Organisation and planning of care

1. Careful planning, taking into account the specific needs of

the patient with diabetes, is required at all stages of the patient
pathway from GP referral to post-operative discharge.
2. The patient should be involved in planning for all stages.
3. Hospital patient administration systems should be able to
identify all patients with diabetes so they can be prioritized on
the operating list.
4. High-risk patients (poor glycaemic control/complications of
diabetes) should be identified in surgical outpatients or at preoperative assessment and plans should be put in place to
manage their risk.
5. Early pre-operative assessment should be arranged to
determine a peri-operative diabetes management strategy and
to identify and optimize other co-morbidities.
6. Routine overnight admission for pre-operative management
of diabetes should not be necessary.
7. Starvation time should be minimized by prioritizing patients
on the operating list.
8. Surgical and anesthetic principles of the Enhanced
Recovery Partnership Programme should be implemented to
promote earlier mobilization with resumption of normal diet
and return to usual diabetes management.
9. Multi-modal analgesia should be combined with appropriate
anti-emetics to enable an early return to normal diet and usual
diabetes regimen.
10. The patient should resume diabetes self management as
soon as possible where appropriate.
11. A policy which includes plans for diabetes management
should be in place for safe discharge.
12. Outcomes should be audited regularly.

Diabetes specialists
13. Clear guidelines should indicate when the diabetes
specialist team should become involved.
14. All hospitals should implement a Diabetes Inpatient
Specialist Nurse (DISN) service.
Peri-operative use of intravenous insulin
15. The term variable rate intravenous insulin infusion (VRIII)
should replace the ambiguous term sliding scale.
16. Patients with a planned short starvation period (no more
than one missed meal in total) should be managed by
modification of their usual diabetes medication, avoiding a
VRIII wherever possible.
17. Patients expected to miss more than one meal should
have a VRIII.
18. The recommended first choice substrate solution for a
VRIII is 0.45% sodium chloride with 5% glucose and either
0.15% potassium chloride (KCl) or 0.3% KCl.
19. Insulin should be prescribed according to National Patient
Safety Agency (NPSA) recommendations for safe use of
insulin.
Peri-operative blood glucose monitoring
20. Capillary blood glucose (CBG) levels should be monitored
and recorded at least hourly during the procedure and in the
immediate postoperative period.
21. Hospitals should have clear guidelines for the
management of blood glucose when it is outside the
acceptable range.
22. Training for blood glucose measurement and diabetes
management should be introduced for clinical staff caring for
patients with diabetes.
23.
The WHO surgical safety checklist bundle should be

implemented. The target blood glucose should be 6-10

mmol/L (acceptable range 4-12 mmol/L).
24.

Nursing Diagnosis Nursing care plans for Diabetes Mellitus

Common nursing diagnosis found in Nursing care plans for Diabetes Mellitus
Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures
Fear related to insulin injection
Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat
Activity Intolerance related to poor glucose control
Deficient Knowledge related to use of oral hypoglycemic agents
Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities
Ineffective Coping related to chronic disease and complex self-care regimen
Nursing Intervention and Evaluation Nursing care plans for Diabetes Mellitus

No
1

Nursing Diagnose
Imbalanced
Nutrition: More
than Body
Requirements
related to intake
in excess of
activity
expenditures

Outcome
Nutrition
balance
between
needs and
intake

Intervention

Fear related to
insulin injection

Fear less or
discrease

Risk for Injury

Injury is not
(hypoglycemia) appears
related to effects
of insulin,

Assess current timing and content of meals.

Advise patient on the importance of an
individualized meal plan in meeting weight-loss
goals. Reducing intake of carbohydrates may
benefit some patients; however, fad diets or diet
plans that stress one food group and eliminate
another are generally not recommended.
Discuss the goals of dietary therapy for the patient.
Setting a goal of a 10% (of patients actual body
weight) weight loss over several months is usually
achievable and effective in reducing blood sugar
and other metabolic parameters.
Assist patient to identify problems that may have an
impact on dietary adherence and possible solutions
to these problems. Emphasize that lifestyle changes
should be maintainable for life.
Explain the importance of exercise in
maintaining/reducing body weight.
Caloric expenditure for energy in exercise
Carryover of enhanced metabolic rate and efficient
food utilization
Assist patient to establish goals for weekly weight
loss and incentives to assist in achieving them.
Strategize with patient to address the potential
social pitfalls of weight reduction.

Evaluation
Maintains ideal
body weight with
body mass index
less than 25

Assist patient to reduce fear of injection by

encouraging verbalization of fears regarding insulin
injection, conveying a sense of empathy, and
identifying supportive coping techniques.
Demonstrate and explain thoroughly the procedure
for insulin self-injection
Help patient to master technique by taking a stepby-step approach.
Allow patient time to handle insulin and syringe to
become familiar with the equipment.
Teach self-injection first to alleviate fear of pain
from injection.
Instruct patient in filling syringe when he or she
expresses confidence in self-injection procedure.
Review dosage and time of injections in relation to
meals, activity, and bedtime based on patients
individualized insulin regimen.

Demonstrates
self-injection of
insulin with
minimal fear

Closely monitor blood glucose levels to detect

hypoglycemia.
Instruct patient in the importance of accuracy in
insulin preparation and meal timing to avoid

Hypoglycemia
identified and
treated
appropriately

inability to eat

Activity
Intolerance
related to poor
glucose control

Normal
Activity is
appears

Deficient
Knowledge
related to use of
oral
hypoglycemic
agents

Knowledge is
sufficient

hypoglycemia.
Assess patient for the signs and symptoms of
hypoglycemia.
Adrenergic (early symptoms) sweating, tremor,
pallor, tachycardia, palpitations, nervousness from
the release of adrenalin when blood glucose falls
rapidly
Neurologic (later symptoms) light-headedness,
headache, confusion, irritability, slurred speech,
lack of coordination, staggering gait from
depression of central nervous system as glucose
level progressively falls
Treat hypoglycemia promptly with 15 to 20 g of
fast-acting carbohydrates.
Encourage patient to carry a portable treatment for
hypoglycemia at all times.
Assess patient for cognitive or physical impairments
that may interfere with ability to accurately
administer insulin.
Between-meal snacks as well as extra food taken
before exercise should be encouraged to prevent
hypoglycemia.
Encourage patients to wear an identification
bracelet or card that may assist in prompt treatment
in a hypoglycemic emergency.
Encourage patient to carry a portable treatment for
hypoglycemia at all times.
Assess patient for cognitive or physical impairments
that may interfere with ability to accurately
administer insulin.
Between-meal snacks as well as extra food taken
before exercise should be encouraged to prevent
hypoglycemia.
Encourage patients to wear an identification
bracelet or card that may assist in prompt treatment
in a hypoglycemic emergency.
Advise patient to assess blood glucose level before
and after strenuous exercise.
Instruct patient to plan exercises on a regular basis
each day.
Encourage patient to eat a carbohydrate snack
before exercising to avoid hypoglycemia.
Advise patient that prolonged strenuous exercise
may require increased food at bedtime to avoid
nocturnal hypoglycemia.
Instruct patient to avoid exercise whenever blood
glucose levels exceed 250 mg/day and urine ketones
are present. Patient should contact health care
provider if levels remain elevated.
Counsel patient to inject insulin into the abdominal
site on days when arms or legs are exercised.

Exercises daily

Assess level of knowledge of disease and ability to

care for self
Assess adherence to diet therapy, monitoring
procedures, medication treatment, and exercise
regimen
Assess for signs of hyperglycemia: polyuria,
polydipsia, polyphagia, weight loss, fatigue, blurred
vision

Verbalizes
appropriate use
and action of oral
hypoglycemic
agents

Risk for Impaired Impaired Skin

Skin Integrity
Integrity is
related to
not appears
decreased

sensation and

circulation to
lower extremities

Ineffective
Effective
Coping related to coping
chronic disease
and complex selfcare regimen

Assess for signs of hypoglycemia: sweating, tremor,

nervousness, tachycardia, light-headedness,
confusion
Perform thorough skin and extremity assessment for
peripheral neuropathy or peripheral vascular disease
and any injury to the feet or lower extremities
Assess for trends in blood glucose and other
laboratory results
Make sure that appropriate insulin dosage is given
at the right time and in relation to meals and
exercise
Make sure patient has adequate knowledge of diet,
exercise, and medication treatment
Immediately report to health care provider any signs
of skin or soft tissue infection (redness, swelling,
warmth, tenderness, drainage)
Get help immediately for signs of hypoglycemia
that do not respond to usual glucose replacement
Get help immediately for patient presenting with
signs of either ketoacidosis (nausea and vomiting,
Kussmaul respirations, fruity breath odor,
hypotension, and altered level of consciousness) or
hyperosmolar hyperglycemic nonketotic syndrome
(nausea and vomiting, hypothermia, muscle
weakness, seizures, stupor, coma).
Assess feet and legs for skin temperature, sensation,
soft tissue injuries, corns, calluses, dryness, hammer
toe or bunion deformation, hair distribution, pulses,
deep tendon reflexes.
Maintain skin integrity by protecting feet from
breakdown.
Use heel protectors, special mattresses, foot cradles
for patients on bed rest.
Avoid applying drying agents to skin (eg, alcohol).
Apply skin moisturizers to maintain suppleness and
prevent cracking and fissures.
Instruct patient in foot care guidelines
Advise the patient who smokes to stop smoking or
reduce if possible, to reduce vasoconstriction and
enhance peripheral blood flow. Help patient to
establish behavior modification techniques to
eliminate smoking in the hospital and to continue
them at home for smoking-cessation program.

No skin
breakdown

Discuss with the patient the perceived effect of

diabetes on lifestyle, finances, family life,
occupation.
Explore previous coping strategies and skills that
have had positive effects.
Encourage patient and family participation in
diabetes self-care regimen to foster confidence.
Identify available support groups to assist in
lifestyle adaptation.
Assist family in providing emotional support.

Verbalizes initial
strategies for
coping with
diabetes

Nursing Diagnosis and Nursing Intervention

Nursing Diagnosis for Diabetes Mellitus

1. Nursing Diagnosis : Fluid Volume Deficit related to osmotic diuresis.
Goal:
Demonstrate adequate hydration evidenced by stable vital signs, palpable peripheral pulse, skin turgor and
capillary refill well, individually appropriate urinary output, and electrolyte levels within normal limits.
Nursing Intervention:
1.) Monitor vital signs.
Rational: hypovolemia can be manifested by hypotension and tachycardia.
2.) Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rational: This is an indicator of the level of dehydration, or an adequate circulating volume.
3.) Monitor input and output, record the specific gravity of urine.
Rational: To provide estimates of the need for fluid replacement, renal function, and effectiveness of the therapy
given.
4.) Measure weight every day.
Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid.
5.) Provide fluid therapy as indicated.
Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual
patients.
2. Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirmentsrelated to insufficiency of insulin,
decreased oral input.
Goal:
Digest the amount of calories / nutrients right
Shows the energy level is usually
Stable or increasing weight.
Nursing Intervention:
1.) Determine the patient's diet and eating patterns and compared with food that can be spent by the patient.
Rationale: Identify deficiencies and deviations from the therapeutic needs.
2.) Weigh weight per day or as indicated.
Rational: Assessing an adequate food intake (including absorption and utilization).
3.) Identification of preferred food / desired include the needs of ethnic / cultural.
Rational: If the patient's food preferences can be included in meal planning, this cooperation can be pursued after
discharge.
4.) Involve patients in planning the family meal as indicated.
Rationale: Increase the sense of involvement; provide information on the family to understand the patient's nutrition.
5.) Give regular insulin treatment as indicated.
Rational: regular insulin has a rapid onset and quickly and therefore can help move glucose into cells.
3. Nursing Diagnosis : Risk for Infection related to hyperglikemia.
Goal:
Identify interventions to prevent / reduce the risk of infection.
Demonstrate techniques, lifestyle changes to prevent infection.
Nursing Intervention:
1). Observed signs of infection and inflammation.
Rationale: Patients may be entered with an infection that usually has sparked a state of ketoacidosis or may have
nosocomial infections.
2). Improve efforts to prevention by good hand washing for all people in contact with patients including the patients
themselves.
Rationale: Prevents cross infection.
3). Maintain aseptic technique in invasive procedures.
Rational: high glucose levels in blood would be the best medium for the growth of germs.
4). Give your skin with regular care and earnest.

Rational: the peripheral circulation may be disturbed that puts patients at increased risk of damage to the skin / skin
irritation and infection.
5). Make changes to the position, effective coughing and encourage deep breathing.
Rational: memventilasi Assist in all areas and mobilize pulmonary secretions.
4. Activity Intolerance
Activity Intolerance Definition : Insufficient physiological or psychological energy to endure or complete required or
desired daily activities
Activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and
disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or
pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can
impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity,
malnourishment, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of
confidence to exert one's self.
Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to
maintain a satisfactory lifestyle.
Related Factors:
Generalized weakness
Deconditioned state
Sedentary lifestyle
Insufficient sleep or rest periods
Depression or lack of motivation
Prolonged bed rest
Imposed activity restriction
Imbalance between oxygen supply and demand
Pain
Side effects of medications
Nursing Interventions for Activity Intolerance
1. Assess patient's level of mobility. This aids in defining what patient is capable of, which is necessary before
setting realistic goals.
2. Assess nutritional status. Adequate energy reserves are required for activity.
3. Assess potential for physical injury with activity. Injury may be related to falls or overexertion.
4. Assess patient's cardiopulmonary status before activity using the following measures:
Heart rate Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. This
number will change depending on the intensity of exercise the patient is attempting (e.g., climbing four flights of
stairs versus shoveling snow).
Orthostatic BP changes Elderly patients are more prone to drops in blood pressure with position changes.
Need for oxygen with increased activity Portable pulse oximetry can be used to assess for oxygen desaturation.
Supplemental oxygen may help compensate for the increased oxygen demands.
How Valsalva maneuver affects heart rate when patient moves in bed Valsalva maneuver, which requires breath
holding and bearing down, can cause bradycardia and related reduced cardiac output.
Assess need for ambulation aids: bracing, cane, walker, equipment modification for activities of daily living (ADLs).
Some aids may require more energy expenditure for patients who have reduced upper arm strength (e.g., walking
with crutches). Adequate assessment of energy requirements is indicated.

6. Determine patient's perception of causes of fatigue or activity intolerance. These may be temporary or
permanent, physical or psychological. Assessment guides treatment.
Monitor patient's sleep pattern and amount of sleep achieved over past few days. Difficulties sleeping need to be
addressed before activity progression can be achieved.

Fatigue
Nursing Diagnosis: Fatigue
May be related to
Decreased metabolic energy production
Altered body chemistry: insufficient insulin
Increased energy demands: hypermetabolic state/infection
Possibly evidenced by
Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accidentprone
Impaired ability to concentrate, listlessness, disinterest in surroundings
Desired Outcomes
Verbalize increase in energy level.
Display improved ability to participate in desired activities.
Nursing Interventions

Rationale

Discuss with patient the need for activity. Plan schedule with
patient and identify activities that lead to fatigue.

Education may provide motivation to increase activity level even

though patient may feel too weak initially.

Alternate activity with periods of rest/uninterrupted sleep.

Prevents excessive fatigue.

Monitor pulse, respiratory rate, and BP before/after activity.

Indicates physiological levels of tolerance.

Discuss ways of conserving energy while bathing, transferring, and Patient will be able to accomplish more with a decreased
so on.
expenditure of energy.
Increase patient participation in ADLs as tolerated.

Increases confidence level/self-esteem and tolerance level.

Powerlessness
Nursing Diagnosis: Powerlessness
May be related to
Long-term/progressive illness that is not curable
Dependence on others
Possibly evidenced by
Reluctance to express true feelings; expressions of having no control/influence over situation

Apathy, withdrawal, anger

Does not monitor progress, nonparticipation in care/decision making
Depression over physical deterioration/complications despite patient cooperation with regimen
Desired Outcomes:
Acknowledge feelings of helplessness.
Identify healthy ways to deal with feelings.
Assist in planning own care and independently take responsibility for self-care activities.
Nursing Interventions

Rationale

Encourage patient/SO to express

feelings about hospitalization and
disease in general.

Identifies concerns and facilitates problem solving.

Acknowledge normality of feelings.

Recognition that reactions are normal can help patient problem-solve and seek help as needed.
Diabetic control is a full-time job that serves as a constant reminder of both presence of disease
and threat to patients health/life.

Assess how patient has handled

problems in the past. Identify locus of
control.

Knowledge of individuals style helps determine needs for treatment goals. Patient whose locus
of control is internal usually looks at ways to gain control over own treatment program. Patient
who operates with an external locus of control wants to be cared for by others and may project
blame for circumstances onto external factors.

Provide opportunity for SO to express

Enhances sense of being involved and gives SO a chance to problem-solve solutions to help
concerns and discuss ways in which he
patient prevent recurrence.
or she can be helpful to patient.
Ascertain expectations/goals of
patient and SO.

Unrealistic expectations/pressure from others or self may result in feelings of frustration/loss of

control and may impair coping abilities.

Determine whether a change in

relationship with SO has occurred.

Constant energy and thought required for diabetic control often shifts the focus of a
relationship. Development of psychological concerns/visceral neuropathies affecting selfconcept (especially sexual role function) may add further stress.

Encourage patient to make decisions

related to care, e.g., ambulation, time
for activities, and so forth.

Communicates to patient that some control can be exercised over care.

Support participation in self-care and

give positive feedback for efforts.

Promotes feeling of control over situation.

Risk for Disturbed Sensory Perception

Nursing Diagnosis: Sensory Perception, risk for disturbed (specify)
Risk factors may include
Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance
Desired Outcomes

Maintain usual level of mentation.

Recognize and compensate for existing sensory impairments.
Nursing Interventions
Monitor vital signs and mental status.
Address patient by name; reorient as needed to place, person, and
time. Give short explanations, speaking slowly and enunciating
clearly.

Schedule nursing time to provide for uninterrupted rest periods.

Rationale
Provides a baseline from which to compare abnormal findings,
e.g., fever may affect mentation.

Decreases confusion and helps maintain contact with reality.

Promotes restful sleep, reduces fatigue, and may improve

cognition.

Keep patients routine as consistent as possible. Encourage

participation in activities of daily living (ADLs) as able.

Helps keep patient in touch with reality and maintain orientation

to the environment.

Protect patient from injury (avoid/limit use of restraints as able)

when level of consciousness is impaired. Place bed in low position.
Pad bed rails and provide soft airway if patient is prone to seizures.

Disoriented patient is prone to injury, especially at night, and

precautions need to be taken as indicated. Seizure precautions need
to be taken as appropriate to prevent physical injury, aspiration.

Evaluate visual acuity as indicated.

Investigate reports of hyperesthesia, pain, or sensory loss in the

feet/legs. Look for ulcers, reddened areas, pressure points, loss of
pedal pulses.
Provide bed cradle. Keep hands/feet warm, avoiding exposure to
cool drafts/hot water or use of heating pad.

Assist with ambulation/position changes.

Monitor laboratory values, e.g., blood glucose, serum osmolality,

Hb/Hct, BUN/Cr.

Carry out prescribed regimen for correcting DKA as indicated.

Retinal edema/detachment, hemorrhage, presence of cataracts or

temporary paralysis of extraocular muscles may impair vision,
requiring corrective therapy and/or supportive care.
Peripheral neuropathies may result in severe discomfort, lack
of/distortion of tactile sensation, potentiating risk of dermal injury
and impaired balance.

Reduces discomfort and potential for dermal injury.

Promotes patient safety, especially when sense of balance is

affected.
Imbalances can impair mentation. Note: If fluid is replaced too
quickly, excess water may enter brain cells and cause alteration in
the level of consciousness (water intoxication).
Alteration in thought processes/potential for seizure activity is
usually alleviated once hyperosmolar state is corrected.

Risk for Infection

Nursing Diagnosis: Risk for Infection
Risk factors may include:
High glucose levels, decreased leukocyte function, alterations in circulation
Preexisting respiratory infection, or UTI

Desired Outcomes:
Identify interventions to prevent/reduce risk of infection.
Demonstrate techniques, lifestyle changes to prevent development of infection.
Nursing Interventions

Rationale

Observe for signs of infection and inflammation, e.g.,

fever, flushed appearance, wound drainage, purulent
sputum, cloudy urine.

Patient may be admitted with infection, which could have precipitated the
ketoacidotic state, or may develop a nosocomial infection.

Promote good handwashing by staff and patient.

Reduces risk of cross-contamination.

Maintain aseptic technique for IV insertion procedure,

administration of medications, and providing
High glucose in the blood creates an excellent medium for bacterial growth.
maintenance/site care. Rotate IV sites as indicated.
Provide catheter/perineal care. Teach the female
patient to clean from front to back after elimination

Minimizes risk of UTI. Comatose patient may be at particular risk if urinary

retention occurred before hospitalization. Note: Elderly female diabetic patients
are especially prone to urinary tract/vaginal yeast infections.

Provide conscientious skin care; gently massage bony Peripheral circulation may be impaired, placing patient at increased risk for skin
areas. Keep the skin dry, linens dry and wrinkle-free. irritation/breakdown and infection.

Auscultate breath sounds.

Rhonchi indicate accumulation of secretions possibly related to

pneumonia/bronchitis (may have precipitated the DKA). Pulmonary
congestion/edema (crackles) may result from rapid fluid replacement/HF.

Place in semi-Fowlers position.

Facilitates lung expansion; reduces risk of aspiration.

Reposition and encourage coughing/deep breathing if

Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of
patient is alert and cooperative. Otherwise, suction
secretions with increased risk of infection.
airway, using sterile technique, as needed.
Provide tissues and trash bag in a convenient location
for sputum and other secretions. Instruct patient in
proper handling of secretions.
Encourage/assist with oral hygiene.

Minimizes spread of infection.

Reduces risk of oral/gum disease.

Encourage adequate dietary and fluid intake

(approximately3000 mL/day if not contraindicated by
cardiac or renal dysfunction), including 8 oz of
cranberry juice per day as appropriate.

Decreases susceptibility to infection. Increased urinary flow prevents stasis and

aids in maintaining urine pH/acidity, reducing bacteria growth and flushing
organisms out of system. Note: Use of cranberry juice can help prevent bacteria
from adhering to the bladder wall, reducing the risk of recurrent UTI.

Administer antibiotics as appropriate.

Early treatment may help prevent sepsis.

5. Knowledge Deficit
Goal: patient expressed understanding of the conditions, procedures and effects of the treatment process.
Expected outcomes:
Perform the necessary procedures and explain the rationale of an action.

Initiate the necessary lifestyle changes and participate in treatment regimen.

Intervention / Implementation:
1. Assess the level of knowledge of the client and family about the disease.
R: Find out how much experience and knowledge of the client and family about the disease.
2. Give an explanation to the client about diseases and conditions now.
R: By knowing the diseases and conditions now, clients and their families will feel calm and reduce anxiety.
3. Encourage clients and families to pay attention to her diet.
R: Diet and proper diet helps the healing process.
4. Ask the client and reiterated family of materials that have been given.
R: Knowing how much understanding of clients and their families and assess the success of the action taken.

MANAGEMENT
DIABETES MANAGEMENT
The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of
vascular and neuropathic complications.
Drugs for Treating Hyperglycemia
The drugs for treating type 2 diabetes fall into several categories:
1)Drugs that primarily stimulate insulin secretion by binding to the sulfonylurea receptor. Sulfonylureas remain the most
widely prescribed drugs for treating hyperglycemia. The meglitinide analog repaglinide and the D-phenylalanine derivative
nateglinide also bind the sulfonylurea receptor and stimulate insulin secretion.
2)Drugs that alter insulin action: Metformin works in the liver. The thiazolidinediones appear to have their main effect on
skeletal muscle and adipose tissue.
3)Drugs that principally affect absorption of glucose: The glucosidase inhibitors acarbose and miglitol are such currently
available drugs.
4) Drugs that mimic incretin effect or prolong incretin action: Exenatide and DPP 1V inhibitors fall into this category.
5) Other: Pramlintide lowers glucose by suppressing glucagon and slowing gastric emptying.
Insulin
Insulin is indicated for type 1 diabetes as well as for type 2 diabetic patients with insulinopenia whose hyperglycemia does
not respond to diet therapy either alone or combined with other hypoglycemic drugs.
Therefore, the therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without
hypoglycemia and without seriously disrupting the patients usual lifestyle and activity.
There are five components of diabetes management
Nutritional management

Exercise
Monitoring
Pharmacologic therapy
Education
Classification of Diabetes Mellitus
There are several different types of diabetes mellitus; they may differ in cause, clinical course, and treatment. The major
classifications of diabetes are:
Type 1 diabetes (insulin dependent diabetes mellitus) is caused by B-cell destruction, usually leading to absolute insulin
deficiency
a) Immune mediated
b) Idiopathic
Type 2 diabetes (previously referred to as non insulin dependent diabetes mellitus) ranges from those with predominant

insulin resistance associated with relative insulin deficiency, to those with a predominantly insulin secretory defect with
insulin resistance

Causes for Diabetes Mellitus

The cause of both type 1 and type 2 diabetes remains unknown, although genetic factors may play a role. Diabetes mellitus
results from insulin deficiency or resistance. Insulin transports glucose into the cell for use as energy and storage as
glycogen. It also stimulates protein synthesis and free fatty acid storage. Insulin deficiency or resistance compromises the
body tissues access to essential nutrients for fuel and storage. The resulting hyperglycemia can damage many of the bodys
organs and tissues.
Type 1 diabetes is due to pancreatic islet B cell destruction predominantly by an autoimmune process, and these patients are
prone to ketoacidosis.
Type 2 diabetes is the more prevalent form and results from insulin resistance with a defect in compensatory insulin secretion
Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and
storage of glucose.
Risk Factors For Diabetes Mellitus Include:
Obesity.
Physiologic or emotional stress, which can cause prolonged elevation of stress hormone levels.
pregnancy, which causes weight gain and increases levels of estrogen and placental hormones, which antagonize insulin
metabolic syndrome, which is considered a precursor to the development of type 2 diabetes mellitus
some medications that can antagonize the effects of insulin, including thiazide diuretics, adrenal corticosteroids, and
hormonal contraceptives

Statistics

Diabetes affects 18% of people over the age of 65, and approximately 625,000 new cases of diabetes are
diagnosed annually in the general population. Conditions or situations known to exacerbate glucose/insulin
imbalance include (1) previously undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in
excess of available insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5)
stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes can be complicated
by instability and diabetic ketoacidosis (DKA). DKA is a life-threatening emergency caused by a relative or
absolute deficiency of insulin.

PHARMACOLOGY MANAGEMENT
Drugs. 1997 Jun;53(6):1081-105.

Lisinopril. A review of its pharmacology

and use in the management of the
complications of diabetes mellitus.
S
o
u
r
c
e

Goa KL, Haria M, Wilde MI.

Adis International Limited, Auckland, New Zealand. demail@adis.co.nz

Abstract
Lisinopril, like other ACE inhibitors, lowers blood pressure and preserves renal function in hypertensive patients
with non-insulin-dependent or insulin-dependent diabetes mellitus (NIDDM or IDDM) and early or overt
nephropathy, without adversely affecting glycaemic control or lipid profiles. On available evidence, renoprotective
effects appear to be greater with lisinopril than with comparator calcium channel blockers, diuretics and betablockers, despite similar antihypertensive efficacy. As shown by the EUCLID (EUrodiab Controlled trial of Lisinopril
in Insulin-Dependent Diabetes) trial, lisinopril is also renoprotective in normotensive patients with IDDM and
microalbuminuria. The effect in normotensive patients with normoalbuminuria was smaller than in those with
microalbuminuria, and no conclusions can yet be made about its use in patients with normoalbuminuria. In
complications other than nephropathy, lisinopril has shown some benefit. Progression to retinopathy was slowed
during 2 years' lisinopril therapy in the EUCLID study. Although not yet fully published, these results provide the
most convincing evidence to date for an effect of an ACE inhibitor in retinopathy. The drug may also improve
neurological function, but this finding is preliminary. Lastly, post hoc analysis of the GISSI-3 trial indicates that
lisinopril reduces 6-week mortality rates in diabetic patients when begun as early treatment after an acute
myocardial infarction. The tolerability profile of lisinopril is typical of ACE inhibitors and appears to be similar in
diabetic and nondiabetic individuals. Hypoglycaemia has occurred at a similar frequency with lisinopril and placebo,
as shown in the EUCLID trial. In addition, the GISSI-3 study indicates that the incidence of persistent hypotension
and renal dysfunction is increased with lisinopril in general, but the presence of diabetes does not appear to confer
additional risk of these events in diabetic patients with acute myocardial infarction receiving lisinopril. In summary,
lisinopril lowers blood pressure and produces a renoprotective effect in patients with IDDM and NIDDM without
detriment to glycaemic control or lipid profiles. Like other ACE inhibitors, lisinopril should thus be viewed as a firstline agent for reducing blood pressure and preventing or attenuating nephropathy in hypertensive diabetic patients
with IDDM or NIDDM and microalbuminuria or overt renal disease. The EUCLID study, using lisinopril, provides
new data supporting an additional place in managing normotensive patients with microalbuminuria and IDDM.
These findings, together with some evidence for an effect of lisinopril in delaying progression of retinopathy and in
reducing mortality, suggest a broader role for the drug in managing diabetic vascular complications.

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