Monday, March 12, 2007

A Diabetic's Checklist

A 60 year old man walked into my clinic the other day to get his diabetes medication. This was the first time I am seeing him. He said he was taking a certain type of medication for the last 5 years and this has not been changed.

So I went through some preliminary questions to see how well his diabetes is being controlled.

What was your last HbA1C reading?
He replied: "What is HbA1C?"

Ok, when was your last blood test done?
He replied: "Never had any blood test"

How is your fasting blood glucose levels?
He said the last time it was tested it was a bit high

When was the last time you did a Retinogram?
He said: "What's that?"

At the end of the consultation, I told him there was quite a few things he needed to do to manage his diabetes because it was clearly not under good control.

To which he replied: "I just want to take my usual medication, that's all I need"

I hope you are shocked, because if you are not, you should be.

Diabetes affects 8.2% of the Singaporean population. Uncontrolled diabetes will invariably lead to other more critical problems like heart disease, kidney disease, eye problems and may even cause legs to be amputated. This man was heading towards an inevitable fate and he does not even know it.

Diabetes is a disease that is best managed by the patient himself in consultation with his Family Doctor and may involve other paramedical persons like the podiatrist and dietician.

Since it is such a long topic and I don't want to bore you, I will just quickly distill the most important information so that if you know of anyone with diabetes, you can sort of tell if his condition is managed properly.

Things a Diabetic Patient needs to do:
1. Ensure his Fasting Blood Sugar is between 4.0-8.0 mmol/l.

2. The HbA1C needs to be done at least twice a year or more often if necessary. The HbA1C gives an indication of how well the blood glucose level has been controlled in the last 2 to 3 months. The levels should be between 4.5-7.0%

3. The Blood Pressure must be kept below 130/80mmHg and monitored every 3 months

4. The Cholesterol levels must be checked at least yearly to ensure that it is below 2.6mmol/l or 100mg/dL

5. The BMI should kept between 18.5-22.9kg/m2. ie, he should lose weight if he is too fat!

6. A Retinogram, which is a photograph of the retina (back of the eye), should be done yearly.

7. Urine and blood tests should be done at least yearly to screen for early kidney problems

8. The feet should be checked at least yearly to screen for early nerve deterioration.
Diabetes is a progressive disease. That means that diabetics will invariably have to keep increasing medications as they age. Uncontrolled diabetes coupled with high blood pressure and cholesterol is a recipe for disasters like heart attacks, strokes and kidney failure. On the other hand, all these problems can be avoided and the person can lead an almost normal life without suffering severe disabilities if it is managed well. So it is important to MANAGE the disease from the start rather than waiting till something goes wrong.

More information about diabetes can be found here.


Anonymous said...

Hi Dr Tay

Can you please provide some insight on this new diabetic medicine Avandia. What's the difference between this and the usual medicine taken for diabetes. Thank you for your advise.

Dr Leslie said...

Avandia is a whole new class of drugs that has been developed for use in diabetes and can be used in conjunction with the other diabetes medication. It works at the DNA level by getting the cells to absorb more glucose and in doing so keeps the blood level of glucose lower.

The onset of action is slow and it may take 8 to 12 weeks for it to be maximally effective. Patients who are on Avandia will need to do periodic liver function tests to ensure that the drug has not affected the liver in some way

There are some indications that Avandia can slow down the progression of diabetes or even reverse it.

Anonymous said...

Thanks for your prompt respond. Under what circumstances would you recommend a change to Avandia or add that to the other diabetes medication ?

Dr Leslie said...

It is a good drug to add onto your other drugs when the existing drugs begin to lose control of the blood sugar. The decision when to add is a balance between your financial means and the disease condition and is best to discuss with your Doctor.

Anonymous said...

Hi Dr Tay,

Hi, i have got a few qs on diabetes that has puzzled me for some time so i hope you could help me out.
1stly, i am aware that there is a general rule that only type 1 diabetics get diabetic ketoacidosis but type 2 diabetics generally dont unless their body is put under some form of stress like infection. is it possible for a type 2 diabetic to get diabetic ketoacidosis (DKA) in the very late stages when beta cell failure sets in? because at that stage, it would make the type 2 diabetes almost the same as type 1. 2ndly, is it possible that a diabetic becomes hypoglycemic upon fasting? (assuming he has not been on his diabetic medications at all) if so, how does it happen? because the rate of uptake of glucose into the peripheral cells would be very very low and the blood sugar levels wld be high. If not, how would you be able to distinguish a diabetic in DKA and a diabetic in ketoacidosis secondary to starvation? Thank you very much for your help!

Anonymous said...

yes just to add on to that interesting question.. cos the older generation has always told us when we see a diabetic in distress to feed him/her a sugar cube or some sugary that advisable? (which would be dependent on whether the diabetic can become hypoglycemic upon fasting and no medication rite?)

Anonymous said...

wah so chiem one ah? doctor dont want to answer u! hah!