Diabetes and hypertension

1. 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 ) .

3. 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 .

4. 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 .

5. 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 .

6. Investigations to diagnose diabetes : Fasting blood sugar ( FBS ) > 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 ) > 200 mg \ 100 ml ( 11 mmol \ L ) . Two readings on different days are needed for diagnosis , or one reading with obvious symptoms .

7. 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 .

8. 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 .

9. 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 >11.0 mmol\ L . Management group discussion .

10. 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 < 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 .

11. 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 ( < 12 mmol \ L indicates severe acidosis ) .

12. 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 .

13. 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 = or> 40 years , those with positive family history , obese persons , women with a history of a big offspring , patients with premature arteriosclerosis .

14. 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

15. 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 > 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 > 2\3 arm width and its length is > 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 .

16. 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

17. BP evaluation : systolic diastolic Normal < 130 < 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 ) > 210 > 120 ( Goroll , 2002 .USA ) page 82 )

18. . HYN Management : For all patients : Salt restriction < 5 gm \ day . Advise weight reduction , esp. if wt is > 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 .

19. 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 .

20. 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 .

21. 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 .