Assisted during interview by
Dr Bilal bin Younas MRCP
Assistant Professor of Medicine (FJMC)
Panel consisted of Dr Arshad Javaid Sh,Dr Mehboob Ashraf and Dr Saleem A Rana.
How Diabetes Mellitus is being managed in Pakistan by family physicians?
Problems are not at primary care level only, but these are being shared by all
levels.Physicians are not sensitive enough to the need of rigid control.When
patients are on borderline of control we are satisfied.We should be striving for
rigid control in appropriate patients.Second problem is lack of education of
patients.Diabetes Mellitus can not be managed without the co-operation of
patients.Co-operation is not possible until patients understand this disease and
they know where they have to be responsible themselves.There are many
misconceptions in the minds of patients.These have to be clarified.Broadly
speaking patient has to be educated on following points
DM is a life long disease ,so please do not discontinue treatment,if it is
controlled.
Misconceptions about insulin (It is last resort medicine),Tablets (These
effect kidneys) have to be addressed.Physicians should take little time to
educate patiens in different sittings.
Patients must understand different diets ,in the light of caloric values and
glycemic index, rather than sweetness.
Doctors only or one doctor can not provide all services due to lack of time.Time
has come when in institutions and in private practices nutritionists,Diabetic
paramedics and educators have to be recruited in the management,only then
adequate attention can be paid to all aspects of the problem.Discussing the
local facts and figures and relevant local reaserch,absence of follow up
(Patients do not come back on appointments) was considered as major hurdle in
addition to lack of resources.
Epidemiology of DM
Diabetes is on rise,more and more populations and individual are suffering from
it.Its incidence is expected to be double in next 10 years.Most of this increase
is going to be in developing counteries.
Pakistan National Health Survey has detected this increase in our
population.This increase is more marked in urban areas than in rural
areas.Reason for this is in the change of lifestyle in our population.It is
postulated that thrifty genes were present in the human beings to store extra
energy in the shape of fat.This fat was supposed to see us through the periods
when food suply was scarce.Now food supply is abundant.Physical work is
decreasing and decreasing ,especially in urban areas.So truncal obesity is being
seen more and more in our population with the consequent rise in DM incidence.
Definition of Diabetes Mellitus. Figures.
Fasting plasma glucose levels (FPG) = > 126 mgs
2 hr Postprandial levels = > 200 mgs
are the values which are being used as cut off point.When attention towards WHO
figures was drawn then a grey area of following figures was defined.
Fasting Blood Glucose levels = Between 110 mgs and 126 mgs/dl
2 hr post prandial Blood Glucose Levels = Between 140 mgs and 200 mgs/dl
Patients falling in between these figures are problematic.How to label
these?Normal or Diabetic? Glucose Tolerence Curve can be done.Two hours post
prandial reading after 75 gms of glucose meal are important.If this reading is
more than 200 mgs then this patient must be labeled as diabetic.
Value of HbA1c was regarded as important only in monitoring.No importance as for
as diagnosis is concerned.
Impaired Glucose Tolerence.
This is another variety of patients.These are not diabetic.They may progress to
DM.If fasting values are above 108 mgs and 2 hour post prandial figures after 75
gms glucose meal are between 140 mgs 200 mgs,then It is noticed they have
increased risk for ischaemic heart disease.If their blood glucose is drawn down
with diet,exercise or drugs they improve their chances against IHD.
Combination therapy of DM
Glucobay can be combined with any other drug.Metformin and sulfonyl-ureas can be
combined with insulin and with each other.Sulfonyl-ureas provide endogenous
insulin.So patients can gain wieght.Known propensity of endogenous insulin to be
atherogenic is another feature to be kept in mind when sulfonyl-ureas are
used.Exogenous insulin is not atherogenic.Metformins are also free of effect on
insulin.These are insulin sensitizers.
Sufonyl-ureas alone can bring down HbA1C 2 % down.Glucobay can bring down HbA1c
1 % down if given alone.Normal values of HbA1c vary from laboratory to
Laboratory.Standard values of 6.8 % to 7 % are considered normal with controlled
glucose levels.
Clinical Manifestations
Classical triad of symptoms is not very common in NIDDM.It is more commonly seen
in IDDM patients.DM is mostly diagnosed when we are looking for it in certain
clinical situations where its association is strong.Second scenario is when we
are doing routine screening for any medical condition including DM.Third
situation is be where we are routinely looking for DM only.Fourth situation is
coming up fast in the shape of genetic screening.
Clinical situations where Association of DM is strong and we shall be
routinely screening for DM whenever there is any of the following situations
present.
Classic triad of symptoms:Polyurea,Polydypsia,Polyphagia.All or any one of
these.
Coma
Hypertension
I H D
CCF
CRF
Chronic Liver conditions.
Difficult Infections
Pregnancy
Retinopathies
Peripheral Vascular Disease
Obesity
Recent Weight loss
Chronic foot Ulcers
Weakness
Male impotence :In all cases of weakness this aspect must be enquired.
Cramps,numbness of extremities,and all types of paraesthesias,burning of hands
and feet.
Routine medical check up for Employment,Insurance policy,Haj etc.
All patients having family history of DM
All persons celebrating their 40th birthday.
Genetic Screening.Nowadays genetic mapping for known defective genes ,prediposing
for certain diseases,is being undertaken.Soon we might be routinely checking
whole population.So persons detected having genes associated with DM will be
undergoing routine screenig for DM from time to time.
Diabetic Neuropathy.
Some of our patients come for the problems produced by neuropathy.This may take
anyone of the following presentations.
Mononeuropathy
Radiculitis
Nerve palsies
Peripheral neuropathy
Autonomic neuropathy
Diabetic
Amyotrophy
7th Nerve palsy is one example.Individual nerve involvements and acute
presentations usually recover fully with treatment.Symptoms in polyneuropathies
are usually subjective.These are
Pain,
Numbness
Burning sensations
Paraesthesias.
Following lesions may be present in the patient and detected by examination.
Ulcers on foot
Callosities on foot and hand.
Hammer toe
Glove and stocking anaesthesia of skin.
Impaired ankle jerks
Impaired knee jerks with upgoing plantar reflex (DiabeticAmyotrophy)
Painful upper thighs
These have to be substansiated with examination.
EMG (electromyography) is gold standard.It picks up almost all cases.This is
available in Lahore.So patients who can afford and are presenting with
subjective feelings can have EMG to comfirm their complaints as due to diabetic
neuropathy.If this test is negative then other etiologies should be considered.
Most sensitive examintion is testing with monofilament.(This is not available in
Pakistan.).Sense of touch is tested with it.This filamnet is pressed against the
skin gently,until it is bent.It exerts the pressure of 10 gms.If patient can
detect this touch before its bending then the tactile sense is normal.If it is
bent down and patient is still not aware of it then the test is positive and
patient can be labelled as having diabetic neuropathy.In the absence of this
monofilament cotton wool can be used to test the tactile touch in different
areas of skin.
Examination for Anaesthesia and Paraesthesias of Skin
With eyes of the patient closed move your fingers along the anterior and lateral
aspects of foot ,to the knee joints .Ask the patient to report when he can pick
up the sensation.Second point is that he should report when the nature of
tactile sensation changes.He may describe it as change in pain,touch or nature
of the touching substance.
Autonomic Neuropathy. This type of neuropathy is very common.This is incremented
in postural hyp0rtension which is experiened by the patient.Giddiness,cold
extremities,sweating may be due to autonomic neuropathy.
Many abdominal or Gastrointestinal symptoms can be due to autonomic
neuropthy.Diarrhoea,consipation,feeling of gas (fullness & tightness of abdomen)
are common symptoms.
Testing for Autonomic Neuropathy
Postural hypotension has to be demonstrated to certain level.Measure the BP when
patient is lying down.Then ask him to stand up.He should remain standing for 3
minutes.Then again measure the BP.Difference of 10 in lying and standing figures
in systolic pressure is labeled as simple postural hypotension which is
normal.But when difference is greater than 20 then it can be labeled as due to
autonomic neuropathy if patient is not taking any drugs affacting these
figures.Mean pressure is also decreased.
Management of Diabetic Neuropathy.
Go on to insulin immediately.Keep the blood glucose controled.This is the most
effective step one can take.Control with insulin will slow down further
deterioration.Other symtoms should be managed as following.
Minimal analgesics & NSAIDS
Second step is addition of one drug from antidepressants group.Any group.If
one group is not working try something from other groups.
Gabapectin can be used.
Capsacin Lotion is also available.It can be used localy to decrease the
feelings of pain.This compound,present naturaly in red chillies,raises the
threshhold of pain after getting absorbed.This is available in Pakistan as
Capsidol Lotion.
Other Clinical Manifestations.
All conditions enlisted above have their own specific findings.Whenever any
complication is present control with insulin shall be the target.
Renal Glycosuria
This is not uncommon.Patient passes sugar in urine.But his blood glucose levels
are always normal.First step is to be definite that reducing substance being
picked up is glucose and not some other substance.Then patient shall have blood
sugar checked as for DM.If these are normal then nothing more shall be done.It
is an innocent condition.Yearly check up for DM is not a bad idea.