1 / 21

Diabetes and hypertension

Diabetes and hypertension.

Télécharger la présentation

Diabetes and hypertension

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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 .

More Related