facilitators guide (module 10, 11 & 12) guide (10,11,12) .pdf · certificate course in evidence...

Facilitators Guide (Module 10, 11 & 12)

Certificate Course in Evidence Based Diabetes Management 1

Disclaimer

Public Health Foundation of India (PHFI) and Dr. Mohan’s Diabetes Education Academy (DMDEA) do not recommend or provide individualized medical diagnosis, treatment or advice, nor do they recommend specific therapies or prescribe medication for anyone using or consulting this publication. The information contained in this publication is intended for general educational and informational purposes only.

Medical information changes rapidly. Therefore, PHFI and DMDEA assume no responsibility for how readers use the information contained in this publication and hence assume no legal liability or responsibility arising out of use of this information.

Contents included in this module are solely provided by designated experts and represents their viewpoints entirely.

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Certificate Course in Evidence Based Diabetes Management

Facilitators Guide (Module 10, 11 & 12)2



Contents

Module 10: Special Topics in Care of Patients with Type 2 Diabetes

Module 11: Other Types of Diabetes Mellitus

Module 12: Conclusions and Take Home Messages

5

15

25



Module 10

Special Topics inCare of Patients with

Type 2 Diabetes



MODULE 10

Special Topics in Care of Patients with Type 2 Diabetes

The learning objectives of this module are as follows:

• Learnabouttheperi-operativemanagementofadiabetespatientundergoingsurgery

• Learnhowtomanagecriticallyandnoncriticallyilldiabetespatientsinthehospital

• Learntoidentify,evaluateandtreatsexualdysfunctioninadiabetespatient

• Learnhowtomanagediabetesinanelderlypatient

• Learnaboutthesyndromeofnonalcoholicfattyliverdiseaseanditsmanagement

• Learnaboutthecommondentalandrheumatologicalproblemsindiabetespatients

• Learnhowtomanageotherspecialsituationsindiabetesliketravel,sickdaysandoccupationalproblems

To achieve these objectives, the day’s discussions are organized as follows:

• CasePresentation

• Pre-test

• Lecture1:SpecialProblemsinDiabetes1

• Lecture2:SpecialProblemsinDiabetes2

• CaseStudies

• Post-test

• PrimertoModule11

Pre-test(This will also serve as post-test after the day’s sessions)

Choose the most appropriate answer

1. A diabetes patient is slated to undergo cataract surgery. On evaluation, you find that his fasting and postprandial blood sugars are 115 and 174 mg/dl, respectively and his HbA1c is 6.9%. He is presently on Glipizide and sitagliptin. What is the ideal preoperative plan for managing blood glucose in this patient?

A. Stop all OADs and start him on insulin

B. Stop sitagliptin but continue glipizide; omit glimepiride on morning of surgery

C. Stop glipizide but continue sitagliptin; omit pioglitazone on morning of surgery

D. Continue both glipizide and sitagliptin; omit both on morning of surgery



2. A 62 year old female diabetes patient complains of flexion deformity of the middle finger of her right hand. On examination you palpate hard nodules on the palmar surface of the hand just proximal to the proximal phalanx of middle finger. What is the likely diagnosis?

A. Diabetic cheiroarthropathy

B. Trigger finger

C. Dupuytren’s contracture

D. De Quervain’s tenosynovitis

3. A 54 year old male with diabetes of 22 years’ duration comes to you with complaints of erectile dysfunction. What other diabetes complication should you specifically look for?

A. Nephropathy

B. Cardiovascular disease

C. Retinopathy

D. Infection

4. A 44 year old businessman is travelling from India to the US by air. He has had diabetes for 12 years and is presently on insulin lispro three times daily along with insulin glargine at bedtime. He is slated to leave from India at 12:45 am, after taking his night dose of glargine. What will you advise him regarding his insulin doses while travelling?

A. Take the next dose of insulin glargine at his usual time by the Indian clock

B. Take the next dose of insulin glargine by the US clock

C. Reduce the next dose of glargine by 4 to 5 units

D. Increase the next dose of glargine by 4 to 5 units

5. A 46 year old male patient, who has had diabet es for 7 years comes to you for advice. He is presently on tab. Glipizide 5mg twice daily and tab. Metformin 500mg twice daily. His latest HbA1c is 6.2%. He wishes to undertake the Ramadan fast and wants to know how he can adjust his medications so that he neither develops hypoglycemia nor his sugars go totally out of control. What would you advise him?

A. Advise him not to fast at all

B. Advise him to reduce the dose of glipizide in the morning, to continue metformin and take the usual

night dose of glipizide at the time of breaking the fast in the evening

C. Advise him to omit both the glipizide and metformin in the morning and to take both tablets only

in the evening

D. Advise him to stop all OADs for the duration of the fast

6. Prayer sign is associated with

A. Retinopathy

B. Liverdisease

C. Cardiovascular disease

D. Peripheral vascular disease



7. What is the effect of general anesthesia on diabetes?

A. Blood glucose is likely to increase

B. Blood glucose is likely to decrease

C. Blood glucose will not change

D. Depends on the level of pre-op control

8. Which of the following is not a contraindication to driving?

A. Nonproliferative diabetic retinopathy

B. Severe sensorimotor neuropathy

C. Severe peripheral vascular disease

D. Hypoglycemia unawareness

9. In diabetes, Dupuytren’s contracture usually involves___

A. Ring and little finger

B. Middle and ring finger

C. Middle and index finger

D. Thumb and index finger

10. Which of the following is not a common side effect of sildenafil?

A. Giddiness

B. Hypertension

C. Blurred vision

D. None of the above

Key to Pre-test

1. D

2. C

3. B

4. B

5. B

6. A

7. A

8. A

9. B

10. B



Lecture 1: Special Problems in Diabetes 1

This lecture deals with surgery in the diabetes patient, care of the hospitalized patient with diabetes, sexual dysfunction in diabetes and care of the senior citizen with diabetes.

The first part of this lecture deals with diabetes in the surgical patient. Many of the trainees who work in large hospitals would have been often called in to control blood glucose preoperatively and postoperatively. Ask them what regimens they use in these situations.

The different regimens for control of glycemia in surgical patients are presented next. Always emphasize the need for regular monitoring of blood glucose and prompt changes in the doses of medications as indicated.

A few pointers are given as to the management of diabetes in the hospitalized patient. Clearly differentiate between critically ill and non critically ill patients and emphasize that very tight control of blood glucose may be deleterious in the former category.

Most of the trainees would already have had experience in dealing with erectile dysfunction in their patients. It is worthwhile eliciting their views on how common they think the problem is in diabetes patients and what they think the causes are (neuropathy, vascular disease, psychological).

The most important lesson to be learnt here is that one should learn to dissect out what the patient means when he says “sexual problem”. Erectile dysfunction is mainly organic in nature whereas problems like premature ejaculation are psychological in origin. The diabetologist should be in a position to provide effective treatment for organic disease without recourse to specialized counseling services, which may not be easily available.

Moreover, presence of erectile dysfunction mandates a careful search for other diabetes complications since it is a marker of generalized endothelial dysfunction.

It should be emphasized that phosphodiesterase inhibitors (sildenafil and the like) are extremely safe drugs which can be prescribed by any diabetologist, provided a few basic precautions are kept in mind (cardiac status, nitrate intake).

Also spend a few minutes on female sexual dysfunction, an oft-neglected aspect of diabetes.

Lecture 2: Special Problems in Diabetes 2

Thislecturedealswithnonalcoholicfattyliverdisease(NAFLD),acommonaccompanimentoftype2diabetesand also with diabetes in situations like travel, fasting and sick days. Some of the common dental and rheumatological problems met with in diabetes are also included.

ThesubjectofNAFLDhasreceivedmuch interest inthe lastdecadeand isnowregardedasthehepaticcomponent of themetabolic syndrome. Emphasize to the trainees thatNAFLD andNASH are now theleading cause of hepatic cirrhosis in the western world, overtaking alcoholic liver disease.

The next section deals with dental problems in the diabetes patient. It is important for the trainees to appreciate that not only can diabetes lead to dental problems, but dental problems are often a major cause for uncontrolled diabetes. Dental examination is an oft-neglected aspect of diabetes care!

The next section of the lecture deals with diabetes during sick days, travel and fasting. It is most important that trainees learn how to manage diabetes during international air travel and during religious fasts like Ramadan fast.

The final section of the lecture deals briefly with rheumatological problems in diabetes like shoulder capsulitis, trigger finger and Dupuytren’s contracture. Much time need not be spent on management of these conditions since it does not radically differ from that in the non-diabetic population.



Case Studies

Case Study 1

A 66 year old patient with type 2 diabetes of 12 years’ duration comes to you for preoperative control for hernia surgery. His blood reports are as follows:

FBS= 188 mg/dl, PPBS= 232 mg/dl, HbA1c= 9.8%.

He is on Tab. Gliclazide 80 mg BD and Tab. Metformin 1000 mg BD.

1. Is he fit fotr the surgery from the diabetes anglte at present?

2. What will you do to bring down his blood glucose so that he can undergo surgery at the earliest?

Cases 1 deal with diabetes in the surgical patient so it is posted for minor surgery. The pre and perioperative diabetes care protocols can be discussed.

Case Study 2

Mr. V is 64 years old, undergoing treatment for Type2DM for the past 20 years.

He has recently undergone a coronary angiogram which has revealed a Triple Vessel Disease.

He wants to undergo Coronary Artery Bypass Grafting surgery.

His blood pressure is 130/88mmHg. His x-ray chest is within normal limits. His E.C.G shows extensive anterior wall Ischemia.

His FBS is 156mg/dl; PPBG is 228mg/dl. His HbA1c is 8.2 %.

His blood urea, creatinine and electrolytes are within normal limits.

His current medications are Glibenclamide 10 mg/day, metformin 1000mg/day, Acarbose 50mg tds, Aspirin 150mg/day, Atorvastatin 20 mg/day, Telmisartan 40 mg /day.

1. Is he fit for surgery?

2. Is there any need to change the medications?

3. What advice you will give for intra operative management?

Case 2 also deals with diabetes in the surgical patient so it is slated for major surgery. The pre and perioperative diabetes care protocols can be discussed.



Case Study 3

Mr. X, a 45 years old male patient has Type 2 Diabetes for the last 5 years. He is currently on a combination of Glimepiride 2 mg plus Metformin 1000 SR twice a day. His BMI is 29.5 and waist circumference 108 cms. His Fasting and PP glucose levels are 132 and 190 mg/dl respectively and HbA1C is 8.0. His exercise program is 20 minutes walk about three times a week. He is not very compliant with dietary advice. He complains of erectile dysfunction for the last 3 to 4 years.

How will you manage this patient?

Case 3 introduces the problem of erectile dysfunction in diabetes.

Case Study 4

86 year old Mr. V T2DM for 42 years. Was on Chlorformin initially for many year later on switched over to Gliclazide and Metformin combination. Glycaemic control was good. Had a fall following a slip at home. Fractured neck of femur. Underwent hemiarthroplasty.

Did not require insulin or OHA in the intra operative period as he had recurrent hypoglycemia.

His activities and diet reduced. Later on his glucose levels are under control with half the dose What he required before. He is stable.

What advice would you give to him?

Case 4 presents an elderly patient with diabetes and emphasizes the importance of not attempting very stringent glycemic control in such patients.

Case Study 5

Mr. L is 47 years old. He is known Type 2 DM for the past 11 years.

He has come to you with complaints of mild abdominal pain.

He does not take alcohol. He is a non smoker.

His height is 167 cm and weight 98kg. His BMI is 35.13. Acanthosis Nigricans is present.

Examination of abdomen shows an enlarged liver which is firm, non tender with rounded edges.

Liver function shows ALT and AST values elevated to more than 3 times the upper limit of normal.

1. What is working diagnosis?

2. What investigation will confirm the diagnosis?

3. What is the treatment?

Case 5 introducestheconceptofNAFLD.Doemphasizethatmostofthesepatientshavenosymptomsandare accidentally picked up based on ultrasound findings and elevated liver enzymes (not necessarily as high



as those depicted in the case).

Case Study 6

Mr C, a 52 year old businessman with longstanding type 2 diabetes is travelling nonstop from Mumbai to New York. He will leave from Mumbai at 1220 a.m. IST and reach New York by 1115 am New York time.

He wants to know how he can administer his insulin shots while travelling so as to reduce the risk of both hypo- and hyper-glycemia.

He is presently on Injection Regular Insulin three times daily before meals and Injection NPH insulin once daily before dinner.

What advice will you give him ?

Case 6 deals with diabetes during international travel. In this case the businessman should take the next dose of NPH insulin at the usual time by the New York clock. In between he should check his blood glucose at least 2 hourly and administer regular insulin if it goes high during the flight.

Case Study 7

Mrs. A is a known diabetic for the past 15 years. She consults you once in three months.

The last consultation was 15 days ago. At that time her blood glucose was under very good control with HbA1c of 6.8%. Her blood pressure was normal. She is on Insulin and OHA.

She calls you from her home. She tells you that she is suffering from fever with occasional vomiting. She is not able to eat her usual diet.

She wants to know what diet she can take, and should she continue her usual medications.

She also tells you that she is living far away and will not be able to come for immediate consultation.

1. What advice will you give her over phone?

2. What sort of diabetic education will you give to her when she comes to see you next time?

Case 7 deals with sick day guidelines. Although these are more critical in type 1 diabetes, patients with type 2 diabetes should also know what to do if suffering from any illness that inhibits oral intake.

Case Study 8

A 70 year old lady with type 2 diabetes wishes to observe a dawn-to-dusk fast for religious reasons. She is on tab. Gliclazide 80 mg twice daily (morning and night), tab. Metformin 500mg twice daily (morning and night) and tab Acarbose 25 mg thrice daily (along with each meal).

What will you advise her regarding her medications ?

Case 8 the lady can safely undergo the fast. It is sufficient if she omits gliclazide and acarbose on the morning of the fast and the noon dose of acarbose.



Module 11

Other Types of Diabetes Mellitus



MODULE 11

Other Types of Diabetes Mellitus

The learning objectives of this module are as follows:

• Learntoidentify,evaluateandtreatdiabetesinpregnancy

• Learnabouttheidentificationandmanagementofotheruncommontypesofdiabetessuchastype1

diabetes, drug induced diabetes and diabetes due to endocrinopathies

To achieve these objectives, the day’s discussions are organized as follows:

• CasePresentation

• Pre-test

• Lecture1:DiabetesinPregnancy

• Lecture2:OtherUncommonTypesofDiabetes

• CaseStudies

• Post-test

Pre-test(This will also serve as post-test after the day’s sessions)

Choose the most appropriate answer

1. The most specific congenital anomaly seen in infant of a diabetic mother is

A. Spina bifida

B. Sacral agenesis

C. Atrial septal defect

D. Anorectal malformation

2. A 28 weeks pregnant lady undergoes a glucose tolerance test with 75g glucose load and her blood glucose values are 86 mg/dl at 0 hours, 188 mg/dl at 1 hour and 138 mg/dl at 2 hours. What is the diagnosis as per the IADPSG guidelines?

A. Normal

B. IGT

C. Gestational diabetes

D. Gestational glucose intolerance



3. Which of the following agents is not approved in pregnancy?

A. Regular insulin

B. NPH insulin

C. Insulin glargine

D. Insulin detemir

4. Which of the following is false regarding honeymoon phase of type 1 diabetes?

A. It is characterized by greatly reduced insulin requirements

B. It is due to partial beta cell recovery

C. It last only for a few weeks or months

D. It is more common in adult patients

5. Which of the following endocrinopathies is associated with type 1 diabetes?

A. Acromegaly

B. Cushing syndrome

C. Pheochromocytoma

D. Graves’ disease

6. Thiazide diuretics induce hyperglycemia by

A. Increasing insulin resistance

B. Reducing insulin secretion

C. Both

D. Neither

7. Which of the following cannot cross the placental barrier?

A. Glucose

B. Amino acids

C. Ketones

D. Insulin

8. Which of the following oral antidiabetic agents is recently being considered as a safe treatment option in pregnancy?

A. Glibenclamide

B. Glipizide

C. Gliclazide

D. Glimepiride



9. Which of the following diabetes complications does not worsen during pregnancy?

A. Nephropathy

B. Neuropathy

C. Retinopathy

D. All of the above

10. Insulin requirement is maximum during ___ weeks of pregnancy.

A. 24 to 28 weeks

B. 28 to 30 weeks

C. 32 to 36 weeks

D. 12 to 14 weeks

Key to Pre-test

1. B

2. C

3. D

4. D

5. D

6. C

7. D

8. A

9. B

10. C

Lecture 1: Diabetes in Pregnancy

This is a very important lecture which introduces the topic of pregnancy and diabetes. It is important for the trainees to distinguish between diabetes complicating pregnancy and gestational diabetes.

Emphasize that Asian Indians are a high-risk ethnic group for development of diabetes and hence all pregnant women should be screened for diabetes as early as possible during pregnancy.

Ask the trainees which criteria they use for the diagnosis of GDM in their practice. Introduce the IADPSG guidelines and emphasize that these have started replacing the older guidelines.

Also discuss what the ideal glycemic targets in pregnancy are and how to achieve these goals. Discuss the role of insulin and insulin analogues in pregnancy.



Do discuss about the role of glibenclamide in pregnancy, but warn the trainees that its use is not yet widely accepted by all organizations.

Do not forget to emphasize the need for post partum screening of GDM cases and the importance of regular follow-up thereafter.

Lecture 2: Other Uncommon Types of Diabetes

This lecture briefly touches on the other types of diabetes which may be seen in adults.

Even though type 1 diabetes usually has onset in childhood, an occasional patient may develop it in adolescence. Moreover, as type 1 diabetes patients become adults, they shift from pediatric to adult medical care, often accompanied by a disruption in the previously well-maintained diabetes control.

The salient features of type 2 diabetes including etiopathogenesis, clinical features and treatment are dealt with in this module.

A brief outline is also given on drug induced diabetes and diabetes due to endocrinopathies.

Case Studies

Case Study 1

Mrs. S is 32 years old. She is planning to conceive her second child. She is a known diabetic for the past 2 years.

She is currently taking Tab. Glimepride 2mg bd, Tab. Metformin 500 mg bd.

Her HbA1c is 6.8.

What advice you will give her regarding the OHA?

Case 1 deals with prepregnancy counseling.

Case Study 2

28 years old lady with bad obstetric history with 6 months amenorrhoea has the following GTT using 75 grams glucose

0’ 60’ 120’

BG 86 188 146

US TRACE TRACE +

What is your diagnosis ?

Case 2 deals with the diagnosis of GDM using the revised IADPSG criteria.



Case Study 3

A 25 year old primigravida is found to have diabetes during the 21st week of gestation. Since the diabetes was mild she was advised lifestyle modification only. At the next review visit 2 weeks later her reports are as follows.

FPG= 88 mg/dl, PPPG= 187 mg/dl, Fructosamine 298 umol/ml (poor control)

1. Is her glycemic control acceptable?

2. Would you modify the treatment and if so, how?

3. What will you advise her regarding blood glucose monitoring?

Case 3 deals with a pregnant lady who has failed diet therapy for GDM and now needs medication. Discuss regarding initiation of insulin in GDM and principles of monitoring in GDM.

Case Study 4

Mr. S is 48 years old. He is diagnosed to have high blood sugar 3 months back. No family history of diabetes. His height is 174 cm. weight is 56 kg. BMI is 18.49.

His fasting blood sugar is 198mg/dl; PPBG is 286 mg/dl. His HbA1c is 9.2%

He is on glimepiride 4 mg/day and metformin 1500 mg/day for the past three months

He says his blood sugar remains the same for the last 3 months.

1. What is your diagnosis?

2. What test will confirm the diagnosis?

3. How will you manage the patient?

Case 4 introducestheconceptofLADA,whichistype1diabetespresentinginlateadulthood.



Module 12

Conclusions and

Take Home Messages



MODULE 12

Conclusions and Take Home Messages

At end of module 12 participants will be able to:

• To understand the Take Home Messages and conclusion of all the 11 modules of the course.

• This Module summarises the entire curriculum of CCEBDM in the form of Take-Home Messages. This provides an ideal opportunity to revise the salient points of each module and re-emphasize those points which the trainees feel require further attention. You may also elect to have an open session during the Module conduction, at which time the trainees can raise any question related to diabetes and which have not been discussed in detail in the course. Please feel free to share your experiences with the Program Secretariat - this feedback will form an important part of our curriculum revision for the next cycle.

• The Exit Examination will also be conducted during this session. The examination consists of 50 multiple choice questions. These, along with detailed instructions on the conduct of the examination, will be communicated to you closer to the date of the examination.



Notes

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