Diabetes and hypertension

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Diabetes and hypertension
2

• One of the activities of the PHC centre is
  diagnosis , management , follow up and referral
  of patients with chronic diseases such as
  diabetes and hypertension . These two diseases
  are precipitated by some general risk factors (
  see 4th year lecture ) .Type-2 diabetes ,
  hyperlipidaemia and hypertension are strongly
  associated with obesity . The prevalence of
  obesity in KSA is 6 among preschool children ,
  20-30 in school children , 25-45 in adolescent
  , 48-60 in adult females and 45-70 in adult
  males ( Madani ,WHO ,2000 ) .

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• Diabetes is a chronic disease that occurs when
  the pancreas does not produce enough insulin or
  the body cannt effectively use the insulin it
  produces . Prevalence of the disease , worldwide
  180 million ( WHO, 2000 ) this number is likely
  to be double by 2030 . In KSA 890000 ( 2002 ) and
  2523000 ( 2030 ) . In Sudan 447000 ( 2002 ) and
  1275000 ( 2030 ) . Worldwide 1.1 million died
  from diabetes ( 2005 ) . 80 of diabetes deaths
  occur in low and middle income countries .

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• Dx , Rx , complications and health education in
  diabetes
• There are three types . Type-1 ( IDD or
  child-onset ) is due to lack of insulin
  production . Its symptoms are polyuria ( in
  difference from UTI , the amount of urine is
  large ) , polydipsia , polyphegia , weight loss ,
  vision changes , fatigue . These symptoms may
  occur suddenly .
• Type-2 ( NIDD or adult-onset ) results from the
  body s ineffective use of insulin . It comprises
  90 of diabetics around then world , and largely
  a result of obesity and physical inactivity .

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• Its symptoms may be similar to type-1 ,but less
  marked . As a result , it may be diagnosed
  several years after onset when complications have
  already arisen . It was seen only in adults , but
  now it also occurs in obese children .
• Gestational diabetes is a hyperglycaemia , which
  is first recognized during pregnancy .Its
  symptoms are similar to type-2 diabetes , often
  is diagnosed during prenatal screening rather
  than reported symptoms .

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• Investigations to diagnose diabetes
• Fasting blood sugar ( FBS ) gt 126 mg \ 100 ml ( 7
  mmol \ L )
• Blood glucose , 2 hours after 75 gm of glucose
  meal 11.1 mmol \ L
• Random blood sugsr ( RBS ) gt 200 mg \ 100 ml ( 11
  mmol \ L ) .
• Two readings on different days are needed for
  diagnosis , or one reading with obvious symptoms .

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• Impaired fasting glucose ( IFG ) is 7 mmol \ L
• Impaired glucose tolerance ( IGT ) after 2 hours
  meal is 7.8-11.0 mmol \ L
• IFG IGT are intermediate conditions between
  normality and disease , people with these
  conditions are at high risk of developing type-2
  diabetes , but not inevitable .

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• Treatment of diabetes , chronic complications ,
  causes of referral to advanced health care ,
  follow up at health centre , health education for
  diabetics , a diabetic patient identical card (
  group discussion )
• Treatment Three methods . Diet , oral
  hypoglycaemics( used in type-2 ) sulphonlyureas
  e,g, glibenclamides and biguanides ( long acting
  ) e,g, metformin is the only one available ,
  insulin .

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• Chronic diabetic complications retinopathy ,
  nephropathy , neuropathy , diabetic foot .Cause
  for referral chronic complications and \ or
  uncontrolled diabetes .
• Acute diabetic complications are hyperglycaemia
  , hypoglaecima and ketoacidosis
• Hyperglycaemia Symptoms in diabetes are thirst
  , dry mouth , polyuria , notcuria , tiredness ,
  fatigue , irritability , apathy , blurring of
  vision , pruritis vulvae , genital candidiasis ,
  nausea , headache , hyperphagia , predilection
  for sweet foods . RBS gt11.0 mmol\ L . Management
  group discussion .

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• Hypoglcaemia in diabetes Its symptoms are
  sweating , trembling , hunger , anxiety ,
  pounding heart , confusion , inability to
  concentrate , drowsiness , incoordination ,
  speech difficulty , nausea , headache , tiredness
  . It often occurs in diabetics treated with
  insulin , but relatively rare in those taking
  sulphonylurea drugs . RBS lt 3.5 mmol \ L . Its
  causes are Missed , delayed or inadequate meal
  . Unexpected or unusual exercise . Alcohol
  overdose . Errors in oral hypoglcaemic drug or
  insulin dose . Poorly designed insulin regimen
  especially at night . Unrecognised endocrine
  diseases e.g. Addison disease . If hypoglycaemia
  is frequently occurring , reduce dose by 20 and
  seek medical advice for dose adjustment .

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• Diabetic ketoacidosis ( DKA ) is a major medical
  emergency and a serious cause of morbidity and
  mortality especially in type-1 patients . It is
  caused by insulin deficiency and an increase in
  catabolic hormones , leading to hepatic
  overproduction of glucose and ketone bodies .
  Biochemical features of DKA are hyperglycaemia ,
  hyperketonaemia and metabolic acidosis .
  Hypewrglycaemia causes profound osmotic diuresis
  leading to dehydration . Haemoconcentration leads
  to a decrease in blood volume and fall in blood
  pressure with associated renal ischaemia and
  oliguria . Fluid and electrolytes loss especially
  potassium . The severity of DKA is assessed by
  plasma bicarbonate ( lt 12 mmol \ L indicates
  severe acidosis ) .

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• Average loss of fluid and electrolytes in adult
  DKA of moderate severity Water 6 L , sodium 500
  mmol , chloride 400 mmol , potassium 350 mmol .
• Complications of DKA Cerebral oedema , which
  may be caused by rapid reduction of blood glucose
  , hypotonic fluids and \ or bicarbonate . It
  causes high mortality . It is treated by mannitol
  and oxygen . Acute respiratory distress syndrome
  . thromboembolism , disseminated intravascular
  coagulation ( rare ) , acute circulatory failure
  . Treatment of DKA by i\m short-acting insulin (
  soluble ) , fluid replacement by normal saline ,
  potassium and bicarbonate replacement ,
  antibiotics if infection is present .

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• Screening for diabetes The reason for screening
  is the assumption that early detection and
  effective control of hyperglycaemia in
  asymptomatic diabetics decreases morbidity . RBS
  is used as a screening test , FBS and 2 hours
  after meal of 75 gm of oral glucose as a
  confirmatory test .
• Target population screening is conducted among
  high risk groups such as those in age-group orgt
  40 years , those with positive family history ,
  obese persons , women with a history of a big
  offspring , patients with premature
  arteriosclerosis .

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• Hypertension ( HYN ) WHO ( 1978 ) defined HYN
  in adults as a systolic pressure 160 mm Hg and
  \ or diastolic pressure 95 . There are two types
  of HYN , primary ( essential ) when the cause is
  unknown , it accounts for 90 of cases and
  secondary which accounts for 10 . Secondary HYN
  when other diseases or abnormalities such as
  chronic glomerulonephritis and chronic
  pyelonephritis , tumors of adrenal glands ,
  congenital narrowing of the aorta and toxemia of
  pregnancy . Prevalence of
  HYN In idustrialized co25 in adults , in
  developing countries and some European ranging
  from 10 to 20 . HYN is a major cause for
  stroke , CHD , heart or kidney failure , the
  majority of mortality associated with HYN is due
  to CVD

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• Measuring Bp Have patient rest for 5 mins
  before taking measurement . Take Bp in both arms
  with patient seated comfortably with back and arm
  supported . Take 2 or more readings separated by
  2 mins and repeat if readings differ by gt 5 mm Hg
  . Have patient refrain from smoking or having
  coffee 30 mins before measuring Bp . Make sure
  before measurement that patient is not cold
  neither anxious .his bladder is empty , he has
  not recently exercised . Place cuff as high on
  arm as possible and support arm positioned at
  heart level . Be sure that the width of cuff
  inflatable bladder is gt 2\3 arm width and its
  length is gt 2\3 arm circumference . Auscultate
  using stethoscope bell . Determine SBP as point
  at which sound is first heard ( Korotkoff-1 ) ,
  determine DBP as point at which sound disappears
  ( Korotkoff-5 ) rather than when it changes in
  quality ( Korotkoff-4 ) . Average 2 successive
  measurements in each arm . Confirm HYN Dx by
  taking multiple determinations over several
  visits .

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• There are three sources of error in recording BP
  a. observer error due to hearing acuity and
  interpretation of Korotkoff sounds ,b.
  instrumental error e.g. leaking value , cuffs
  that do not encircle the arm , c, subject errors
  , these include the physical environment, patient
  position , external stimuli such as fear and
  anxiety

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• BP evaluation
• systolic
  diastolic
• Normal
  lt 130
  lt 85
• High normal
  130-139
  85-89
• HYN
• Stage 1 ( mild )
  140-159
  90-99
• Stage 2 ( moderate )
  160-179
  100-109
• Stage 3 ( severe )
  180-209
  110-119
• Stage 4 ( malignant )
  gt 210
  gt 120
• ( Goroll ,
  2002 .USA ) page 82 )

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• .
• HYN Management
• For all patients Salt restriction lt 5 gm \ day
  . Advise weight reduction , esp. if wt is gt 15
  above ideal wt . Complete smoking cessation .
  Exercise program .
• For patients in stage 1 , with no complications
  Full non-pharmacological measures . Repeat BP
  determination regularly for 6 mos , if no
  improvement , continue non- pharmacological
  measures and BP determination for another 3 mos ,
  if no improvement after 6-12 mos , add first-line
  antihypertensive agent to non-pharmacological
  measures .

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• For pts with stage 1 CVD risk factors or signs
  of target-organ disease Non pharmacological
  program , regular BP determination for 3 mos , if
  BP not normalized add first line agent .

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• For pts with stage 2 esp if with CVD risk factors
  or target-organ damage Non pharmacological
  program , if after 1-2 mos , not normalized , add
  first-line agent and then advance pharmacological
  program as needed , monitor BP closely .
• For pts with stage 3 immediately give full doses
  of first-line agent and consider early use of
  second first-line if necessary , if BP improved
  ,but not normalized within 1 week , add second
  first-line agent . If no response to initial
  first-line agent within a few days , begin second
  first-line agent from different class at full
  doses and consider adding second drug at same
  time . Full non pharmacological program with
  closely follow up .

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• For pts with stage 4 Consider emergency
  hospitalization esp if evidence of acute
  target-organ injury ( papilledema , retinal
  hemorrhage , heart failure , altered mental
  status ) , start 2- 3 drug regimen and follow up
  in a few days .
• First-line agents Thiazides (
  hydrochlorothiazide 12.5-25 mg\day ) . beta
  blockers for pts with high CVD risk c\i in pts
  with bronchospasm . ACE inhibitors preferred for
  pts with DM c\i in pregnancy and bilateral renal
  stenosis , calcium channel blockers ( amlodipine
  5 -10 mg\ day ) .
• Screening and prevention of HYN Screen all
  adults regularly for HYN by measuring BP at every
  health encounter , pay esp attention to persons
  with DM , heart failure , coronary disease , or
  renal disease , because HYN can markedly worsen
  prognosis and treatment can greatly improve it .