DIABETES Diabetes and the role of MURS
Diabetes is a metabolic condition that affects 3.5million in the UK, with an estimated 550,000 people undiagnosed.(1)
blood glucose concentration than normal. Written by Gareth McCabe. U
nder normal conditions, whenever blood glucose concentration rises, the
pancreas produces the hormone insulin. Insulin acts like the ‘key’ to ‘unlock’ the body’s cells and to allow glucose to enter. The cells can then convert glucose into a source of energy or store it for use at a later time.
Diabetes arises due to one of three possibilities:
1 The pancreas doesn’t produce any insulin
2 The pancreas doesn’t produce enough insulin
3 The insulin that is produced doesn’t work properly (insulin resistance).
There are 2 main types of Diabetes, type 1 and type 2.
Type 1 (2) In type 1, diabetes is caused by destruction of insulin-producing beta cells in the pancreas most commonly caused by autoimmunity. Patients who have type 1 usually present with a family history of the condition. In rare cases however, it may be caused by pancreatic conditions such as chronic pancreatitis.
Type 2 (3) In type 2 diabetes, the cause is generally related/ caused by lifestyle choices. Being overweight or
with a waist measurement of - 31.5 inches or over for women; 35 inches or over for Asian men; and 37 inches or over for white and black men - increases the risk.
The majority of those diagnosed have a family history. Age is also a risk factor for those with type 2 diabetes (over 40 years old if white; over 25 if black, Asian or from another minority ethnic group).
Other risk factors include: hypertension, history of heart disease or stroke, impaired glucose tolerance/impaired fasting glycaemia, women with history of gestational diabetes and women with polycystic ovarian syndrome who are overweight.
Symptoms of diabetes: (4) • Frequent urination, especially at night
• Increased thirst • Feeling more tired than usual • Unexplained weight loss • Genital itching or thrush • Cuts and wounds take longer to heal
• Blurred vision.
Complications of diabetes If diabetes is undiagnosed for a prolonged period of time or is poorly controlled (hyperglycaemia) it can lead to a number of health problems. These are separated into macrovascular complications (coronary artery disease, peripheral arterial disease, and stroke) and microvascular complications (diabetic nephropathy, neuropathy, and retinopathy): (5) • Diabetic retinopathy (eye disease): caused by small blood vessel damage to the back layer of the eye, the retina, leading to progressive loss of vision, even blindness; •Nephropathy (kidney disease): caused by damage
to small blood vessels in the kidneys. This can cause kidney failure, and eventually lead to death. In developed countries, this is a leading cause of dialysis and kidney transplant; • Neuropathy (nerve damage): damage through different mechanisms, including direct damage by the hyperglycaemia and decreased blood flow to nerves by damaging small blood vessels. This nerve damage can lead to sensory loss, damage to limbs, and impotence in diabetic men. It is the most common complication of diabetes; • Cardiovascular disease: damages blood vessels through a process called “atherosclerosis”, or clogging of arteries. This narrowing of arteries can lead to decreased blood flow to heart muscle (causing a heart attack), or to brain (leading to stroke), or to extremities (leading to pain and decreased healing of infections.
Treatment and management of diabetes
Type 1 (6) Insulin is the mainstay treatment for those with type 1 diabetes. The target for long-term glycaemic control is an HbA1C less than 59 mmol/mol. NICE recommends the following regimes:
Multiple injection regimens in adults who prefer them in an integrated package with education, food, skills training and appropriate self- monitoring.
• Multiple injection regimens involve the use of a short-acting (soluble) or rapid acting insulin analogue (e.g. insulin aspart, insulin lispro, insuling glulisine) before meals, with intermediate (isophane insulin) or long-acting (insulin glargine, insulin detemir) given once or twice daily for basal insulin supply.
Twice-daily insulin regimens for those: • Who want them • Who find adherence to lunch-time insulin injections difficult
• With learning difficulties who may require assistance.
The optimal targets for short-term glycaemic control (that is, for glucose self-monitoring) are: • For children and young people, a pre-prandial (before eating) blood glucose level of 4.0–8.0 mmol/L and a post-prandial (1 hour after eating) blood glucose level less than 10.0 mmol/L. • For adults, a pre-prandial blood glucose level of 4.0–7.0
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mmol/L and a post-prandial blood glucose level of less than 9.0 mmol/L. • Biphasic insulins (a mixture of short acting insulin or a rapid-acting insulin analogue with intermediate-acting or long-acting insulin) are given twice daily before meals.
Type 2 (7) First line therapy for those with type 2 diabetes is diet and lifestyle changes. However oral glucose-lowering drugs will have been initiated where blood glucose is inadequately controlled by lifestyle interventions of diet and exercise alone.
First line medication is Metformin. For those patients who are not overweight, cannot tolerate metformin or if a rapid response to hyperglycaemic symptoms is required then a Sulfonylurea (typically gliclazide) can be considered.
Second line (where blood glucose control remains or becomes inadequate with monotherapy) treatment involves • adding sulfonylurea to the metformin
• adding dipeptidyl peptidase-4 (DPP-4) inhibitor (sitagliptin, valdagliptin) or a thiazolidinedione (pioglitazone) to metformin if: 1. the person is at significant risk of hypoglycaemia 2. sulfonylurea is not tolerated or contraindicated
• if metformin is not tolerated or is contraindicated, add DP-4 inhibitor or thiazolidinedione to sulfonylurea
• Third line (where blood glucose control remains or becomes inadequate with dual therapy) treatment involves
• add DPP-4, thiazolidinedione or glucogon-like peptide-1 (GLP-1) analogue or mimetic (exenatide) to metformin and sulfonylurea when insulin is inappropriate/ unacceptable.
Once all above measures have been exhausted then the patient should be initiated on insulin.
It must also be mentioned the importance of managing cardiovascular risk and doing so can achieve much to reduce the risk of micro - and macrovascular complications. Therefore recommendations (8)
are to add
medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or
> Diabetes causes those with the condition to have a higher
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