <150 m. Eq / L) 0. 45% solution of sodium chloride - hypotonic (at the level of plasma sodium - 150 m. Eq / L) When blood glucose below 14 mmol / l - 5. 10% glucose, with nat. The colloidal solution of plasma expanders (hypovolemia - systolic blood pressure below 80 mm Hg or central venous pressure less than 4 mm of water. cent. )
Speed rehydration n 1 st hour - 1000 ml saline. solution for the next 2 hours and 3 hours - 500 ml saline. rehydration solution rate is adjusted depending on the performance of the central venous pressure, or by the rule of the typing for 1 hour of liquid can not exceed the hourly urine output of more than 500 - 1000 ml
Insulin therapy – treatment of small doses (short insulin action) n In the first hour - 10 -14 units. in / jet. Preparation of insulin solution for simultaneous / in the introduction (in the 'gum' infusion system) required to dial in the amount of insulin and insulin syringe to add up to 1 ml saline. solution, administered for 1 min
n In the following hours (until blood glucose falls to 14 mmol / L) - insulin 48 units / hour / in continuously by perfuzatora (infusomats) or 1 per hour in the 'gum' infusion system. Preparation of the solution for i / v drip of insulin. For every 100 ml saline. solution - 10 units of insulin 2 ml of 20% human serum albumin (infusion at a rate of 4080 ml per hour)
n If after 2 -3 hours after initiation of insulin therapy does not decrease blood glucose levels, doubling the dose of insulin in the next hour glucose lowering speed - less than 5. 5 mmol / h and no less than 13 -14 mg / d. L in the first day (with the rapid decrease - the risk of osmotic imbalance syndrome and cerebral edema)
Restoration of electrolyte abnormalities n Due to the high risk of rapid development of hypokalemia in / drip drugs potassium begin with the onset of insulin calculations at the level of <3 m. Eq / L - 3 g / h KCL 33, 9 - 2 g / h; 4 -4, 9 - 1. 5 g / h, 5 -5, 9 - 1. 0 g / h If the level of plasma potassium is unknown in / drip drugs potassium begin no later than 2 hours after the start of insulin therapy under the supervision of the ECG and diuresis.
Hypoglycemic coma
n Hyperinsulinemia is due at this time, which contributes to increased permeability of the cell membrane, in the insulin-dependent activation geksogenaz tissues. It is as if the redistribution of glucose with its prevalence at the tissue level.
n Despite the fact that the amount of glucose in the cells of the brain at this point less than in the insulin-dependent tissues, but notes its relative abundance of intercellular space. And the law is Osmosis water transfer from the extracellular sector in the cage with her hydration. Thus, based on the development of hypoglycemic coma - swelling of the brain cells.
n In turn limit glucose influx immediately causes energy starvation Brain cells and sharp disorganization substrate - Recovery processes in неиронах, that is tantamount to acute hypoxia the brain.
CLINICAL PICTURE Tachycardia. n Mydriasis. n Pale skin. n Enhanced sweating. n Nausea, hungry. n Anxiety, and aggression. n
n n n Weakness. Paresthesia. The fear of Declining attention span headache, dizziness, Disorientation, amnesia Speech, vision, behavioral violation Violation coordinate movements sputannosti consciousness possible convulsions, temporary paresis and paralysis Coma
The main causes of hypoglycemia in diabetes n 1. Inadequate food intake, for example, an insufficient number of Xe on the dose of insulin with a reference blood glucose 2. High physical activity while maintaining the same dose of insulin or antidiabetic drugs tablets (TSP) 3. An overdose of insulin or TSP - Receive Mannino in constant dosage, despite the reduction in body weight. - Failed to set the insulin into the syringe
n 4. Autonomic neuropathy with neuropathy of the stomach with the development of gastropareza and evacuation of food diabetic encephalopathy with impaired recognition of hypoglycemia (no sense of hunger) 5. accelerating the resorption of insulin intramuscular rather than subcutaneous introduction prolonged insulin in the abdomen
n TREATMENT OF MILD HYPOGLYCEMIA
n Intake of digestible carbohydrate (simple) in the amount of 1 -2 YOO sugar (4 -5 pieces of dissolve in water, tea) or Jam (1 -1, 5 -table spoon) or 200 ml of sweet fruit juice or a 100 ml glass of lemonade, Pepsi-Cola, Fanta or 4 -5 large glucose tablets or 1 -2 chocolate candies
n If the hypoglycemia is caused by insulin of the prolonged action, in addition to eat 1 -2 XE medlennousvoyaemy carbohydrates Piece of bread n 2 tablespoons of porridge n
n TREATMENT of the SERIOUS HYPOGLYCEMIA (with a loss of consciousness or without it but demanding the help of other person)
n n n Before arrival of the doctor of the fainted patient to lay sideways, to exempt an oral cavity from the nutrition remains. At a loss of consciousness the patient can't pour in in an oral cavity sweet solutions (danger of an asphyxia! ! ) I. v. jet introduction of 40% of solution of a glucose in quantity from 20 to 100 ml – to a complete recovery of consciousness Alternative – п / to or in/m introduction of 1 ml of solution of a glucagon (it can be carried out by the relative of the patient)
If the patient doesn't recover the consciousness after i. v. introduction of 100 ml of 40% of solution of a glucose, to begin i. v. drop introduction of 5 -10% of solution of a glucose and to deliver the patient in a hospital n In some cases п / to enter an adrenaline of 0, 1%, i. v. or in/m enter Hidrocortizonum of 150 -200 mg n
If after hypoglycemia elimination the consciousness doesn't come back, it is necessary to continue introduction of 5% of solution of a glucose. Each 2 hours such patient enter into 1 -2 ml of a glucagon, 4 times per day glucocorticoids. n At wet brain – осмодиуретики (Mannitolum 1ú/kg body masses n
n If hypoglycemic coma caused by an overdose of oral antidiabetic drugs with a long duration of action, especially in elderly patients or in concomitant abuse kidneys, / drip 510% glucose solution can last as long as necessary for the normalization of glycemia
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