Insulin diabetes type 2 pdf espa?ol,i have diabetes can i take honey oil,june in january movie trailer - PDF 2016


The materials contained on this website are provided for general information purposes only and do not constitute medical, legal, financial or other professional advice on any subject matter. Hyperglycaemia is an indicator of poor clinical outcome and mortality in patients with or without a history of diabetes in hospitalised patients in non-critical care condition. Diabetes is increasing at an alarming rate affecting more than 371 million people worldwide.1 Recent estimates report a 5 million increase in prevalence from 2011 to 2012, with many more undiagnosed. Existing guidelines on management of in-patient hyperglycaemia are provided by Society of Hospital Medicine,14 American Diabetes Association-American Association of Clinical Endocrinologists (ADA-AACE),15 Endocrine Society,16 Australian Diabetes Society (ADS),17 Association of Physicians of India (API),18 and Canadian Diabetes Association (CDA).19 These organisations provide clinical practice guidelines for management of in-patient hyperglycaemia in their respective regions. However, due to confounding biases and non-applicability of these guidelines in Indian scenario, these cannot be widely used in Indian clinical practice. In-hospital hyperglycaemia is observed in patients admitted to hospital in both critical and non-critical care condition. A systematic review of literature from medical databases was conducted to provide the best possible evidence base for the recommendations. The current consensus guidelines have been developed in accordance to the AACE protocol for standardised production of clinical practice guidelines.20 Recommendations are organised by topic and are assigned evidence level (EL) ratings on the basis of the quality of supporting evidence all of which have also been rated for strength.
Hyperglycaemia is reported in approximately 33% and 80% of patienta€™s admitted to non-ICU and ICU settings, respectively21,22 and is diagnosed by measuring either fasting blood glucose (FBG) or glycated haemoglobin (HbA1c). Monitoring of BG levels using POC testing in in-patients varies with the time of nutritional intake, medication pattern and therapy of choice. Blood Glucose BG values alter significantly depending on the site of blood drawn, finger-stick vs. In patients with stable glycaemic control on oral diet, blood glucose should be monitored post-prandially and at 3 a.m. Attaining target BG values in in-patients is essential to decrease the morbidity and mortality associated with hyperglycaemia. Although patients with type 1 diabetes mellitus (T1DM) continue to require insulin during their home-to-hospital transition, the need for patients with type 2 diabetes mellitus (T2DM) has to be reassessed upon admission. The use of oral and other non-insulin therapies pose unique challenges in hospital setting due to frequent contraindications to their use in many in-patient situations such as sepsis, NPO status, pancreatic disorders, renal failure, etc.
Basal-bolus regimens have an important advantage over sliding scale regimens in that they are proactive in controlling hyperglycaemia. There are three components to a basal bolus regimen: basal insulin, bolus or meal or nutritional insulin and correction insulin. In select patients with controlled diabetes on premix insulin therapy prior to admission and in in-patients with stable glycaemic control, continuation of premix insulin should be considered. For patients with diabetes controlled on premix insulin therapy prior to admission, same regimen may be continued (Grade A; EL 4). For patients admitted to non-critical care setting and required to take insulin, the first step in ordering insulin is to estimate the patientsa€™ total daily dose (TDD) of insulin requirement.
In general, type 1 diabetes patients typically exhibit less insulin resistance and require lower daily insulin dosage than type 2 diabetes patients, especially if they are not obese. The Endocrine Society16 recommends that correctional insulin dose should be added to the scheduled insulin dose as part of bolus insulin before each meal (only half at bedtime). Although slight variations in correctional insulin doses is presented in Bajwa et al18, the current consensus guidelines recommend the dosing range presented by well accepted guidelines from Endocrine Society.16 However, in select individual patients, the correctional insulin dose can vary based on the clinical condition and treating physiciana€™s discretion. Hospital discharge can be stressful to patients and their family, and insulin regimens are often complex, entailing administration of 2 different insulin preparations. Proper coordination of patient care services during discharge of in-patients with hyperglycaemia from hospital to home is essential for safe transition to outpatient setting and reduced need for readmission.49 Measurement of HbA1c concentration in patients at the time of admission and during the hospital stay can assist in tailoring the glycaemic management in these patients at the time of discharge.
Most in-patients recovering from a critical illness or after a surgical procedure are moved to non-ICU setting. The stress of surgery or critical illness will increase insulin requirements, and, as stress decreases, basal insulin requirements will also decrease. Enteral nutrition (EN) or parenteral nutrition (PN) given to in-patients (to overcome malnutrition), is an independent risk factor for the onset or aggravation of hyperglycaemia.
There is a lack of evidence from existing guidelines on management of hyperglycaemia in in-patients undergoing non-intensive surgery. In patients with diabetes undergoing day care surgery, require SC insulin during perioperative period.
In patients with or without a history of diabetes, use of glucocorticoids results in hyperglycaemia. In patients with mild hyperglycaemia oral anti-hyperglycaemic agents can be considered (Grade B; EL 4).
Management of different types of hyperglycaemia in the non-critical condition involves systematic evaluation of glycaemic status, setting of glycaemic target and providing therapeutic interventions.
Based on the consensus guidelines developed for in-patient management of hyperglycaemia in non-critical care settings, an algorithm has been proposed (Figure 3). The authors thank Jeevan Scientific Technology Limited, Hyderabad, India, for providing medical writing assistance in the development of this article. Handelsman Y, Mechanick JI, Blonde L, et al; AACE Task Force for Developing Diabetes Comprehensive Care Plan.
Saudek CD, Derr RL, Kalyani RR Assessing glycemia in diabetes using self-monitoring blood glucose and haemoglobin A1c. A consensus guideline has been developed by a panel of experts based on existing guidelines with specific attention to Indian clinical practice on the management of hyperglycaemia in patients admitted to non-critical care settings.
As a condition that persists throughout a patienta€™s lifespan with progressively increasing complications, diabetes decreases the quality of life, increases economic burden on the individual, their family and society. Further, it was observed that new hyperglycaemic patients had a longer hospital stay, higher admission rate to an intensive care unit (ICU), and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility.
The India specific guideline formulated by the Association of Physicians of India18 is brief and does not provide sufficient details in the management of in-patient hyperglycaemia in specific circumstances of non-critical care conditions.
The clinical condition at the time of admission and care process in the intensive care unit (ICU) and non-ICU settings are different. Existing guidelines, metaa€?analyses, systematic reviews and key cited articles relating to the medical condition were reviewed by a group of doctors and recommendations relevant to Indian scenario were framed. Recommendations are based on clinical importance and graded as A (strongly recommend), B (intermediate), C (weak) and D (not evidence based), those are coupled by four intuitive levels of evidence: 1,2,3,4. The Endocrine society recommends that all patients be assessed for history of diabetes and determine blood glucose levels by laboratory tests, irrespective of prior diagnosis of diabetes.
However, currently HbA1c is not considered a suitable diagnostic test for diabetes or intermediate hyperglycaemia. Sulphonylureas can cause severe and prolonged hypoglycaemia, particularly in the elderly, in patients with impaired renal function, and in those with poor nutritional intake. Intermediate- or long-acting insulin is administered once or twice daily as basal component and short- or rapid-acting insulin is administered in co-ordination with food intake for bolus or prandial component. For patients who are not taking oral diet, basal insulin is continued once daily (glargine or detemir) or twice daily [neutral protamine Hagedorn (NPH)], bolus insulin is held and correction doses of rapid insulin analogue (aspart, lispro, glulisine) or regular insulin (RI) every 4- to 6-h interval are added as needed.
The TDD of insulin is calculated based on the bodyweight, divided equally between basal (50%) and bolus (50%) insulin.
Correction insulin protocol for usual, insulin sensitive and insulin resistant patients is followed as per Table 2. Insulin regimen requires daily adjustments according to glucose readings; hence orally communicated instructions alone are often inadequate. Although intravenous (IV) insulin is administered during operative procedure, shifting to SC insulin is recommended post-operatively since many patients begin to eat by the first postoperative day. Achieving desired glycaemic goals in patients receiving EN poses unique challenges such as unexpected interruption of feedings that can lead to hypoglycaemia. In the absence of evidence, recommendations were based on general principles of blood glucose control in patients with diabetes, and review articles62 as well as clinical experience in Indian practice. It alters a variety of metabolic pathways including hepatic glucose production, impaired glucose uptake in peripheral tissues with resulting hyperglycaemia.64 Due to inadequate quality evidence in the management of hyperglycaemia in these patients, framing appropriate guidelines is difficult.
For most patients in non-critical condition, a scheduled subcutaneous insulin regimen is the preferred therapy. Combining GLP-1 receptor agonists with insulin: therapeutic rationales and clinical findings. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes.


Stress hyperglycemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview.
Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis.
Hyperglycemia is associated with poor outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease. Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non-critically ill, adult patient.
American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Initial management of septic patients with hyperglycemia in the noncritical care inpatient setting. Prevalence of elevated haemoglobin A1c among patients admitted to the hospital without a diagnosis of diabetes. Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients.
Institutional blood glucose monitoring system for hospitalized patients: an integral component of the inpatient glucose control program. Parenteral nutrition-associated hyperglycemia in non-critically ill inpatients increases the risk of in-hospital mortality (multicenter study). Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine Hagedorn plus regular in medical patients with type 2 diabetes.
Randomized study of basal bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (rabbit surgery). Retrospective review of metformin in inpatients and outpatients at the University of Michigan. Assessing the appropriate use of metformin in an inpatient setting and the effectiveness of two pharmacy-based measures to improve guideline adherence. Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.
Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (Rabbit 2 Trial). Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Improved inpatient use of basal insulin, reduced hypoglycaemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm. Society of Hospital Medicine Glycemic Control Task Force Summary: practical recommendations for assessing the impact of glycemic control efforts. Inpatient to outpatient transfer of diabetes care: planning for an effective hospital discharge. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Conversion of intravenous insulin infusions to subcutaneously administered insulin glargine in patients with hyperglycemia.
Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Comparison of 3 algorithms for Basal insulin in transitioning from intravenous to subcutaneous insulin in stable patients after cardiothoracic surgery. Enteral nutritional support and use of diabetes-specific formulas for patients with diabetes: a systematic review and meta-analysis.
Hyperglycemia during total parenteral nutrition: an important marker of poor outcome and mortality in hospitalized patients. Insulin therapy and glycemic control in hospitalized patients with diabetes during enteral nutrition therapy: a randomized controlled clinical trial. All tips, guides and recommendations are followed at your own risk and should be followed up with your own research. Diagnosis for hyperglycaemia at the time of hospital admission is essential for appropriate treatment during the hospital stay and at the time of discharge.
Thus, there is a need for more elaborate guidelines on specific conditions of in-patient hyperglycaemia management and development of consensus for Indian clinical practice. The corresponding hyperglycaemic status of the subject and requirements for management procedure also differ. The recommendations were discussed at the National Insulin Summit, held in August 2013 by an expert panel of physicians, endocrinologists and key opinion leaders.
They have been positioned on the basis of available evidence to be used for grading recommendations as follows. Metformin has to be discontinued in patients with decompensated congestive heart failure, renal insufficiency, hypoperfusion, or chronic pulmonary disease, in patients at risk of developing renal failure and lactic acidosis. Correction insulin (short- or rapid-acting) is administered together with the usual dose of bolus insulin for patients with higher BG levels.
Bolus insulin (adjusted daily based on patientsa€™ anticipated caloric intake) is divided into 3 parts for each meal.
In patients taking oral diet, correctional insulin (regular or rapid-acting) is administered following the a€?Usuala€™ column, before each meal (Table 2). Establishing formalised discharge instructions for patients at each hospital and educating on the same are essential. Due to the lack of recommendations from other organisations on use of medication at time of discharge, current consensus guidelines adapted the suggestions from Endocrine Society for clinical practice in Indian conditions.
Continuing IV insulin in response to prandial hyperglycaemia in these patients has a risk of hypoglycaemia occurring after the postprandial hyperglycaemia declines.
However limitations exist in dispensing accurate doses of basal and bolus insulin during and after the hospital stay, based on clinical conditions. Effect of hyperglycaemia on inflammatory and stress responses and clinical outcome of pneumonia in non-critical-care inpatients: results from an observational cohort study.
Following a consistent blood glucose target from admission to discharge is recommended for optimal glycaemic management in these settings. The scope of the current review is to frame appropriate guidelines for the management of hyperglycaemia in patients admitted to non-critical care settings, broadly divided into diagnosis and monitoring, target blood glucose, pharmacological therapy including insulin and non-insulin medications and management in special conditions. At this summit, recommendations for each section of the guidelines, and overall recommendations were agreed upon. Thiazolidinediones are known to take long time for exerting full hypoglycaemic effect, limiting their usefulness. Daily adjustments of insulin dose are required, depending on patientsa€™ blood glucose testing results and caloric intake. The Endocrine Society16 recommends that- for patients initiated on insulin therapy as a new medication as in-patient and discharged home, providing patient education and written information on the method and timing of insulin administration at prescribed doses and recognition and treatment of hypoglycaemic episodes are important. If interrupted for > 2 hours, all insulin dose should be withheld and patient supplemented with IV 10% dextrose, same as enteral feedings to prevent hypoglycaemia. However, API recommends that in select patients with controlled glycaemia, undergoing relatively minor surgical procedures (cataract surgery) can be maintained on OAD therapy.18 Patients with diabetes undergoing major surgery require continuous IV insulin infusion during perioperative period. The advent of new rapid acting insulin analogues like aspart and ultra-long acting insulin degludec provide better therapeutic options for the physician to control the glycaemic excursions during the prandial and basal conditions.
Intervention with scheduled subcutaneous insulin therapy using basal, bolus and correctional insulin, and avoiding sliding scale insulin therapy is the key to effective management of in-patient hyperglycaemia.
The consensus guidelines have been framed in consideration with the existing guidelines from ADA-AACE, Endocrine society, and Society of Hospital Medicine from USA, ADS from Australia, CDA from Canada and API and justified for use according to routine Indian clinical practice. Where there was little or no evidence, the committee relied on experience, judgement and consensus to make their recommendations. Dipeptidyl peptidase IV inhibitors delay the enzymatic inactivation of glucagon-like peptide-1 that reduces postprandial glycaemic excursions, thus limiting their use in patients who are not eating or have reduced oral intake. It suggests initiating insulin therapy at least one day before discharge to assess the efficacy and safety of therapy.


The current consensus guideline was developed based on the best clinical observations for hyperglycaemia management from exiting guidelines and protocols (Table 5). A safe and effective transition of therapy between home and hospital setting based on hyperglycaemic status is essential to avoid large variations in glycaemic status. The consensus document was drafted and circulated for further feedback from the participants and others who could not attend. In selected patients who are clinically stable, taking regular meals and have no contraindications to their use may be continued on OADs prescribed at home.16 Continuation on home-based OADs is also recommended by ADS and CDA14,17,19 and recommended in the current guidelines. Dehydration is a common complication of enteral feedings and a frequently overlooked cause of hyperglycaemia. Alternatively, the pre-admission TDD insulin can be divided by 24 hours to determine the infusion rate.
Further, this guideline aims to provide better management of hyperglycemia in non-critical care setting as per Indian scenario. The consensus guidelines will provide a basis for better clinical practice in the Indian scenario for the management of hyperglycaemia in non-critical care settings. A sample calculation of insulin requirements for a patient on enteral feeds is presented in Table 4.
It is further suggested to start CII at least 2 hours before surgery and continue until BG levels fall in normal range.62 In the absence of guidelines on hyperglycaemia management in these patients, recommendations were framed from review articles62 as well as clinical experience of expert panel. How do we become resistant to insulin and what causes our beta cells to fail?Insulin resistance can develop as a result of fat cells releasing more pro-inflammatory chemicals such as IL-6, and fewer anti-inflammatory chemicals such as adiponectin. That is not what some of my textbooks say, which claim that type 2 diabetes has a stronger genetic component than type 1 diabetes.
Unfortunately their authors have been lazy and taken the fact that type 2 diabetes runs in families as evidence of a genetic link. It is all to do with the fact that people in the same family follow a similar dietary pattern, and often a similar exercise pattern as well. In fact type 1 diabetes has a much stronger genetic component with a few genes on chromosome 6 being responsible for much of the susceptability. In type 2 diabetes a large number of genes are associated with risk and none particularly strongly.What happens in the diabeticThere are some tissues in our body that let glucose in without insulin. Fat and muscle cells contain GLUT-4 transporters, which don't allow much glucose in without insulin being present. The brain on the other hand has a lot of GLUT-3 transporters, which allow appreciable amounts of glucose in without insulin being present.Tissues which let in glucose without insulin are found in the eye, kidneys, peripheral nervous system as well as the liver, ovaries and seminal vesicles.
The unfortunate result for these cells is that they can accumulate too much glucose over time.
However, those cells in the eyes, kidneys and in our peripheral circulation accumulate sorbitol, which causes swelling of the cells due to osmotic pressure. Most of these complications result from raised levels of glucose in cells which do not rely on insulin to obtain it.
In particular some cells lining capillaries and nerves in the kidneys, eyes and limbs are vulnerable. As a result they leak proteins which ultimately result in constriction of the blood vessels supplying the kidney. Since the brain uses sugar as its main energy source it goes to plan B which is creating ketones, which can provide energy also. Too many ketones acidify our blood and cause excess urination, thirst, vomiting and tummy pain. Ultimately severe dehydration, swelling of the brain and coma can occur, which is why hospitalisation is often needed. This is a serious complication of type 1 diabetes. However, it is uncommon with type 2 as some insulin is normally available.Curing diabetes naturallyExercising more and consuming foods that do not raise blood sugar levels is the key to reversing diabetes. While it becomes harder to regain full health the longer you have had diabetes, when first diagnosed, the vast majority of people have the potential to completely cure themselves of the condition.The correct dietThe modern western diet is the main cause of diabetes. For instance on one of my GI lists I have a baked potato with a GI of 111, greater than pure glucose while peanuts are listed with a GI of just 7, which implies that foods containing the East Asian sauce, satay would be very low GI.
So in other words the GI is not an absolute value, but just a guideline. Sometimes it is more realistic to consider the glycaemic load or GL of a food, which takes account of the amount of a food you eat. Obviously one Cornflake (GI=93) is not going to raise blood sugar as much as a whole can of baked beans (GI=40), but a small bowl of them probably will.Foods that are normally low GI can be eaten as the main part of a diet for someone with diabetes. These include meat, fish, eggs, dairy as well as nuts, seeds, most vegetables and some fruits. The one vegetable that has a high GI is the potato (this includes the sweet potato), and the fruits with a high GI include ripe bananas, dates and raisins. Generally speaking fruits from warm climates have a higher GI than those from more temperate climates.
For instance if you exercise soon after consuming the food then some of the blood sugar it creates will be taken up by your muscle cells. If you combine it with other foods of much lower GI or eat a small portion of it you will also find your blood sugar does not rise as far.Timing foodsIn general if you exercise then you will reduce your blood sugar level. A 30 minute exercise stint before food will allow you to get away with a higher overall glycaemic load. Equally if you do some light exercise soon after a large meal you can lower the peak which your blood sugar will reach.In general it is best to leave some time between any meal and completely sedentary activity such as bed or watching the TV.
Kids get it about right when they automatically rush about after a meal, often to the frustration of their bloated parents.
A bit of housework, gardening or short walk are often quite effective at making a real dent in your blood sugar readings.Treating diabetes with drugsIt really is best to avoid the need for drugs. I would always advise making concerted efforts to control blood sugar levels with increases in exercise and changes to the diet. Many people find they can come off drugs completely when they do this properly.For those who cannot control their blood sugar levels without drugs then it is sensible to take them.
The cumulative effect over time of high blood sugar levels is extremely damaging, and this is why so many diabetics suffer from amputations, blindness, heart attacks and strokes.Blood sugar lowering agentsThe main one is perhaps Metformin which lowers the amount of sugar your liver produces. Thiazilienediones such as Rosiglitazone increase insulin sensitivity of the tissues and glucosidase inhibitors such as Acarbose reduce absorption of glucose from the gut. All these drugs will be more or less effective in different people depending on how their diabetes is affecting them. Measuring blood sugar levelsDiabetes is diagnosed using criteria that are arbitrary.
There are several ways that are used to measure blood sugar problems:Fasted blood sugar level - FBGThis measures blood sugar levels after not eating anything for at least 8 hours.
However, this value will vary depending on factors such as stress, recent exercise and illness.
Secondly their muscles get used to using fat as a fuel place of glucose and so more glucose is left in the blood. If you come into this category the measure below could be more useful to you.Long term blood sugar controlTo assess this we measure the amount of glycosylated haemoglobin - HbA1c, in your red blood cells.
Haemoglobin - Hb, is the protein found in red blood cells that is responsible for carrying oxygen to your tissues. In good health somewhere between 3-5% of our haemoglobin is in the HbA1c form.Red blood cells live for an average of 120 days. There are a number of factors that can skew the measurement:People with healthy low blood sugar have longer lived red blood cells that may survive for an average of 150 days.
In this case a high end reading for HbA1c does not imply bad blood sugar control.Diabetics with high blood sugar levels have red blood cells that live shorter lives than average, typically around 90days. It may be a better measure than HbA1c, and gives an indication of blood sugar levels over the previous 2-3 weeks(5).Glucose challenge or OGTTThe oral glucose tolerance test - OGTT is a measure of our response to consuming 75g of glucose in one hit.
It is unrealistic as most people never consume such a large and purified amount of glucose. For most people achieving the low GI meal involves limiting the amount of starchy carbohydrates they eat.



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    17.05.2015

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