Diabetes & GDM

a)          These  tests should be done  every  six months in those who  have pre diabetes  and every 3 months in those who are known diabetics provided they are  well controlled d In known diabetics instead of post glucose blood  glucose post meal blood glucose should be ordered. In the initial  period  and in those who have  unstable control   blood glucose  tests should be repeated  more frequently  whereas  in emergencies  such  as diabetic  ketoacidosis  hypoglycemic coma etc  blood glucose  should be done several  times  a day.

b)         In a newly  detected diabetic  patient  the following  additional   baseline  investigations should be ordered

a)           Lipid profile

b)         Serum  creatinine

c)           Full urine  examination  and test for micro albuminuria if routine  urine exam  . shows absence   of albuminuria

d)         Electrocardiogram

Detailed  ophthalmic  check up  Tip 18 : Urinary ketones in DM::: Know about DM from these posts  & treat your pt by your own skill & wisdom:-Tr  on diabetes:--:- How & when to tets Urine examination  for ketones :

It is  very important to examine urine for ketones in certain  specific situations such as :

1)                     When  patient has excessive  thirst hunger  and urination

2)                     Whenever   there is  vomiting  with or without  deterioration  in general condition

3)                     Whenever  a diabetic is drowsy and urine is loaded with   glucose  and blood glucose  is above 250 mg% 

In above mentioned situations presence of ketones in urine indicates diabetic  ketosis  and the patient should be instructed to seek immediate  medical attention .

e)          Method for examination of ketones in urine  is simple  and essentially same as that for glucose  estimation . Many  companies  market  dry strips  for urine ketone  examination  e.g. Keto diastick , which is designed to simultaneously 

Tip 20  on diabetes evolution by markers of damage already dome by loom standing  untreated / uncontrolled  DM ??  A) Serum tests :- like Serum  creatinine, Dyslipidaemia, CRP,  ,,ophthalmic  check up and  urine   for micro & quantitative estimation albuminuria  should be repeated every year . Neurological evaluation essential yearly basis .If the patient  develops  proliferate  retinopathy. It should be further  evaluated with Flouroscein  aangiography and treated  with Laser photocoagulation  to prevent  blindness.

. Tip 20 to members of this Group:--For advancement of knowledge in diabetes. Treat your pts by yourself without referring to diabetologists as far as possible ,ore so iffy is poor and comes from a rural area. :-  when   a patient  develops  diabetic nephropathy his OAD should be reassessed and use of nephrotoxic drugs e.g. .Aminoglycoside antibiotics and NSAIDs should be avoided. Whenever a diabetic patient loses  control and in those who are difficult  to control from the beginning a thorough  search should be made for  occult  tuberculosis and other infections and X ray  chest and other  appropriate  investigations should be ordered. Whenever   a long standing   diabetic  gradually requires  lesser  dosage  of OAD  or Insulin or he goes into hypoglycemia  with  the same dosage  suspect  diabetic  nephropathy. .

Q.16 :-  Among  the micro vascular  complications of diabetes diabetic retinopathy is the most extensively studied complication as regards  its co relationship  with  fasting and post  glucose   load blood glucose   values. Till 1997  fasting venous plasma  glucose and two hours post 75 g oral glucose load cut off point  for diagnosis of diabetes were 140 mg% and 200

Mg% respectively  . These points were based on symptoms  of  diabetes and not on risk for development of micro vascular  complications  Even though there is no clear cut threshold  blood glucose value for retinopathy some people with fasting  blood glucose values  between  126-140 mg% have  evidence  of early non proliferative diabetic retinopathy however retinopathy  is very rare in those having fasting venous  plasma glucose value below 126 mg% .

Do you know ??!!! Tip 16 : Know about DM from these posts  & treat your pt by your own skill & wisdom:-Tr  on diabetes What lamed mark event was there in 1997 regarding diagnosis of DM ?? In 1997  criteria for diagnosis  of diabetes based on fasting blood glucose were lowered  from 140 to 126  mg.  Moreover  fasting value of 126 mg% has better co  relation with post glucose  load  value of 200 mg%  as regards  micro vascular   complications  Even  though lowering  of diagnostic  fasting blood  glucose  value  was seen  as a definite  improvement  using blood glucose  values for diagnosis  of diabetes  still have some limitations

Q. 18: What are the limitations of FBS estimations??  1)  poor reproducibility due to analytical variance 2) need to remain in fasting state  for 8hours 3) false  lower values if the blood sample is not analyzed with  in 1 hour  due to glycolysis . Q, 20: What is meant by “National Glycohamoglobin standardization program Laboratory methods for estimation of Haemoglobin  A1c  and instruments used for estimation “ ?? Ans: These  have been standardized in the advance countries by National Glycohamoglobin standardization program 99% of the laboratories estimating HbA1c  are NSGP  certified in USA. HbA1c  values  are reproducible storage of  collected blood for few hours does not  lead to faulty estimation . In addition HbA1c  has a better co  relationship with micro vascular complications as compared to blood  glucose values. While   the former is an indicator of average  glycemic control over preceding 12 weeks the later gives  information  about glycemic control at the precise point of time of drawing glucose from the  body. Thus HbA1c  is relatively  unaffected  by acute stressful  conditions. Moreover blood for it estimation can be  drawn at any time of the day.

Tip 20 :  from Dr S K Pal  : Know about DM from these posts  & treat your pt by your own skill & wisdom:-Tr  on diabetes: Should we then consider  HbA1c   test as a diagnostic criteria of DM? What is going to be the  current and  future means  of diagnosing diabetes in non pregnant adults??   Ans;-    Considering  the above  listed advantage of using HbA1c   test some  diabetologists  in advanced  countries  are of the opinion  that it should be used  as an additional option for the diagnosis  of diabetes in non pregnant persons. In 2008  The American  Diabetes Association along with international Diabetes  Federation  and European  Society for study of Diabetes   had jointly set up a committee of experts   to study  the current and  future means  of diagnosing diabetes in non pregnant adults . The international committee’s  reports  was discussed in a symposium held during American Diabetes Association’s annual Congress in June 2009 and published in June 2009  issue of Diabetes Care.