a

2557

Clinical Practice Guideline for Diabetes

2014

 .. 2557

50 10 2 47
10310
0 2716 5412 0 2716 5411
www.diabassocthai.org

50 10 2 47
10310
0 2716 6337 0 2716 6338
www.thaiendocrine.org

11000
0 2590 6395 0 2965 9844
www.dms.moph.go.th

120 3 2 - 4
80 5 2550
10210
0 2141 4000 0 2143 9730
www.nhso.go.th

0 2214 4660 0 2612 4509
E-mail : smprt2005@yahoo.com

ISBN

 .. 2557

2552




(Chronic Care Model)
/

/

2557


2557

( )

2557

.. 2557

..2557

( )

 .. 2557

2557

d
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f

 .. 2557

2557

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22. .
23.

d
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f

 .. 2557

2557

.. 2557

(Quality of Evidence)

1

1. (systematic review) -
(randomized -controlled clinical trial)

2. -
1 (well-designed
randomized-controlled clinical trial)

2

1. (non-randomized
controlled clinical trial)

2. (well-designed non-randomized
controlled clinical trial)

3. (cohort)
(case control analytic studies)
/

4. (multiple time series)


.. 2480
3

1. (descriptive studies)

2. (fair-designed controlled clinical trial)

 .. 2557

4

1. (consensus)


2.
2
(anecdotal report)

(Strength of Recommendation)
+ +
(cost effective)

+/-

-

- -

.. 2557

2557

13

2.
4.
5.
6.
7.

21
29
37
47

1.
1.
2.

3.

3.

8.

9.
10.

11.

1
3

51
63
73
79

 .. 2557

4.
12.
89
13. 103
14.
109
115
121
125

5.

15.
16.
17.

6.

1.
2. (Oral Glucose Tolerance Test)
3.
4.
5.

6.
7.
8.
9.
10. diabetic ketoacidosis (DKA)

11.

131
133
135
141
145
147
151
153
161
165
173

d
r
a
f

t
f

d
r
a
f

4
1. 1 (type 1 diabetes mellitus, T1DM)
2. 2 (type 2 diabetes mellitus, T2DM)
3. (other specific types)
4. (gestational diabetes mellitus, GDM)

(provisional diagnosis)
/

1
30
()
(ketoacidosis)
ketoacidosis
-
(C-peptide) /
Anti-GAD, islet cell autoantibody, IA-2

2 95

30
2



( 1)
MODY (Maturity-Onset Diabetes of the Young)

.. 2557

glucose tolerance test

1. : ,
, . Diabetes Mellitus. 1. :
2548; 1-19.
2. American Diabetes Association. Diagnosis and classification of diabetes mellitus.
Diabetes Care 2014; 37 Suppl 1: S81-90.

15 4
.. 2551-2552
1

(screening test)


(high risk screening strategy)


1 2

cohort study2
1
(risk score)
( 12 )
( ++)

.. 2557

1. 2 2
Diabetes risk score
0
0
1
2

0
2

34 39
40 44
45 49
50




23 ./.2
23 27.5 /.2
27.5 ./2

90 . 80 .
90 . , 80 .



( )

0
3
5

0
2
0
2
0
4

0-17

2

2. 2

-
-
-
- 3
-
-
-
- 1-3
-
-
-
-
- 1-3
-
-
-
-
- 1

12



1/20
2 5



3-5
5-10
1/12




6-8
11-20

1/7




1/ - 1/
8


4 3

20

( 1)

3 ( 2, ++)

.. 2557

1. 35

2. (BMI 25 ./.2 / )


3.

4.

5. 4

6. impaired glucose tolerance (IGT) impaired fasting
glucose (IFG)

7. (cardiovascular disease)

8. (polycystic ovarian syndrome)


8

(waist circumference) 90
80 0.5



1. 2 10

2.

3.


4.

fasting capillary
blood glucose

fasting
plasma glucose

> 100 ./.

fasting plasma
glucose < 100 ./.

fasting plasma glucose

Impaired fasting glucose

fasting plasma glucose

> 126 ./.

fasting plasma glucose

fasting plasma glucose

100-125 ./.

< 100 ./.

< 126 ./.

> 126 ./.

1. 35
2. *
3.
4. ( > 250 ././ < 35 ./.
5. 4
6. IGT IFG
7. (cardiovascular disease)
8. ( polycystic ovarian syndrome )
* BMI > 25 ./.2 / 90 .
80 . ( 0.5)

1. ()

.. 2557

(fasting
plasma glucose, FPG, venous blood) FPG
(fasting capillary blood glucose) ( ++) FPG > 126
./. FPG > 126 ./.
( 1) FPG 100-125 ./. IFG

FPG 1-3

capillary blood glucose
FPG ( ++)
capillary blood glucose 110 ./.
FPG4 capillary blood glucose
capillary blood glucose 110 ./.
3 ( 2,
++)

4

1.

200 ./.

2. 8 (FPG)
> 126 ./.

3. (75 g Oral Glucose Tolerance Test, OGTT)
2 > 200 ./.

4. hemoglobin A1c (HbA1c) 6.5%

(NGSP certified and standardized to DCCT assay)


3

3.

impaired fasting impaired glucose


glucose (IFG) tolerance (IGT)
,
< 100
100 - 125
-
> 126
FPG (./.)
2
< 140
-
140 - 199
> 200
75
OGTT 2 hr-PG (./.)

> 200
(./.)

HbA1c
standardization quality control HbA1c
HbA1c 6.0-6.4%
25-50%5

6,7


( 1, ++)



glucocorticoid
(
)

( 4)

()
(carotid bruit)
(diabetic retinopathy) (diabetic nephropathy)
(diabetic neuropathy)

10

.. 2557

4.

( )












HbA1c
Lipid profiles (total choleseterol, HDL-cholesterol, triglycerides)
Liver function tests
serum creatinine
urine exam proteinuria microalbuminuria

11

1 5

FPG, HbA1c, total
cholesterol, triglyceride, HDL-cholesterol, ( LDL-cholesterol LDLcholesterol), serum creatinine, (urinalysis)
albuminuria

(ECG) /

1. ().
4 .. 2551-2552. : /
; 2553.
2. Aekplakorn W, Cheepudomwit S, Bunnag P, et al. A risk score for predicting incident
diabetes in the Thai population. Diabetes Care 2006; 29: 1872-7.
3. American Diabetes Association. Position statement. Diagnosis and classification of
diabetes mellitus. Diabetes Care 2010; 33 (Suppl 1): S62-S69.
4. Puavilai G, Kheesukapan P, Chanprasertyotin S, et al. Random capillary plasma
measurement in the screening of diabetes mellitus in high risk subjects in Thailand.
Diabetes Res Clin Pract 2001; 51: 125-31.
5. Zhang X, Gregg E, Williamson D, Barker L, Thomas W, Bullard K, et al. A1C Level and
future risk of diabetes: A systemic review. Diabetes Care 2010; 33: 1665-73.
6. American Diabetes Association. Standards of medical care in diabetes 2014. Diabetes
Care 2014; 37 (Suppl 1): S15-S80.
7. Clinical Guidelines Task Force. Global guideline for type 2 diabetes. International
Diabetes Federation 2012.

d
r
a
f

1.

2.

3.

4.

5.

1,2


1. 1,2
HbA1c
< 6.5% ( 1)
HbA1c
< 7.0%
1. 1-4

70 - 110 ./. 90 - < 130 ./. < 150 ./.
2
< 140 ./.

-
< 180 ./.
Hemoglobin A1c (% of total hemoglobin) < 6.5 %
< 7.0 %
7.0 - 8.0 %

14

.. 2557

2.
HbA1c 7.0%

3. ( > 65 ) 3
( 2)
3.1 3 HbA1c
< 7.0%
3.2 (functionally
independent) (comorbidity) HbA1c 7.0-7.5%
3.3
(functionally dependent)
HbA1c 7.0-8.0%

3.3.1 (fraility)
HbA1c 8.5%
3.3.2 (dementia)
HbA1c 8.5%

4. 1 (life expectancy < 1 )
()

(
)
2. 3
HbA1c


<7%


7.0 - 7.5 %

8.5 %

8.5 %

15

1-3 ( 3)

3. 1,2

*
< 100 ./.


< 150 ./.

:
> 40 ./.

> 50 ./.
**

(systolic BP)
< 140 .

(diastolic BP)
< 80 .

18.5-22.9 ./.

:
< 90 .

< 80 .

()
2 ***

* LDL-C
70 ./.
** 7,8 110 .
70 .
*** 0.5 (M. Ashwell, P. Gunn, S. Gibson. Waist-to-height ratio is a better
screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review
and meta-analysis. Obesity Reviews 2012; 13: 27586.)

16

.. 2557

1-4
3-6
1-3
/ HbA1c ( 1)


(/)
() HbA1c 1
(lipid profiles) 1
1

HbA1c
HbA1c
HbA1c < 7.0% 7.0 - 7.5%
7.0 - 8.0%

( 4)

HbA1c
3-6

* ()
1.

17

4. //
/ /
/

* *
**
HbA1c 7.0-7.9%
HbA1c < 7%
HbA1c > 8%

hypoglycemia > 3

proteinuria, urine albumin/ urine albumin/

eGFR 30-59 ml/min/

urine albumin/ creatinine ratio

creatinine ratio >300
1.73 m2/yr.
creatinine ratio 30-300 /. /.
>7 ml/ min/ 1.73
< 30 /.
eGFR 30-59 ml/min/ 1.73 m2/yr eGFR < 30
m2/yr. ml/min/1.73 m2/yr.
< 7 ml/min/ 1.73 m2/yr.
retinopathy mild NPDR
moderate NPDR
severe NPDR, PDR

VA
macular edema
Protective
peripheral

rest pain

sensation neuropathy,
previous amputation gangrene
peripheral pulse peripheral pulse intermittent claudication

hypertension hypertension / hypertension

angina pectoris
dyslipidemia dyslipidemia / dyslipidemia CAD myocardial

infarction

CABG CVA heart
failure

*
**
eGFR12 = estimated glomerular filtration rate; NPDR = non-proliferative diabetic retinopathy;
PDR = proliferative diabetic retinopathy; VA = visual acuity; CAD = coronary artery disease;
CABG = coronary artery bypass graft; CVA = cerebrovascular accident,
eGFR 12

serum creatinine < 0.7 (mg/dl)

serum creatinine > 0.7 (mg/dl)
serum creatinine < 0.9 (mg/dl)
serum creatinine > 0.9 (mg/dl)

eGFR = 144 (SCr/0.7)-0.329 (0.993)Age

eGFR = 144 (SCr/0.7)-1.209 (0.993)Age
eGFR = 141 (SCr/0.7)-0.411 (0.993)Age
eGFR = 141 (SCr/0.7)-1.209 (0.993)Age

18

.. 2557

1,2,9-14

4

( ++)



1



albuminuria (microalbuminuria) urine albumin/creatinine
ratio 1 12




1 2 (1 45 .
120 . 330 .)

()

19

1. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes

Care 2014; 37 (Suppl 1): S14-S80.
2. Clinical Guidelines Task Force. Global guideline for type 2 diabetes. International
Diabetes Federation 2012.
3. Sinclair A, Dunning T, Colagiuri S. IDF Global guideline for Managing older people with
type 2 Diabetes. International Diabetes Federation 2013.
4. Morley JE, Sinclair A. Individualizing treatment for older people with diabetes. Lancet
2013; 382: 378-80.
5. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between
glycemic control and cardiovascular outcomes in diabetes. A cohort study. Ann Intern
Med 2009; 151: 854-60.
6. Skyler JS, Bergenstal R, Bonow RO, Buse J, Deedwania P, Gale EAM, et al. Intensive
Glycemic Control and the Prevention of Cardiovascular Events: Implications of the
ACCORD, ADVANCE, and VA Diabetes Trials: A position statement of the American
Diabetes Association and a scientific statement of the American College of Cardiology
Foundation and the American Heart Association. Diabetes Care 2009; 32: 18792.
7. Meier M, Hummel M. Cardiovascular disease and intensive glucose control in type 2
diabetes mellitus: moving practice toward evidence-based strategies. Vasc Health Risk
Management 2009; 5: 85971.
8. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA1c in people with
type 2 diabetes: a retrospective cohort study. Lancet 2010; 375: 481-9.
9. Anderson RJ, Bahn GD, Moritz TE, et al. Blood pressure and cardiovascular disease risk
in the Veterans Affairs Diabetes Trial (VADT). Diabetes Care 2011; 34: 134-8.
10. Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and
cardiovascular outcomes among hypertensive patients with diabetes and coronary
artery disease. JAMA 2010; 304: 61-8.
11. Mazze RS, Strock E, Simonson G, Bergenstal R. Macrovascular Diseases. In: Staged
Diabetes Management: a Systemic Approach, 2nd ed. International Diabetes Center.
West Sussex, England. John Wiley & Sons, Ltd 2004: 299-321.
12.

20

.. 2557

. , .
2555.
13. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases
in people with diabetes mellitus: a scientific statement from the American Heart
Association and the American Diabetes Association. Circulation 2007; 115: 114-26.
14. .. 2552.
2552.

t
f
a
r
d

d
r
a
f

1-4






(empowerment)

4-9
10

22

.. 2557

5

1.

11

2.

3.

4.




5.

11



1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

1

(Self monitoring of blood glucose, SMBG)

23

(

)

24

.. 2557

GLP-1 agonist

(diabetic ketoacidosis, DKA) (hyperglycemic

25

hyperosmolar non-ketotic syndrome, HHNS)

26

.. 2557

1.

2.

3.

4.

5.

6.

2

1.
1.

2.
:


1

2.

27

1. Norris SC, Lau J, Smita SJ, Schmid CH, Engelgau MM. Self-management education for
adults with type 2 diabetes: a meta-analysis of the effect on glycemic control.
Diabetes Care 2002; 25: 1159-71.
2. Gary T, Genkinger J, Guallar E, Peyrot M, Brancati F. Meta-analysis of randomized
educational and behavioral interventions in type 2 diabetes. Diabetes Edu 2003; 29:
488-501.
3. Steed L, Cooke D, Newman S. A systemic review of psychosocial outcomes following
education, self-management and psychological interventions in diabetes mellitus.
Patient Educ Cons 2003; 51: 5-15.
4. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self management
strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005;
2: CD003417.
5. Funnell MM, Tang TS, Anderson RM. From DSME to DSMS: Developing empowerment-based diabetes self-management support. Diabetes Spectrum 2007; 20: 221-6.
6. Bodenheimer T, Davis C, Holman H. Helping patients adopt healthier behaviors. Clin
Diabetes 2007; 25: 66-70.
7. International Diabetes Federation Consultative Section on Diabetes Education. The
International Curriculum for Diabetes Health Professional Education. International
Diabetes Federation 2011.

28

.. 2557

8. Haas L, Maryniuk M, Beck J, et al. on behalf of the 2012 Task Force. National Standards
for Diabetes Self-Management Education and Support. Diabetes Care 2014; 37
(Suppl 1): S144-S153.
9. American Diabetes Association. Standards of Medical Care in Diabetes-2014. Diabetes
Care 2014; 37 (Suppl 1): S30-S31.
10. DeCoste K, Maurer L. The Diabetes Self-Management Education Process. In: The Art
and Science of Diabetes Self-Management Education Desk Reference, Mensing C,
et al. 2nd edition, 2011. American Association of Diabetes Educator, p 21-69.
11. Remier DK, Teresi JA, Weinstock RS, et al. Health care utilization and self-care
behaviors of Medicare beneficiaries with diabetes: comparison of national and
ethnically diverse underserved populations. Popu Health Manag 2011; 14: 11-20.
12. . , ,
, , .
2553.

(Lifestyle modification)

(Lifestyle modification)




1
1 2

1-3

2
















( 1, ++)



4,5 7
( ++) 5
5

30

.. 2557

1 ( ++)

(maintenance of weight loss) (
+)

/

( +)


HbA1c 0.3-1% 1 0.5-2%
21,2 (medical nutrition therapy)
1
1. 2,3,5,6

2 50
3,5,6
( 2, ++)

< 130 / ( -)

( ++)
glycemic index
glycemic load ( +)

5 6 ( 3-6 ) 2-3

( +)

31

(
++)
14 1000 (
++)
sorbitol, xylitol mannitol
( ++)
7
- 50 . 1 .
- 15 . 1 .
- 5 . 1 .
- 5 . 1 .

30-35
7 10

( ++)
300 ./ ( ++)
1
( ++)

15-20 ( +)
4 2 / 3
( ++)
(
++)
( -)

1 / 2 /
2 ( +) 1 ( 12-15 )
45 . 330 . 120 .

( +)

32

.. 2557

( ++)

(
-)

( -)

1
1
( +)

( +)

( +)

( 11)

( ++)
ketosis
( +)
( +)

( ++)
( +)

( +)

1.3 //
( 4-5 eGFR <30 .//1.73 .2) 0.8 /

/ ( ++)8 60

33

9 ( ++)

46-76
30 10
3-5 /11 30 / 2
/ 1
2000 ./ ( ++)
2300 ./
( ++) 1 1160-1420 . 1
960-1420 . 1 492 . 1
2000 .7
( +)

3, 12-15




10

50
( = 220 )
50-70
( 70 )
(talk test)

( 2)
(resistance) 2
8-10 ()

34

.. 2557

8-12 2-4 13, 14 ( ++)

15
2.

150 / 30-50
3-5 2-3
75 / 3 /
2 ( ++)13
7 (
+)13

1 2
/
12,13,16



/ / /
( ++)
3,13

16
16 17
( ++)

35

3.
ketosis
ketosis

< 100 ./.

proliferative diabetic retinopathy (PDR) severe NPDR

resistance exercise

(peripheral neuropathy)

(non-weight bearing exercise)

( 250
./. 1
300 ./. 2)

1. Clinical Guidelines Task Force. Lifestyle management. In: Global guideline for type 2
diabetes. International Diabetes Federation 2012, p 32-7.
2. Evert AB, Boucher JL, Cypress M, Dunbar SA, Franz MJ, Mayer-Davis EJ, et al. Nutrition
therapy recommendations for the management of adults with diabetes. Diabetes Care
2014; 37 (Suppl 1): S120-S142.
3. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes
Care 2014; 37 (Suppl 1): S14-S80.
4. Dunkley AJ, Bodicoat DH, Greaves CJ, Russell C, Yates T, Davies MJ, Khunti K. Diabetes
prevention in the real world: effectiveness of pragmatic lifestyle interventions for the
prevention of type 2 diabetes and of the impact of adherence to guideline
recommendations. A systematic review and meta-analysis. Diabetes Care 2014; 37:
922-33.
5. Esposito K, Chiodini P, Maiorino MI, Bellastella G, Panagiotakos D, Giugliano D.Which
diet for prevention of type 2 diabetes? A meta-analysis of prospective studies.
Endocrine. 2014 Apr 18. [Epub ahead of print] doi: 10.2337/dc13-2195

36

.. 2557

6. Georgoulis M, Kontogianni MD, Yiannakouris N. Mediterranean diet and diabetes:

prevention and treatment. Nutrients 2014; 6: 1406-23.
7. . . : .
, , , , .
2553, 35-55.
8. KDIGO CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and
management of chronic kidney disease. Kidney Int 2013; 3 (Suppl): 1150.
9. Bhupathiraju SN, Wedick NM, Pan A, et al. Quantity and variety in fruit and vegetable
intake and risk of coronary heart disease. Am J Clin Nutr 2013; 98: 1514-23.
10. Ros E. Health benefits of nut consumption. Nutrients 2010; 2: 652-82.
11. Bow Y, Han J, Hu FB, et al. Association of nut consumption with total and causespecific mortality. N Engl J Med 2013; 369: 2001-11.
12. . :
. , .
2555.
13. Colberg SR, Rubin RR, Sigal RJ, et al. Exercise and type 2 diabetes. The American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010; 33: e147-e167.
14. Westcott WL. Resistance training is medicine: effects of strength training on health.
Curr Sports Med Reports 2012; 11: 209-16.
15. Sun GC, Lovejoy JC, Gillham S, Putiri A, Sasagawa M, Bradley R. Effects of Qigong on
glucose control in type 2 diabetes. Diabetes Care 2010; 33: e8.
16. Toni S, Reali MF, Barni F, Lenzi L, Festin F. Managing insulin therapy during exercise in
Type 1 diabetes mellitus. Acta Biomed 2006; 77 (Suppl 1): 34-40.
17. . , .
. , 2556.
18. . . :
2. , . .
, 2553 95-107.

3 GLP-1 analog 1
2


1-4

3 ( 1)

1. (insulin secretagogue)
(sulfonylurea) (non-sulfonylurea glinide)
glucagon like peptide-1 (GLP-1) DPP-4 inhibitor (
gliptin)

2. biguanide thiazolidinedione glitazone

3. alpha-glucosidase (alpha-glucosidase inhibitor)

genetic engineering
(human insulin)
human insulin
(insulin analog) 4 ( 9)

1. (short acting regular human insulin, RI)

2. (intermediate acting insulin, NPH)

3. (rapid acting insulin analog, RAA)

38

.. 2557

4. (long acting insulin analog, LAA)

(premixed insulin)



100
RI, NPH

GLP-1 Analog

GLP-1


exenatide, liraglutide

1. 2
1


2.
2.1 HbA1c ()
2.2 ()
2.3

3. 1-4
HbA1c
2-6 3 ( 2, ++)

4. 2 ( 1) metformin
( 2, ++)
2 (combination therapy)

39

1.

HbA1c*

Metformin

0.5-2%

Sulfonylurea

1-2%

Glinide

1-1.5%

/




serum creatinine 1.5 ./.
estimated GFR 30 .//1.73 .2


glibenclamide

serum creatinine 1.5 ./.

estimated GFR 30 .//1.73 .2 ( glipizide
)







metformin
2-4
congestive heart failure

1-2%

Thiazolidinedione

0.5-1.4%

40

.. 2557

1. ()

0.5-0.8%

0.8%


metformin thiazolidinedione




1%

medullary thyroid
carcinoma


1.5-3.5%

()

Insulin

GLP-1Analog

Alpha-glucosidase
Inhibitor (-Gl)
DPP-4 inhibitor

HbA1c*

2
metformin 2 sulfonylurea6
( glibenclamide )
sulfonylurea > 220
./. HbA1c > 9% 2 ( +)

5. 3 3
2 ( 1) 2 3
5.1 Thiazolidinedione: 2 metformin
( 2, +) 3

> 220 ./. HbA1c > 9%5

2

>300
./. HbA1c > 11%

> 300 ./.
HbA1c > 11%

180 ./. HbA1c > 8 %5

1-3

metformin
: Sulfonylurea Glitazone

DPP-4 inhibitor
- glucosidase inhibitor Repaglinide

2 ( metformin)
2 Sulfonylurea

1. Thiazolidinedione

2. DPP-4 inhibitor
3. glucosidase inhibitor

4. Repaglinide
5. Basal insulin

NPH (21.00

23.00 .) LAA

premixed human insulin

3
premixed insulin analog
1-2

< 180 ./. HbA1c < 8.0 %5

41

RAA = Rapid Acting Insulin Analog

RI = Regular Human Insulin
NPH = Neutral Protamine Hagedorn Insulin
LAA = Long Acting Insulin Analog

NPH LAA
RI
RAA

1. 2 ( metformin )

42

.. 2557

5.2 DDP-4 inhibitor: 2 3

( 2, +/-) metformin /
thiazolidinedione
5.3 Alpha-glucosidase inhibitor: 2 3
( 2, +)
5.4 Repaglinide: 2 3 sulfonylurea

( +) sulfonylurea
5.5 GLP-1 analog: 3
30 . (
2, +/-)

6. 2 basal insulin
( 2, ++)
6.1 basal insulin ( 9)
Intermediate acting insulin NPH 21.00-23.00 .
Long acting insulin analog (LAA) insulin glargine insulin detemir
insulin glargine
6.2 basal insulin NPH 0.1 - 0.2 /./
2-4
3-7


NPH LAA
6.3 RI basal insulin
pre-mixed insulin 1-2

insulin analog

7. 2
3 / 3-7
( 2, ++) RI
basal insulin pre-mixed insulin 2
1

43

1
*

RI-RI-RI-NPH or LAA RAA-RAA-RAA-NPH or LAA

(LAA )
RAA RI

3
RI/NPH-0-RI-NPH
4

RI/NPH-0-RI/NPH-0

3 4

RAA = Rapid Acting Insulin Analog

RI = Regular Human Insulin
NPH = Neutral Protamine Hegadon Insulin
LAA = Long Acting Insulin Analog
0 = None

( )


3

1. -
2. 0.4-0.6 / 1 ./

*1. 1 15
15
2. 5 10
3.

2. 1

44

.. 2557

8. 1

( 2) 0.4-0.6
/./ NPH basal insulin
RI 30-40 basal insulin

1. 1

2. (diabetic ketoacidosis)
(hyperglycemic hypersmolar nonketotic
syndrome)

3. 2

2-3

(malnutrition)




4.

45

1. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes

Care 2014; 37 (Suppl 1): S14-S80.
2. Clinical Guidelines Task Force. Global Guideline for type 2 diabetes. International
Diabetes Federation 2012.
3. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL,
Tsapas A, Wender R, Matthews DR. Management of hyperglycaemia in type 2 diabetes:
a patient-centered approach. Position statement of the American Diabetes Association
(ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia.
2012; 55: 1577-96.
4. National Institute for Health and Clinical Excellence. NICE short clinical guideline 87.
Type 2 diabetes: newer agents. London: May 2009. <www.nice.org.uk>
5. Wei N, Zheng H, Nathan DM. Empirically establishing blood glucose targets to achieve
HbA1c goals. Diabetes Care 2014; 37: 1048-51.
6. Zhang Y, McCoy RG, Mason JE, Smith SA, Shah ND, Denton BT. Second-line Agents for
glycemic control for type 2 diabetes: Are newer agents better? Diabetes Care 2014.
DOI: 10.2337/dc13-1901.

d
r
a
f

(self-monitoring of blood glucose, SMBG)
(empowerment)
SMBG
(capillary blood)
(blood glucose meter) SMBG
SMBG
SMBG

SMBG1-5

1. SMBG
1.1 (pre-gestational
DM) (gestational DM) ( 1, ++)
1.2 1 ( 1, ++)
1.3 (hypoglycemia)
hypoglycemia unawareness ( 2, +)

2. SMBG
2.1 2 (
1, ++)

3. SMBG
3.1 2
SMBG / SMBG

48

.. 2557

3.2
( 4,
+/-)
3.3 SMBG


3.4 SMBG

SMBG

SMBG



1. SMBG 1-2
3 ( 7 )

2. 3 SMBG 3
SMBG 2 .
02.00-04.00 .

3. SMBG

4. SMBG

5. 1 insulin pump SMBG 4-6

6. 2 SMBG 2



7. SMBG 4 4 6

49

8. 2 SMBG
3 / SMBG
HbA1c

2 SMBG
(structural) 7 3
3 HbA1c 0.3%6

SMBG

SMBG SMBG (
3) / (
)

SMBG

SMBG
SMBG

SMBG


SMBG

whole blood (
) whole blood 1.1 x
( ./.)

50

.. 2557

1. International Diabetes Federation. Guideline: Self-monitoring of blood glucose in

non-insulin treated type 2 diabetes 2009.
2. Towfigh A, Romanova M, Weinreb JE, Munjas B, Suttorp MJ, Zhou A. Self-monitoring
of blood glucose levels in patients with type 2 diabetes mellitus not taking insulin: A
meta-analysis. Am J Manag Care 2008; 14: 468-75.
3. Boutati EI, Raptis SA. Self-monitoring of blood glucose as part of the integral care of
type 2 diabetes. Diabetes Care 2009; 32 (Suppl2): S205-S210.
4. Diabetes UK. Care recommendations: Self monitoring of blood glucose (SMBG).
Accessed on 15 September 2010 from http://www.diabetes.org.uk/About_us/Our_
Views/Care_recommendations/Self-monitoring_of_blood_glucose/
5. American Diabetes Association. Standard of medical care in diabetes 2014. Diabetes
Care 2014; 37 (Suppl 1): S14-S80.
6. Polonsky WH, Fisher L, Schikman CH, et al. Structured self-monitoring of blood glucose
significantly reduces A1C levels in poorly controlled, noninsulin-treated type 2
diabetes: results from the Structured Testing Program study. Diabetes Care 2011; 34:
262267.

t
f

d
r
a
f

1,2

1.


2.


3.

3 (Whipple
triad) 70 ./.

1,2

2 (autonomic symptom)
(neuroglycopenic symptom)

1.

(hypoglycemia awareness)

2.
cognitive
(hemiparesis)
(stroke)

52

.. 2557

1 2


(hypoglycemia unawareness)1,3,4

5 1,2

1. Severe hypoglycemia


2. Documented symptomatic hypoglycemia

70 ./.

3. Asymptomatic hypoglycemia
< 70 ./.

4. Probable symptomatic hypoglycemia


5. Pseudo-hypoglycemia relative hypoglycemia
> 70 ./.
70 ./.

3

1,5

1. (mild hypoglycemia)



2. (moderate hypoglycemia)

53

3. (severe hypoglycemia)



1

6-10 ( 4)

(insulin secretagogue)
glinide1,5


metformin, thiazolidinedione, dipeptidyl peptidase-IV
inhibitor glucagon-like peptide-1 receptor agonist (monotherapy) -glucosidase inhibitor
(combination
therapy)
1,2,5
1,2


1.

2.
/

3. (glucose utilization)
4. (endogenous hepatic glucose production)

54

.. 2557

5. (insulin sensitivity)

6. /

7.
8. HbA1c /

9.
10.

2

11 2
1

1,5,12



( 1)
1. 15

30 12 15 3 180 .
180 . 3 1 240 . 2
1 15-20

2. pointof-care-device () 15-20
3. 15 < 70 ./.
4. > 80 ./.
1
(snack) 15

55

5. pointof-care-device

6.

( )


(complex carbohydrate)




.

-
1. 1 .
2.

-

.

-
1. 1 .
2.

10-15
15
50%

-
50%

56

.. 2557

( 1)
1. 20 1
2. 10 .

()
3.

4. 1 2
2 50% 50 . ( 25 )
10-20 . 1

5. 50% 10-20 .
2 50% 30-40 .
50% 50 .

6. 50%

50%
7.
50% 50 .
()
10% (10%D) 2 ./ 1 ./ ( 60 ./
50 .) 80 ./.
180 ./.


6
8. 10%D
9. 10%D
15-30

57

70 ./.

()


cognitive

15
3 180 .
180 . 3 1
1
15
15
< 70 ./.

> 80 ./.
1
1
1 1

:
() 1 . (
< 5 0.5 .)
:

50% 10-20 .
50%
50 . ( 50%
< 70
./.) 10%
2 ./ 1 ./
15
> 80 ./.
10%

()

1.

58

.. 2557

10. 10%D
10%D (
osmotic diarrhea )

octreotide 50-100 8-12
diazoxide 100 . 8
dexamethasone 5 . 6

11.
10%D

12. 10%D
10%D (
10%D 5%D )
13.

14. 15-30
> 80 ./. 3
(posthypoglycemic brain edema)


dexamethasone 5 . 6 / 20%
mannitol 300 .
1,2



< 70 ./. (
2, +)


(

59

1, ++)


(microvascular
complication) ( 1,
++)1


( 2, ++)

(diabetes care

team)

( 1, ++)



(
1, ++)
1.
(regimen)
glinide
2.
3. (self-monitoring of blood
glucose, SMBG)
4. (diabetes self-management)

5.

6.
2-3 12
( 1, +)



( 1,
++) 15 38 ./.
20 20 65 ./.

60

.. 2557

45 30 5
15-30

( 1, ++)

2
50% (
1, ++) 50%

( 1, +)

1. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ.
Evaluation and management of adult hypoglycemic disorders: an Endocrine Society
Clinical Practice Guideline. J Clin Endocrinol Metab 2009; 94: 70928.
2. Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack SE, Fish L, Heller SR, Rodriguez
H, Rosenzweig J, Vigersky R. Hypoglycemia and diabetes: a report of a workgroup of
the American Diabetes Association and the Endocrine Society. Diabetes Care 2013;
36: 1384-95.
3. Dagogo-Jack SE, Craft S, Cryer PE. Hypoglycemia-associated autonomic failure in
insulin-dependent diabetes mellitus. Recent antecedent hypoglycemia reduces
autonomic responses to, symptoms of, and defense against subsequent hypoglycemia.
J Clin Invest 1993; 91: 81928.
4. Segel SA, Paramore DS, Cryer PE. Hypoglycemia-associated autonomic failure in
advanced type 2 diabetes. Diabetes 2002; 51: 72433.
5. Yale JF, Begg I, Gerstein H, Houlden R, Jones H, Meheux P, Pacaud D. 2001 Canadian
Diabetes Association Clinical Practice Guidelines for the prevention and management
of hypoglycemia in diabetes. Can J Diabetes 2001; 26: 22-35.
6. Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest 2007;
117: 86870.

61

7. Laing SP, Swerdlow AJ, Slater SD, Botha JL, Burden AC, Waugh NR, et al. The British
Diabetic Association Cohort Study, II: cause-specific mortality in patients with
insulin-treated diabetes mellitus. Diabet Med 1999; 16: 46671.
8. Gerstein HC, Miller ME, Byington RP, Goff Jr DC, Bigger JT, Buse JB, et al. Effects of
intensive glucose lowering in type 2 diabetes. The Action to Control Cardiovascular
Risk in Diabetes Study Group. N Engl J Med 2008; 358: 254559.
9. Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, Woodward M, et al. for the
ADVANCE Collaborative Group. Severe hypoglycemia and risks of vascular events and
death. N Engl J Med 2010; 363: 1410-8.
10. Desouza CV, Bolli GB, Fonseca V. Hypoglycemia, diabetes, and cardiovascular events.
Diabetes Care. 2010; 33: 1389-94.
11. UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes:
effects of treatment modalities and their duration. Diabetologia 2007; 50: 11407.
12. Fanelli CG, Epifano L, Rambotti AM, Pampanelli S, Di Vincenzo A, Modarelli F, et al.
Meticulous prevention of hypoglycemia normalizes the glycemic thresholds and
magnitude of most of neuroendocrine responses to, symptoms of, and cognitive
function during hypoglycemia in intensively treated patients with short-term IDDM.
Diabetes 1993; 42: 16839.

d
r
a
f

/
(diabetic retinopathy) (diabetic nephropathy)1-3
4

(diabetic retinopathy)

1. Non-proliferative diabetic retinopathy (NPDR) 3 (mild)
(moderate) (severe)

2. Proliferative diabetic retinopathy (PDR)

3. Diabetic macula edema

NPDR


HbA1c
PDR macula edema

64

.. 2557

5,6

( 1)




visual acuity
( 2 ++)
(Fundus photography)
digital camera
( 4 ++)
1 5 12

1 ( ++)

2
1 ( ++)




> 126
./.

2,7 ( 1 ++)
HbA1c

8 ( ++)

( +)


severe NPDR PDR macular edema
( ++)


9,10 ( ++)

65

Anti-vascular endothelial growth factor (VEGF)
diabetic macular edema11

12

5 12

No DR

Mild NPDR

Moderate NPDR

6 - 12

3 - 6

Severe NPDR

PDR

Macular edema

1.

66

.. 2557

( ++)



( ++)



( ++)



( +)

3

( ++)

(diabetic nephropathy)

diabetic nephropathy
13,14 ( 1)
(albuminuria)
30 . 30 . dipstick
300 . 300 .
dipstick

15,16

( 2)

1 5 2

1 ( 2, ++)

67

12

urine protein
()

albumin/creatinine ratio (Alb/Cr)

Alb/Cr < 30 mg/g Alb/Cr 30-299 mg/g Alb/Cr > 300 mg/g

1-2 6
2 3

eGFR < 60 ml/min/1.73 m2

eGFR > 60 ml/min/1.73 m2

albuminuria

2. (Alb/Cr = albumin creatinine ratio)

68

.. 2557

albuminuria urinary albumin
creatinine ratio (Alb/Cr) Alb/Cr 30-299 ./ 1-2 3-6
2 albuminuria
16

(estimated GFR, eGFR)
serum creatinine ( 2, ++)

2 albuminuria
diabetic nephropathy

14-16

1. albuminuria


( ++)
140/80
( ++)
(Rennin-Angiotensin
System inhibition) angiotensin converting enzyme inhibitor (ACEI) angiotensin II
receptor blocker (ARB) albuminuria 17,18 (
++)

2. albuminuria 30-299 ./


albuminuria ( ++)


140/80 ( ++)
(Rennin-Angiotensin
System inhibition) angiotensin converting enzyme inhibitor (ACEI) angiotensin II
receptor blocker (ARB)19,20
( ++) 2

69

aminoglycoside


diabetic retinopathy

3. albuminuria 300 ./
140/80
(
++)
(Rennin-Angiotensin
System inhibition) angiotensin converting enzyme inhibitor (ACEI) angiotensin II
receptor blocker (ARB)
( ++)
diabetic retinopathy
60 //1.73 .2
( ++)
0.8-1.0 1 .
( ++)

4. (end stage renal disease)
30 /
( ++)
0.8 1 .
( ++)

1. Chetthakul T, Deerochanawong S, Suwanwalaikorn S, et al. Thailand Diabetes Registry

Project: Prevalence of diabetic retinopathy and associated factors in type 2 diabetes
mellitus. J Med AssocThai 2006; 89 (Suppl 1): S27-S36.
2. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and
Complications Research Group. Retinopathy and nephropathy in patients with type 1
diabetes four years after a trial of intensive therapy. N Engl J Med 2000; 342: 381-9.

70

.. 2557

3. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW. 10-Year Follow-up of intensive
glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577-89.
4. Pratipanawatr T, Rawdaree P, Chetthakul T,etal. Smoking and death in Thai diabetic
patients: the Thailand Diabetic cohort. J Med Assoc Thai. 2013; 96: 280-7.
5. .
( ). . - ()
, 2553.
6. Holman RR, Paul SK, Bethel MA, Neil HAW, Matthews DR. Long-term follow-up after
tight control of blood pressure in type 2 diabetes. N Engl J Med 2008; 359: 1565-76.
7. Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and
microvascular complications of type 2 diabetes (UKPDS 35): prospective observational
study. BMJ 2000; 321: 405412.
8. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of
macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ
1998; 317: 70313.
9. The Diabetic Retinopathy Study Research Group. Preliminary report on effects of
photocoagulation therapy. Am J Ophthalmol 1976; 81: 383396.
10. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for
diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number
1. Arch Ophthalmol 1985; 103: 1796806.
11. Nguyen QD, Brown DM, Marcus DM, et al. RISE and RIDE Research Group. Ranibizumab
for diabetic macularedema: results from 2 phase III randomized trials: RISE and RIDE.
Ophthalmology 2012; 119: 789801.
12. Chew EY, Klein ML, Murphy RP, et al. Effects of aspirin on vitreous/preretinal
hemorrhage in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy
Study report no. 20. Arch Ophthalmol 1995; 113: 52-5.
13. Ngarmukos C, Bunnag P, Kosachunhanun N, et al. Thailand Diabetes Registry Project:
Prevalence characteristics and treatment of patients with diabetic nephropathy. J Med
Assoc Thai 2006; 89 (Suppl 1): S37-S42.
14. KDIGO CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and
management of chronic kidney disease. Kidney Int 2013; 3 (Suppl): 1150.

71

15. Kramer H, Molitch M. Screening for kidney disease in adults with diabetes. Diabetes
Care 2005; 28: 1813-6.
16. .
. 2555.
17. Remuzzi G, Macia M, Ruggenenti P. Prevention and treatment of diabetic renal disease
in type 2 diabetes: the BENEDICT study. J Am Soc Nephrol 2006; 17 (Suppl. 2): S90S97.
18. Haller H, Ito S, Izzo JL Jr, et al. ROADMAP Trial Investigators. Olmesartan for the delay
or prevention of microalbuminuria in type 2 diabetes. N Engl J Med 2011; 364: 90717
19. Lewis EJ, Hunsicker LG, Clarke WR, et al. Collaborative Study Group. Renoprotective
effect of the angiotensin receptor antagonist irbesartan in patients with nephropathy
due to type 2 diabetes. N Engl J Med 2001; 345: 85160.
20. Brenner BM, Cooper ME, de Zeeuw D, et al. RENAAL Study Investigators. Effects of
losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and
nephropathy. N Engl J Med 2001; 345: 8619.

d
r
a
f

10

1,2
(Cardioroscular dissases)

2 silent myocardial
ischemia 3


4 ( 1, ++)









peripheral arterial disease ()

albuminuria microalbuminuria macroalbuminuria
(Primary prevention)

74

.. 2557

140/80 . (
2, ++) 120
.
140 .5


2,6
Angiotensin converting enzyme inhibitor (ACEI)
Angiotensin II receptor blocker (ARB)
Diuretics (low dose) hydrochlorothiazide 12.5-25 ./
Calcium-channel blocker
Beta-blocker
ACEI diabetic nephropathy ARB
ACEI ACEI ARB serum potassium
serum creatinine ( 1, ++)
ACEI ARB ARB
ACEI
Calcium-channel blocker

Beta-blocker tachyarrhythmias
1
macrovascular events7

LDL-C4,6,8

40 1
statin LDL-C
30 100 ./.

LDL-C 190 mg/dL statin LDL
50

40

75

LDL-C
statin ( 1, ++)

HDL-C triglyceride8



triglyceride

triglyceride 500 ./. fibrate
niacin ( 2, ++)

triglyceride 500 ./. fibrate
niacin statin
statin

9,10 ( 2, ++)

HbA 7.0%
1c

HbA
1c
6.5%

HbA 7% 8.5%
1c



(short life expectancy)

(
1, ++)

antiplatelet

antiplatelet 50
60 4,8

albuminuria ( 4, +)

antiplatelet aspirin 75-162 ./ ( 1,
++)

2,8,9

76

.. 2557

(Secondary prevention)


2,9,10
2 ( 1, ++)

< 140/80 .
110 .11 70 .12
beta-blocker

statin ( 1, ++)

LDL-C 50 70 ./.

HDL-C triglyceride (
2, ++)

antiplatelet

antiplatelet aspirin 75-162 ./

aspirin antiplatelet clopidogrel
( 2, ++)

1. Gaede P, Lund-Anderseo H, parving HH, Pedersen O. Effect of a multifactorial

intervention on mortality in type 2 diabetes. New Engl J Med 2008; 358: 580-91.
2. Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions
to prevent and control diabetes mellitus: a systematic review. Diabetes Care 2010;
33: 1872-94.
3. Wackers FJ, Young LH, lnzucchi SE, et al. Detection of silent myocardial ischemia in
asymptomatic diabetic subjects: the DIAD study. Diabetes Care 2004; 27: 1954-61.
4. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes
Care 2014; 37 (Suppl 1): S14-S80.
5. The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. New Engl J Med 2010; 362: 1575-85.

77

6. .. 2551
. Thai Hypertension Society: Guidelines in the treatment of hypertension
2008.
7. Hermida RC, Mojon A, Ayara DE, Fernandes JR. Influence of time of day of blood
pressure-lowering treatment on cardiovascular risk in hypertensive patients with type
2 diabetes. Diabetes Care 2011; 34: 1270-6.
8. Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with
cardiometabolic risk: Consensus conference report from the American Diabetes
Association and the American College of Cardiology Foundation. J Am Coll Cardiol
2008; 51: 1512-24.
9. Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycemic control and the prevention
of cardiovascular events: Implications of the ACCORD, ADVANCE and VA Diabetes
Trials. A position statement of the American Diabetes Association and the scientific
statement of the American College of Cardiology Foundation and the American Heart
Association. Circulation 2009; 119: 351-7.
10. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between
glycemic control and cardiovascular outcomes in diabetes. A cohort study. Ann Intern
Med 2009; 151: 854-60.
11. Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and
cardiovascular outcomes among hypertensive patients with diabetes and coronary
artery disease. JAMA 2010; 304: 61-8.
12. Anderson RJ, Bahn GD, Moritz TE, et al. Blood pressure and cardiovascular disease risk
in the Veterans Affairs Diabetes Trial (VADT). Diabetes Care 2011; 34: 134-8.

d
r
a
f

11

(lower limb amputation)

1-4

2,4,5



( 1, ++)6



1-6 7
( 1, ++)



monofilament 10 7
( 1, ++)



7-9 ( 1, ++)
5

(peripheral vascular disease)
3,5 (arterial
bypass surgery) ( 4, +)

80

.. 2557

1-6,10,11

( 1)

( 1)

( 1)

( 1)

(foot deformities) ( 2)

(callus) ( 2)

( 2)

( 2)

( 2)

10 ( 2)

( 2)

HbA ( 2)
1c

( 2)

( 2)

( 2)

( 2)

//

/
/ /
ABI < 0.9

//

81

- : //
- :
- : 10 g - monofilament 4
- : claudication ABI

//
//

/

ABI < 0.9

ABI < 0.9

//

ABI > 0.9

1.

82

.. 2557

2,3

( 1)


( ++)


(self foot-care)
( ++)
5

( ++)


( ++)

( ++)

1 ( ++)

( ++)

ABI < 0.9
( ++)

( ++)

( ++)


( ++)

6 ( ++)

/
( ++) /



12 (
1, ++)

( ++)

( ++)

3 ( ++)

83

( ) (
++)

( ) ( gangrene)
(callus) ( ++)

(ingrown toenail)
( ) (
++)

(deformity) neuropathy
hallux valgus, hallux varus, claw toe, hammer toe, (bony prominence)
Charcot foot (gait)
(mobility) ( ++)

neuropathy
( ++) ankle reflex ( ++) 128
( ++) Semmes-Weinstein monofilament 5.07
10 ( ++) monofilament
1,13-15 (
1) 6

(claudication)
femoral, dorsalis pedis posterior tibial
2 ( ++) ankle-brachial index (ABI)
/
( +) ABI 0.9

( ++)
7

2 (
8)

(neuropathic ulcer)
(ischemic ulcer) (acute ulcer)

84

.. 2557

( ++)

(sterile normal saline) 2
alcohol, betadine , Dakin, hydrogen peroxide
( ++)

alginate, cream, debriding agent, foam, film, gauze,
hydrocolloid hydrogel
2 ( 4, +/-)

( ++)

( ++)


(neuropathic ulcer)2
( 2, ++)
2

(ischemic ulcer)

( 2, ++)
surgical debridement (dry gangrene)
( 2, --)
2,18

(infected ulcer)

debridement ( 2,
++)
(severe infection)
(moderate infection)


( 3, ++)

( 3,
++) biopsy, aspiration curettage
debridement swab
( 2, ++)

85

(osteomylelitis)
/ (probe-to-bone test )
(bony prominence) ( 2, ++)

2


( 2, ++)








19

1. Crawford F, lnkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with

diabetes: a systematic review and meta-analysis. QJM 2007; 100: 65-86.
2. .
. 1.
2556. www.dms.moph.go.th/imrta
3. Mclntosch A, Peters JR, Young RJ, et al. Prevention and management of foot problems
in type 2 diabetes: Clinical guidelines and evidence 2003. (full NICE guideline).
Sheffield: University of Sheffield. www.nice.org.uk
4. Sriussadaporn S, Mekanandha P, Vannasaeng S, et al. Factors associated with diabetic
foot ulceration in Thailand: a case-control study. Diabet Med 1997; 14: 50-6.
5. American Diabetes Association. Standards of medical care in diabetes--2014. Diabetes
Care. 2014; 37 (Suppl 1): S14-80.
6. Donohoe ME, Fletton JA, Hook A, et al. Improving foot care for people with diabetes
mellitus-a randomized controlled trial of an integrated care approach. Diabet Med
2000; 17: 581-7.

86

.. 2557

7. Bakker K, Apelqvist J, Schaper NC, International Working Group on Diabetic Foot.

Practical guidelines on the management and prevention of the diabetic foot 2011.
Diabetes Metab Res Rev 2012; 28 (Suppl 1): 225-31.
8. Dorresteijn JA, Kriegsman DM, Assendelft WJ, Valk GD. Patient education for preventing
diabetic foot ulceration. Cochrane Database Syst Rev. 2012; 10: CD001488.
9. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity
clinical abnormalities in patients with non-insulin dependent diabetes. Ann lntern
Med 1993; 119: 36-41.
10. Monteiro-Soares M, Boyko EJ, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Predictive factors
for diabetic foot ulceration: a systematic review. Diabetes Metab Res Rev 2012; 28:
574-600.
11. Sriussadaporn S, Ploybutr S, Nitiyanant W, Vannasaeng S, Vichayanrat A. Behavior in
self-care of the foot and foot ulcers in Thai non-insulin dependent diabetes mellitus.
J Med Assoc Thai 1998; 81: 29-36.
12. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot re-ulceration
in patients with diabetes. A randomized controlled trial. JAMA 2002; 287: 2552-9.
13. Bracewell N, Game F, Jeffcoate W, Scammell BE. Clinical evaluation of a new device
in the assessment of peripheral sensory neuropathy in diabetes. Diabet Med 2012;
29: 1553-5.
14. Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques
to identify people at high risk for diabetic foot ulceration: a prospective multicenter
trial. Diabetes Care 2000; 23: 606-11.
15. , , .
: .
. 1. 2556.
16. , . . :
, , . Diabetes Mellitus. 1.
: 2548; 583-608.

87

17. Klein R, Levin M, Pfeifer M Rith-Najarian SJ. Detection and treatment of foot
complications. In: Mazze RS, Strock ES, Simonson GD, Bergenstal RM, eds. Staged
Diabetes Management a Systematic Approach, 2nd ed. West Sussex: John Wiley& Sons;
2004; 353-65.
18. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. Infectious
Diseases Society of America clinical practice guideline for the diagnosis and treatment
of diabetic foot infections. Clin Infect Dis. 2012; 54: e132-73.
19. Monami M, Longo R, Desideri CM, Masotti G, Marchionni N, Mannucci E. The diabetic
person beyond a foot ulcer: healing, recurrence, and depressive symptoms. J Am
Podiatr Med Assoc 2008; 98: 130-6.

d
r
a
f

t
f

d
r
a
f

12

1 2
10 2 3

1.

2. (BP > 130/85 .)

3. acanthosis nigricans

1 ( ++)

1
2 > 200 ./.
(diabetic ketoacidosis, DKA)

OGTT
( 2) (
5) 2,3

1. polyuria, polydipsia,
blurring of vision weight loss glycosuria ketouria

2.

ketoacidosis ( ++)

3.
ketoacidosis
( ++)

90

.. 2557

4. 1 90 T-cell mediated
pancreatic islet -cell destruction autoimmune islet cell antibodies
(ICA), insulin auto-antibodies (IAA), glutamic acid decarboxylase (GAD) antibodies, ICA512
or tyrosine phosphatase autoantibodies (IA-2) GAD IA-2

5. 6 neonatal diabetes
(monogenic diabetes) genetic testing

4,5 (
9)

HbA1c
1
1 (ADA / ISPAD / IDF)6
HbA1c 0-18 7.5%

91

10
1. ( 120)

2. 2 3
2.1
2.2 (BP > 130/85 .)
2.3 acanthosis nigricans

5-10


1

Random capillary blood

glucose > 110 ./.

Fasting plasma glucose

> 126 ./. 2

(2-hr plasma glucose < 140 ./.)

(2-hr plasma
glucose > 200 ./.)

1.

2.




3.
Biguanide
Sulfonyluea
4.

OGTT

1.
2.

IGT (2-hr plasma glucose

140-199 ./.)

: 15

1. 2 ( 10 )

92

.. 2557

1. 1

0-6

100 - 180 ./.


110 - 200 ./.
7.5 - 8.5%

(HbA1c)
6-12

90 - 180 ./.


100 - 180 ./.

(HbA1c)
< 8%
13 - 19

90 - 130 ./.


90 - 150 ./.

(HbA1c)
< 7.5%

1. 1 ( 2)
1.1
1.2
(
12 )
1.3 2
- (toddler age) = 0.4-0.6 /./
- (prepubertal age) = 0.7-1.0 /./
- (pubertal age) = 1-2 /./
1.4 4
1.4.1 4 / basalbolus insulin
basal insulin 1-2
(bolus insulin)
30-50 basal insulin 50-70 bolus insulin
1,2,6,7
( ++)

93

, ,

Random capillary
blood glucose (RCBG)

plasma glucose

RCBG > 200 ./.

plasma glucose
> 200 ./.

plasma glucose < 200 ./.

Fasting plasma glucose

> 126 ./. 2

RCBG 110-199 ./.

RCBG < 110 ./.

DKA
DKA
10

: 15

DKA DKA
1.
2.

4 /

3. 1-3 HbA1c 3

2. 1

94

.. 2557

1.4.2 3 / (Modified conventional

method)

,
4/6
1/6 1/6 3,6,7 ( ++)
1.4.3 2 / (conventional method)
(NPH) (regular insulin,
RI) (biphasic insulin analogue)
2/3 1/3
(+) Premixed insulin
3 ( ++)
1.4.4
(insulin pump)
Diabetes self
management education (DSME)

(SMBG) 3
HbA1c
( 1)

1.5
( 2)
50-60 25-30 15-20 70

5
2 : 1
1,2,9 ( ++)

95

2. 9

() ()
0-12
1,000 + [100 x ()]
12-15 ()
1,500 2,000 + [100 x () 12 ]
12-15 ()
2,000 2,500 + [200 x () 12 ]
15-20 ()
[29-33] x DBW* ()
15-20 ()
[33-40] x DBW* ()

* DBW: Desired body weight

(carbohydrate
portion)
( ++)

-
3 2-3 basal-bolus insulin
3-4
1
1. (carbohydrate portion)

( ++)
2.
1
2 4 1 ( ++)
3. (healthy eating
principle)

4.
(cognitive) psychosocial
3
5.

96

.. 2557

(dysfunctional eating habits) ( ++)

6. 5-10
0.25-0.5 ./
250-500 /

1.6 (diabetes self-management education,

DSME)
7-10 5,10
- 1
-

- 3-4
250 ./.
-

-
-
-
-

1.7
(psycho-social adjustment and family support)

-

-
-

97

-

-

-
1.8 1
3
3-6
3 ( ++)

1.

2. (learner
centered)

3.
/

4.





2. 2 ( 1)
2.1
2.2 200 ./. HbA1c > 9%
11,12 ( ++) 1
2.3 metformin
- metformin 250 mg 3 4
250 mg 2 3 4 1000 mg
2 11,12

98

.. 2557

- metformin
10 20 metformin
2 6 metformin
1 2 /

2

2.4

2.5
4 6 1
( 96)
2.6

2.7 (DSME)

7-10
2

2.8
(psycho-social adjustment and family support)
1

1,2,6
3

99

3.

1
10
5
2

1
10
5
2

1

1-2

3-6
1

HbA1c
*

(microalbuminuria)










**

freeT4 TSH

* 2
**
- 2 > 10
-

100

.. 2557

3 4 6-12

1. (medical outcome)
HbA1c



HbA1c DKA

1

2. (psychosocial evaluation)





3. (behavioral evaluation)
(self monitoring of blood glucose)

5,10

1. HbA1c 8.5% 1 7% 2

2. DKA 6

3.
(hypoglycemia unawareness) (severe hypoglycemia)

1. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes

Care 2014; 37 (Suppl 1): S14-S80.
2. International Diabetes Federation. Global IDF/ISPAD guideline for diabetes in childhood
and adolescence 2011.

101

3. International Diabetes Federation. Pocketbook for management of diabetes in

childhood and adolescence in under-resourced countries 2013.
4. International Diabetes Federation. International standards for diabetes educator 3rd
edition. 2009.
5. Likitmaskul S, Wekawanich J, Wongarn R, Chaichanwatanakul K, Kiattisakthavee P,
Nimkarn S, et al. Intensive diabetes education program and multidisciplinary team
approach in management of newly diagnosed type 1 diabetes mellitus: a greater
patient benefit, experience at Siriraj Hospital. J Med Assoc Thai 2002; 85 (Suppl 2):
S488-95.
6. Chiang JL, Kirkman MS, Laffel LMB, Peters AL, on behalf of the Type 1 Diabetes Sourcebook Authors. Type 1 diabetes through the life span: a Position Statement of the
American Diabetes Association. Diabetes Care 2014; 37: 2034-54 Published online
before print June 16, 2014, doi: 10.2337/dc14-1140.
7. Bangstad HJ, Danne T, Deeb LC, Jaroz-Chabot P, Urakami T, Hanas R. Insulin treatment
in children and adolescents with diabetes. Pediatric Diabetes 2009:10 (Suppl 12): 82-99.
8. Bode BW, Davidson PC, Steed RD. How to control and manage diabetes mellitus.
Robertson DG, Skyler JS, editors. Alexandria: American Diabetes Association 2001.
9. Garg A, Barnett JP. Nutritional management of the person with diabetes. In: Porte D
Jr, Sherwin RS, Baron A, editors. Ellenberg & Rifkins diabetes mellitus. 6th ed. New
York: McGraw-Hill; 2003. p.437-52.
10. Likitmaskul S, Santipraphob J, Nakavachara P, Sriussadaporn P, Parkpreaw C, Kolatat
T and 31 members. A holistic care and self management education program for
children and adolescents with diabetes at Siriraj Hospital. Abstract presented in
International Conference on Health Promotion and Quality in Health Services. 19-21
November 2008, Bangkok, Thailand. p 253-5.
11. Copeland KC, Silverstein J, Moore KR, Prazer GE, Raymer T, Shiffman RN, et al.
Management of newly diagnosed type 2 diabetes mellitus in children and adolescents.
Pediatrics 2013; 131: 364-82.
12. Springer SC, Silverstein J, Copeland KC, Moore KR, Prazer GE, Raymer T, et al.
Management of type 2 diabetes mellitus in children and adolescents. Pediatrics 2013;
131: e648-64.

d
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13

(hypoglycemia) (moderate hyperglycemia)
(diabetic ketoacidosis, DKA)

(hypoglycemia)

I. 1,2





(autonomic symptom) (neuroglycopenic symptom)

104

.. 2557

II.

1 2
2
/
1,2

1

1. (mild hypoglycemia)

1.1 70 ./.
( )
( 10 )
20-30

1.2 70 ./.
20-30 5-10

10-15
10

soft drink 90 3-4

1
20-30
15 (1 )

1 (240 )
1
200
1
30-60 80 ./.


2. (moderate hypoglycemia)
< 70 ./.
10
soft drink 90 3-4
1
20-30

105

15 (1 )

1 (240 )
1
200
1
30-60
80 ./.



3. (severe hypoglycemia)

3.1 ()
0.5 < 5 1 > 5

3.2
() 0.5 < 5 1 > 5
50%
50% 1-2 ./ 1 .
10% (10%D) 2-3 ././.
90-120 ./. 6-12

10%D
2-3 ././. 6-12

2

1

106

.. 2557

III.

(moderate hyperglycemia) diabetic

ketoacidosis (DKA)3-5

DKA
1 250 ./.
DKA (ketone)

1.

1.1


250 ./.

5 -10
1.2
/
2-4 2

10-20
4-6
180 ./.
8

107

2.

2.1
4
(2-4 4 )

1
2.2

2.2.1
DKA
/
2-4 2
regular insulin 0.1-0.25 / 1 .
4-6 NPH regular insulin (
)
2-4

4-6
8-24
24
2.2.2 DKA

acetone
( 10 Diabetic
ketoacidosis )

108

.. 2557

1. Silink M, et al. hypoglycemia. In: Silink M, ed. APEG Handbook on Childhood and
Adolescent Diabetes; the management of insulin dependent diabetes mellitus (IDDM).
1st ed. Australia: Parramatta NSW; 1996: 61-8.
2. Clarke W, Jones T, Rewers A, Dunger D, Klingensmith GJ. Assessment and management
of hypoglycemia in children and adolescents with diabetes: ISPAD Clinical Practice
Consensus Guideline 2009. Pediatric Diabetes 2009; 10 (Suppl 12): 134-45.
3. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes
Care 2014; 37 (Suppl 1): S14-S80.
4. Wolfsdort J, Craig ME, Daneman D, et al. Diabetes ketoacidosis in children and
adolescents with diabetes: ISPAD Clinical Practice Consensus Guideline 2009. Pediatric
Diabetes 2009; 10 (Suppl 12): 118-33.
5. . (Management for
diabetic ketoacidosis). 2545: 41 (1): 115-22.

14

2
(pre-gestational diabetes) (gestational
diabetes, GDM)1,2


(tight
control) ( 11)
(conception) 2-3
2 ( 1, ++)

2-3
HbA1c 6.5%
2
( 1)

1.
(./.)

60-95
1
< 140
2
< 120
02.00 04.00 .
> 60

110

.. 2557

proliferative diabetic retinopathy

diabetic nephropathy proteinuria
70 (creatinine clearance)
proteinuria
serum creatinine 3 ./.

(simple sugar) 32
(ideal body weight) 38
2 3
50-55 20 25-30
200 2 accelerated
starvation ketosis
(
1, ++)


arm
ergometry

1 2
3
( 1, ++)
(rapid acting insulin analogue) lispro insulin, aspart insulin

(regular human insulin) glargine insulin
IGF-1 receptor

1
NPH glargine insulin

111

insulin detemir
NPH

2

( 2, ++)

metformin
metformin

10-12

8 2
( 2, ++)
2.

(./2) (.)
< 18.5
12.5 - 18.0
18.5 - 24.9
11.5 - 16.0
25.0 - 29.9
7.0 - 11.5
> 30
5.0 - 9.0

HbA1c HbA1c
(organogenesis)

112

.. 2557

HbA1c
HbA1c 6.0% 6.5%
2 3 fructosamine HbA1c
2 fructosamine 280 ./. (
2, +)



1
180 ./. ( 2, +)

70-120 ./.
ketosis
5%
100-120 ./ 1-2
(normal saline)
1-2 /

(caesarian section)

5% 100-120 ./
1-2 5%
100-140 ./. (normal
saline) 1-2 /
100-140 ./.



2
4-6
400

113

(Gestational diabetes)



(glucose intolerance)
1-14 ( 2)
( 11)

25

24-28
( 2)

2 Carpenter Coustan International Diabetes

Federation (IDF) Carpenter Coustan
100 4 IDF
75 3 Carpenter
Coustan 50
(50 g glucose challenge test) 1
140 ./.
oral glucose tolerance test (OGTT) IDF
(FPG) 92 ./.
92 ./.
75 OGTT

pregestational diabetes
1

114

.. 2557

105 ./.
95 ./. 1 .
2 . 140 120 ./.
1-2
( 1, ++)

glibenclamide metformin
metformin ( 3,
+)

5
7.4 6
75 (75 g oral glucose tolerance test, OGTT) (
9) 1

( 1, ++)

1. . . : 2550.
, , , .
. 2550
2. IDF Clinical Guidelines Task Force. Global Guideline on Pregnancy and Diabetes.
International Diabetes Federation. Brussels, 2009.
3. Deerochanawong C, Putiyanun C, Wongsuryrat M, Jinayon P. Comparison of NDDG and
WHO criteria for detecting gestational diabetes. Diabetologia 1996; 39: 1070-3.
4. The HAPO study cooperative research group. Hyperglycemia and adverse pregnancy
outcomes. New Engl J Med 2008; 358: 1991-202.
5. Bellamy L, Casas JP, Hingoranai AB, Williams D. Type 2 diabetes mellitus after
gestational diabetes: a systemic review and meta-analysis. Lancet 2009; 373: 1273-9.

t
f

d
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f

15

Wagners Chronic Care Model (CCM) WHOs Chronic Care
Model1,2

1.

2.

3.

4.

5. (Self management support)

6.

6

3-7

116

.. 2557

()

(
)

1



( )

117

8

(Process)



impaired fasting glucose (IFG)









HbA
1c

lipid profile

albuminuria

118

.. 2557

albuminuria ACE inhibitor ARB
()









/ /
(..)

(Outcome)
(Prevalence) (Incidence)




fasting plasma glucose (FPG 70 -130 ./.)

HbA
1c

< 140/80 mmHg

LDL-C 100 ./.










diabetic retinopathy
diabetic nephropathy


myocardial infarction

cerebral infarction

impaired fasting glucose (IFG)

119

1. King H, Gruber W, Lander T. Implementing national diabetes programmes. Report of

a WHO Meeting. World Heath Organization. Division of Non-communicable Diseases,
Geneva 1995.
2. Wagner EH. Chronic Disease Management: What will it take to improve care for chronic
illness? Effective Clinical Practice 1998; 1: 2-4.
http://www.improvingchroniccare.org/change/model/components.html>>
verified2/5/2007
3. U.S. Department of Health and Human Service, 2006 National Healthcare Quality
Report AHRQ. Publication No 07-0013, December 2006.
4. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes
Care 2014; 37 (Suppl 1): S14-S80.
5. National Expert Writing Group. A National Diabetes Strategy and Acton Plan 2013.
Diabetes Australia, Australian Diabetes Educators Association, Boden Institute, University
of Sydney, Baker IDI Heart and Diabetes Institute. <www.diabetesaustralia.com.au>
6. Redesigning the Health Care Team: Diabetes Prevention and Lifelong Management.
The U.S. Department of Health and Human Services, National Diabetes Education
Program 2013, National Institutes of Health and the Center for Disease Control and
Prevention. Hager Sharp, Inc., Washington, DC. NIH Publication No. 13-7739 NDEP-37
<www.YourDiabetesInfo.org>
7. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management
in US primary care settings: a systematic review. Prev Chronic Dis. 2013; 10: E26.
Published online Feb 21, 2013. doi: 10.5888/pcd10.120180
8. ( 13 .. 2556)
.

d
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a
f

16

(..)










1.
1. ..

122

.. 2557

..

1.
1.1 .. .
15
(
)
1.2 (
)
1.3
1.4
1.5 Data center

2.
2.1

2.2
/

2.3
2.4
2.5

2.6



3.
3.1

123

3.2 /
1 ( 2)
3.3

3.4
2.

/ 1
-
- (albuminuria, )
- /
- /

- / (
)
- 1-3
- / /

-
6-12
-
3-6
-
-
- /
- /

124

.. 2557

4.
4.1
4.2
4.3 /
4.4

4.5

5.
5.1
5.2
5.3
5.4

5.5
5.6

1.
. . 1. 2555, 31-35

17

1-3

1.
2.
3.

(
) (capillary blood
glucose, CBG) point-of-care-device
(
)

126

.. 2557

1
70-130 ./.
6 ( 1)
()

1. CBG < 70 ./.

2.

3. CBG > 200 ./. 2

4. CBG > 300 ./.

5.

6.

7.

8. ( > 100 /) / orthostatic hypotension

9. /

10. 180/110 .
systolic BP > 140 . / diastolic BP > 80
. 3

11.

12.

127

5
CBG > 130 ./. 3

CBG > 130 ./.

3

(
)

(drug interaction) -
- - -/

(medication error)

(non-compliance)

1 ()

(CBG < 130 ./.)

1.

128

.. 2557

13.

14.


15.

16.


3


1. (non-compliance)



2.

3.

129

1. Katherine K, Max, R, Anandi L, et al. The role of community pharmacies in diabetes

care: eight case studies. California Healthcare Foundation 2005. Available at:
http://www.chcf.org/topics/chronicdsease/index.cfm?itemID=112672. Accessed
November 11, 2006
2. Stacy AM, Kim RK, Warren AN. Identifying at-risk patient through community pharmacy-based
hypertension and stroke prevention screening projects. J AM Pharm Assoc 2003;
43: 50-5

d
r
a
f

t
f
a
r
d

d
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a
f

1. 1 (type 1 diabetes mellitus, T1DM)
1.1. Immune mediated
1.2. Idiopathic

2. 2 (type 2 diabetes mellitus, T2DM)
2.1 Predominant insulin resistance with relative insulin deficiency
2.2 Predominant insulin secretory defect with insulin resistance

3. (other specific types)
3.1
Maturity-onset diabetes in the young (MODY)
Mitochondrial DNA
MODY 3 Chromosome 12 HNF-1
MODY 2 Chromosome 7 glucokinase
MODY 1 Chromosome 20 HNF-4
Transient neonatal diabetes (most commonly ZAC/HYAMI imprinting
defect chromosome 6q24)
Permanent neonatal diabetes (most commonly KCNJ11 gene encoding
Kir6.2 subunit -cell KATP channel)
3.2
Type A insulin resisitance, Leprechaunism, Lipoatrophic diabetes
3.3 Hemochromatosis
fibrocalculous pancreatopathy
3.4 Acromegaly, Cushings syndrome,
Pheochromocytoma, Hyperthyroidism
3.5 Pentamidine, glucocorticoids,
Dilantin, -interferon, Vacor

132

.. 2557

3.6 Congenital rubella, Cytomegalovirus

3.7 Anti-insulin receptor
antibodies, Stiff-man syndrome
3.8 Down syndrome, Turner syndrome,
Klinefelter syndrome, Prader-Willi syndrome, Friedrichs ataxia, Huntingtons chorea,
Myotonic dystrophy

4. (gestational diabetes mellitus, GDM)

(Oral Glucose Tolerance Test)

()

1.
150 3

2.
,

3. 10-16
10 FPG
16

4. FPG
75 250-300 . 5
2
30

5. 6 .
1 .,

1.75 / 1 75

134

.. 2557

(gestational diabetes mellitus)

GDM oral glucose tolerance test

Carpenter Coustan International Diabetes Federation (IDF)
NDDG 3 hour oral glucose tolerance test
8 100 250-300 .
1, 2 3
2 1, 2 3 95,180,155 140
./. IDF IADPSG (International Association Diabetes
Pregnancy Study Group)
75 OGTT
92, 180 153 ./.
1 2

(./.) () GDM
1 2 3
NDDG
100
> 105
> 190
> 165
> 145
> 2
Carpenter & Couston 100
> 95
> 180
> 155
> 140
> 2
WHO
75
-
-
> 140
-
2
IDF (IADPSG)
75
> 92
> 180
> 153
-

NDDG = National Diabetes Data Group; WHO= World Health Organization, IDF = International Diabetes Federation, IADPSG = International Association of Diabetes Pregnancy Study
Group

SMBG

SMBG
1 2
SMBG
SMBG1 meta-analysis stratified
SMBG SMBG

1. SMBG HbA1c

2. SMBG (real time)

3.



4. 2 SMBG

HbA1c

136

.. 2557

/
( )

2-4

:
(finger prick device) 70%

:

10-15




25


(forearm) (thigh) (palm)





( )

4 :
10-40 (
40 )

( 10-90)
(photometer)

7 5

2 .

2 .

2 .

X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

5 5

2 .

X
X
X

2 .

X
X
X

X
X
X

X
X
X

2 .

X
X
X

2 .
2 .

X
X

X
X


X
X

X
X


X
X

2 .

137

138

.. 2557

5




2 .
2 .

X
X


X
X

2 .

2 .

2 .

2 .

X


X


X

X
X
X

SMBG2-3

1.

2.

139

3.


2
1


4.
(photometric method)
(color intensity) (strip)


electrochemical technology
biosensor glucose oxidase (GO) glucose dehydrogenase (GD)
GD GO
oxygen GD
GD

5.

polycythemia

biosensor (glucose
oxidase)
(PaO2) PaO2 150 .

4 The International Organization for Standardization (ISO)

140

.. 2557

< 75 ./. ()
15 ./. > 75 ./. 20
() 95 6

1. Towfigh A, Romanova M, Weinreb JE, Munjas B, Suttorp MJ, Zhou A, et al. Selfmonitoring of blood glucose levels in patients with type 2 diabetes mellitus not
taking insulin: A meta-analysis. Am J Manag Care 2008; 14: 468-75.
2. , , .
: 1. ,
, . , 2548: 81-106.
3. Austin MM, Powers MA. Monitoring. In: Mensing C, McLaughlin S, Halstenson C, eds.
The art and science of diabetes self-management education desk reference. 2 nd ed.
Chicago : American Association of Diabetes Educators, 2011: 167-93.
4. , , , , .
. , .
, 2556.
5. International Diabetes Federation. Guideline: Self-monitoring of blood glucose in
non-insulin treated type 2 diabetes 2009.
6. Garg SK, Hirsch IB. Self-monitoring of blood glucose-an overview. Diabetes Technol
Ther 2013; 15: S3-S12.

1,2

< 70 ./.
< 50 ./.
< 70 ./. (glucose alert level)

(glucose counter-regulatory system)
glucose counter-regulatory hormone , ,
(autonomic
neuro-transmitter) (autonomic
nervous system)

(accuracy)
2

1.
1,2 2-6

2.
7 8
(hypoglycemia unawareness)9,10

3.
7

4.

11

142

.. 2557

1.
(plasma glucose) 7,12
(venous blood)
(anticoagulant) (plasma)
(laboratory-based glucose measurement) glucose oxidase
hexokinase

2. (hypoglycemic agent)
(capillary blood glucose)
(validated
portable glucose meter) (monitor-based glucose measurement)
(self monitoring of blood glucose, SMBG)
(point-of-care testing of blood glucose)
2

3. (plasma glucose)
(whole blood glucose)


(International Federation of Clinical Chemistry IFCC)


(adjusted plasma glucose) 12
correction factor 1.11
adjusted plasma glucose = capillary whole blood glucose x 1.11

4.
(falsely low)
( vasopressor, acetaminophen) 2
( 3) The International Organization for Standardization (ISO)

< 75 ./. () + 15 ./.
> 75 ./. 20 (

143

) 95 2





5. (HbA1c)

13,14
2

1. Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest 2007;
117: 868-70.
2. Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack SE, Fish L, et al. Hypoglycemia
and diabetes: a report of a workgroup of the American Diabetes Association and the
Endocrine Society. Diabetes Care 2013; 36: 1384-95.
3. Laing SP, Swerdlow AJ, Slater SD, Botha JL, Burden AC, Waugh NR, et al. The British
Diabetic Association Cohort Study, II: cause-specific mortality in patients with
insulin-treated diabetes mellitus. Diabet Med 1999; 16: 466-71.
4. Gerstein HC, Miller ME, Byington RP, Goff Jr DC, Bigger JT, Buse JB, et al. Effects of
intensive glucose lowering in type 2 diabetes. The Action to Control Cardiovascular
Risk in Diabetes Study Group. N Engl J Med 2008; 358: 2545-59.
5. Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, Woodward M, et al. for the
ADVANCE Collaborative Group. Severe hypoglycemia and risks of vascular events and
death. N Engl J Med 2010; 363: 1410-8.
6. Desouza CV, Bolli GB, Fonseca V. Hypoglycemia, diabetes, and cardiovascular events.
Diabetes Care. 2010; 33: 1389-94.
7. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ.
Evaluation and management of adult hypoglycemic disorders: an Endocrine Society
Clinical Practice Guideline. J Clin Endocrinol Metab 2009; 94: 709-28.

144

.. 2557

8. Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with
type I diabetes with impaired awareness of hypoglycemia. Diabetes Care 1994; 17:
697-703.
9. Dagogo-Jack SE, Craft S, Cryer PE. 1993 Hypoglycemia-associated autonomic failure in
insulin-dependent diabetes mellitus. Recent antecedent hypoglycemia reduces
autonomic responses to, symptoms of, and defense against subsequent hypoglycemia.
J Clin Invest 1993; 91: 819-28.
10. Segel SA, Paramore DS, Cryer PE. Hypoglycemia-associated autonomic failure in
advanced type 2 diabetes. Diabetes 2002; 51: 724-33.
11. Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of type I
and type II diabetes. Diabetologia 2002; 45: 937-48.
12. DOrazio P, Burnett RW, Fogh-Andersen N, Jacobs E, Kuwa K, Wolf R. Klpmann KK, et
al. The International Federation of Clinical Chemistry Scientific Division Working Group
on selective electrodes and point of care testing. Approved IFCC Recommendation
on reporting results for blood glucose (Abbreviated). Clinical Chemistry 2005; 51: 9:
1573-6.
13. The effect of intensive treatment of diabetes on the development and progression
of long-term complications in insulin-dependent diabetes mellitus. The Diabetes
Control and Complications Trial Research Group. N Engl J Med 1993; 329: 977-86.
14. Intensive blood-glucose control with sulphonylureas or insulin compared with
conventional treatment and risk of complications in patients with type 2 diabetes
(UKPDS33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352: 837-53.

1

2


, , ,







( )

( )
velcro

146

.. 2557

1


(
)











( )

1. , . :
, , . Diabetes Mellitus. 1.
: ; 2548: 583-608.

Semmes-Weinstein monofilament
( 5.07 10 )

Semmes-Weinstein monofilament
light touch deep pressure. Semmes-Weinstein monofilament
() monofilament
monofilament monofilament
monofilament monofilament
5.07 10
(protective sensation)

(reproducibility) 1

monofilament

1. monofilament 2 (reusable)
(disposable) monofilament
monofilament

2. monofilament


3. monofilament
monofilament 2
monofilament

4. monofilament
10 ( 1 10 )
100 monofilament 24
monofilament

148

.. 2557

monofilament

1. 4 metatarsalhead
1 3 5

2. callus

monofilament 5.07 10

The American College of Physicians 20072

1.

2.
monofilament (forearm)
monofilament 1-1.5

3.

4.

5. monofilament
monofilament 1-1.5 () monofilament
monofilament
monofilament

149

3 (real application) monofilament
2 (sham application) monofilament
monofilament ? 1

6. 2 3 (
1 5) protective sense

7. 1 3 (
1 5) 5


8. 1 3


9. 4 2
2

10.
protective sensation (insensate foot)

11. 1

The American College of Physicians 2007


1. 128

2.

150

.. 2557

3.



4.

5. distal interphalangeal joint 2

6.
?

7.
?



1 2


8. 7 1 2
4

9. 2 1

10. 7-9 1 2 2 8

11. 5
peripheral neuropathy

1. Klenerman L, McCabe C, Cogley D, Crerand S, Laing P, White M. Screening for patients

at risk of diabetic foot ulceration in a general diabetic outpatient clinic. Diabet Med
1996; 13: 561-3
2. Stutts B, Miller T, Clark S. Diabetic foot ulcers: screening and presention. A Self-contained workshop curriculum and materials. American Coffee of Physicians Clinical Skills
Workshop Series, 2007.

metatarsophalangeal 1


(
) 3/8 1/2

(forefoot) metatarsophalangeal joints
(claw hammer toe)




(velcro)

2


(foot-orthoses) (ankle-foot-orthoses)

152

.. 2557

1.
1.1

1.2
1.3
3/8 1/2
1.4

2.
2.1



2.2
2.3
2.4


3.
(ankle-foot-orthoses)

1. , . :
, , . Diabetes Mellitus. 1.
: 2548: 583-608
2. .
. 1.
2556

/


(hemorrhagic callus)



(

2


callus
granulation

(claw hammer toe)

154

.. 2557

(intermittent claudication)
(rest pain)
dorsalis pedis
posterior tibial




( )

4

1. (off loading, pressure reduction)4-7

80-90
off-loading8 total contact cast (TCC)
non-weight bearing
TCC
TCC


2. debridement4-7,9,10

callus debridement
sharp surgical debridement forceps
debridement 1 (wound
bed)

3. 7

24.2 12 30.9 20
4

155

4. 4,6
6011

(ischemic ulcer)3




surgical debridement

(infected ulcer)3







aerobe anaerobe ()

(pedal pulse)
(wet gangrene)



3

1. (mild)
2 . subcutaneous
tissue 1-2

156

.. 2557

24-48 . 3-7


2. (moderate)
2 . (lymphangitis)
fasciitis, deep tissue abscess, myositis,
arthritis, osteomyelitis debridement /
drainage
24-48 .
7-10
2

3. (severe)


acidosis azotemia
(necrosis) (bleb)
(loss of plantar arch)

3,12



1.

amoxicillin-clavulanate cephalexin
amoxicillin-clavulanate
cephalexin dicloxacillin
cephalexin ( 1) betalactam clindamycin roxithromycin clindamycin

roxithromycin
erythromycin roxithromycin

157

3-4

patient non-compliance
ciprofloxacin
Pseudomonas aeruginosa third generation
cephalosporins cefdinir
P. aeruginosa

amoxicillin-clavulanate, clindamycin metronidazole
monotherapy metronidazole add-on therapy
metronidazole cephalexin, dicloxacillin roxithromycin
2
(National Antimicrobial Resistance Surveillance
Center)13 tetracyclines Staphylococcus aureus
methicillin
tetracyclines

2.
amoxicillin-clavulanate 1.2 8 .
3-7
clindamycin 600 6-8 .
ceftriaxone 2
beta-lactam ceftriaxone aminoglycosides
(gentamicin amikacin) ciprofloxacin

vancomycin linezolid methicillin resistant
S. aureus carbapenems extended spectrum
beta-lactamase producing organisms (ESBL)

3.

158

.. 2557

1. 12, 13

MILD (usually P.O.)

Staphylococcus aureus (MSSA), Amoxicillin-clavulanate*
Cephalexin*
Streptococcusspp
Dicloxacillin
Clindamycin
Methicillin-resistant S. aureus Linezolid*
Trimethoprim/sulfamethoxazole (
(MRSA)
)
MODERATE (P.O. or initial Staphylococcus aureus (MSSA), Ampicillin-sulbactam*
Ertapenem*
I.V.)
Streptococcus spp,
Imipenem-cilastatin*
Enterobacteriaceae,
Levofloxacin
obligate anaerobes
Cefoxitin
Ceftriaxone
Moxifloxacin
Tigecycline
Levofloxacin or ciprofloxacin with
clindamycin
SEVERE (usually I.V.)
Methicillin-resistant S. aureus Vancomycin*
Linezolid
(MRSA)
Daptomycin
Piperacillin-tazobactam*
Pseudomonas aeruginosa
Methicillin-resistant S. aureus Vancomycin, ceftazidime, cefepime,
piperacillin-tazobactam, carbapenem
(MRSA), Enterobacteriacae,
Pseudomonas,
and obligate anaerobes
P.O. = ; I.V. = ; * =

159

2. 12

SOFT TISSUE ONLY
Mild
T.C. / P.O.
OPD
1-2
4

1-3
Moderate
P.O. ( I.V.)
IPD/OPD
Severe
I.V. P.O.
IPD OPD
2-4
BONE OR JOINT
2-5
No residual infected tissues e.g.
I.V. / P.O.
IPD OPD
post amputation
1-3
Residual soft tissues (not bone)
I.V. / P.O.
IPD OPD
4-6
Residual infected viable bone
I.V. P.O.
IPD OPD
3
Residual dead bone / No surgery
I.V. P.O.
IPD OPD

T.C. = , P.O. = , I.V. = , IPD = inpatient department,

OPD = outpatient department

1. , . :
, , . Diabetes Mellitus. 1.
: ; 2548:583-608.
2. . . : , , .
Diabetes Mellitus. 1. : 2548:
563-82.
3. .
. 1.
2556.
4. Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers.
N Eng J Med 2004; 351: 48-55.
5. Steed DL, Attinger C, Colaizzi T, Crossland M, Franz M, Harkless L, et al. Guidelines for
the treatment of diabetic ulcers. Wound repair and regeneration : official publication
of the Wound Healing Society [and] the European Tissue Repair Society. 2006; 14:
680-92.

160

.. 2557

6. Cavanagh PR, Lipsky BA, Bradbury AW, Botek G. Treatment for diabetic foot ulcers.
Lancet 2005; 366: 1725-35.
7. The University of Michigan Medical School, The University of Michigan Health Systems
Educational Services for Nursing, Barry University School of Podiatric Medicine. The
standard of care for evaluation and treatment of diabetic foot ulcers[Internet]. [cited
2013 Feb 20]. USA: Advanced BioHealing. Avilable from: https://www.barry.edu/
includes/docs/continuing-medical-education/diabetic.pdf.
8. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Offloading the diabetic foot wound: a randomized clinical trial. Diabetes Care 2001; 24:
1019-22.
9. McIntosh C. Diabetic foot ulcers: what is best practice in the UK?. Wound Essentials
[Internet]. 2007 [cited 2013 Feb 18]; 2: 162-169. Avilable from:http://www.wounds-uk.
com/pdf/content_9405.pdf.
10. Bakker K, Apelqvist J, Schaper NC, International Working Group on Diabetic Foot Editorial B. Practical guidelines on the management and prevention of the diabetic foot
2011. Diabet Metab Res Rev 2012; 28 (Suppl 1): 225-31.
11. Connor H, Mahdi OZ. Repetitive ulceration in neuropathic patients. Diabet Metab Res
Rev 2004; 20(Suppl 1): S23-8.
12. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious
Diseases Society of America clinical practice guideline for the diagnosis and treatment
of diabetic foot infections. Clinical infectious diseases : an official publication of the
Infectious Diseases Society of America. 2012; 54: e132-73.
13. National Antimicrobial Resistance Surveillance Center, Thailand. Department of
Medical Sciences, Ministry of Public Health. http://narst.dmsc.moph.go.th access
verified May 25, 2014

()

( ++)

4 /
1 2 / 2

G 32
0.5 . 1.0 . 2
4

( ++)




/

162

.. 2557

/





(Thai Diabetic children and adolescents club)

www.thaidiabetes.com

163

( ++)



(networking)
(PCU)


call
center hotline

1-3
12

()

(regular insulin, RI)

- (Actrapid HM, Humulin R, Gensulin R, Insugen R, Insuman Rapid)
(Insulin Isophane Suspension, NPH)
- (Insulatard HM, Humulin N, Gensulin N, Insugen N, Insuman Basal)

- Premixed 30% RI + 70% NPH (Mixtard 30 HM, Humulin 70/30,

Gensulin M30, Insugen 30/70, Insuman Combo30)
- Premixed 50% RI + 50% NPH (Gensulin M50)

- Insulin Lispro (Humalog)

- Insulin aspart (NovoRapid)
- Insulin Glulisine (Aprida)

- Insulin glargine (Lantus)

- Insulin detemir (Levemir)
(Biphasic insulin analogue)
- Premixed 30% insulin aspart + 70% insulin aspart protamine suspension
(NovoMix 30)
- Premixed 25% insulin lispro + 75% insulin lispro protamine suspension
(Humalog Mix 25)

30-45

2-3

2-4

4-8 10-16

4-8

30-60 2 8 12-20
30-60 2 8 12-20
5-15
10-20
10-20

1-2
1-2
1-2

3-4
3-4
3-4

2
2

24
18-24

10-20 1 8 12-20
10-20 1 8 12-20

d
r
a
f

 10
diabetic ketoacidosis (DKA)
1-3

I.

DKA (Kussmaul
breathing metabolic acidosis) acetone
(dehydration)

DKA

1. : (plasma glucose) > 200 ./.
(> 11 /)

2. (acidosis): HCO3 < 15 /. venous pH < 7.3

3.

DKA

Venous pH
Serum bicarbonate (/)

DKA


7.20-7.29
7.10-7.19
10.0-14.9
5.0-9.9

< 7.10
<5

II.

1.
1.1 DKA
DKA 5-10% mild
DKA 3-5%, moderate DKA 5-7% severe DKA 7-10%
1.2 normal saline (NSS) Ringer lactate solution (RLS)
10-20 ./. 15-30
1.3 NSS 10-20 ././. 1-2

166

.. 2557

1.4 fluid deficit 48

Maintenance 24 . + fluid deficit (5-10%) = (./.)

24
48

NSS 4-6 hypernatremia

NSS/2 ()


24 1.5-2.0 maintenance
( 4 //)
ideal weight for height

( osmotic diuresis)
1.5 KCl initial rehydration
/ hyperkalemia (serum K > 6 /) KCl 3
1.6 fluid balance
2-3
1.7 moderate severe DKA
( mild DKA )

2.
initial rehydration 1-2 . regular insulin (RI)
continuous low-dose intravenous insulin infusion method
1. RI 0.1 /./. insulin infusion RI 50
NSS 50 . 1 . RI 1 insulin infusion infusion pump
side-line
infusion set insulin infusion
10-20 . saturate binding site

 DKA

167

1. insulin IV bolus insulin infusion

2. initial rehydration RI infusion
50-200 ./. dehydration RI
3. 24
2. 75-100 ./.
3.
bedside blood glucose 1
4. 250-300 ./. 5%
dextrose 5% dextrose in 0.45% NaCl
5. Insulin infusion acidosis ketonemia
dextrose
150-250 ./. ( 150 ./.)
RI ( 0.05 /./.)
dextrose 7.5-12.5% ketonemia acidosis RI
RI 0.05 /./.
6. 70 ./. 10% glucose 2 ./.
glucose

1. insulin infusion RI
insulin infusion -1
rebound hyperglycemia rapid-acting insulin aspart lispro
rapid-acting insulin insulin infusion 10-15 (
DKA)
2. insulin infusion infusion
pump insulin intramuscular (IM) insulin administration RI 0.1
/. 1 250-300 ./.
RI 0.25-0.5 /. (subcutaneous) 4-6
severe acidosis, peripheral perfusion
RI

168

.. 2557

3. (potassium, K)
DKA total
body K K potassium
K K initial
rehydration insulin infusion K 40 /
potassium ( 2.5 /) K initial rehydration
( K 0.5 /./.)

K < 2.5 / KCl 0.5 /./.
RI K > 2.5 / EKG
KCl K 0.5 /./.

4. (sodium, Na)
DKA
corrected serum sodium

Corrected Na = Na (mmol/L) + [Plasma glucose (mg/dL)100] x 1.6

100

initial rehydration NSS 10 ././.

NSS 4-6
electrolytes
corrected serum Na 150 /
hypernatremia hyperosmolar Na glucose
cerebral edema
48-72 24
200-300 ./.
0.45-0.9% NaCl (
0.9% NaCl
0.45% NaCl) osmolality

 DKA

169

DKA triglyceride
pseudo-hyponatremia

5. bicarbonate (HCO3)
5.1 acidosis dehydration
insulin bicarbonate HCO3


Persistent severe acidosis pH < 6.9 HCO3 < 5 /
initial rehydration insulin infusion NaHCO3 1-2
/. intravenous drip 1
5.2 bicarbonate cerebral edema,
paradoxical cerebral acidosis, shift to the left of oxyhemoglobin dissociation curve
peripheral oxygen availability severe hypokalemia
K EKG

6. (phosphate, PO4)
DKA
acidosis RI
DKA
(hypocalcemia)
1 ./.
K2HPO4 20-30 /.


7.
DKA
ICU
7.1 vital signs neurological signs 1
7.2 blood glucose 1
7.3 serum electrolytes, blood gases () 2-4
7.4 intake output 2-4
7.5 serum ketone urine ketone 6
250 ./.

170

.. 2557

7.6 serum BUN, Cr, Ca, P severe DKA

7.7 flowsheet
7.8 nasogastric tube urinary catheter

8. DKA
DKA

urinalysis, urine culture, hemoculture, tuberculin test

9.
DKA
9.1 Hypoglycemia continuous insulin infusion

9.2 Persistent acidosis HCO3 < 10 /

8-10 hyperglycemia
RI RI RI
intravenous infusion


hyponatremia, hypokalemia hyperchloremic acidosis
chloride
RI RI
9.3 Hypokalemia K
acidosis K shift K
K K muscle
weakness
9.4 Intracranial complication (cerebral edema)
4-12
< 5
bicarbonate BUN

 DKA

171

decreased sensorium,
,
disorientation, agitation, pupillary change, ophthalmoplegia, papilledema,

< 5 severe DKA

1) ICU
2)

2/3
20% Mannitol 0.5-1 /. 20
30 2
mannitol hypertonic saline (3% NaCl)
5-10 ./. 30
Intubation coma aggressive
hyperventilation PCO2 < 22 mmHg
Monitor neurological signs CT brain
stabilize

DKA

1. 12-24 (
) metabolic blood
glucose < 300 ./., pH >7.3 serum HCO3 >15 / ketosis
mild acidosis
maintenance + deficit

2. insulin infusion
metabolic criteria resolution of DKA (blood glucose < 200 ./., venous
pH > 7.3 serum HCO3 > 15 /.) insulin
- 1 RI 0.2-0.5 /. 6

172

.. 2557

3. (subcutaneous)
RI 0.25-0.5 /./ 3
1-2 DKA basal-bolus regimen
24 . (total daily dose, TDD) (prepuberty)
TDD insulin 0.7-1.0 /./ 1.0-2.0 /./
TDD basal insulin ( glargine detemir)
rapid-acting insulin ( aspart lispro) ( rapidacting insulin 15-20% TDD)
2 24 . (TDD)
RI intermediate acting insulin (NPH) 2 3 TDD
( NPH : RI 2 : 1) 1 3
( NPH : RI 1 : 1)

1. diabetic ketoacidosis (
.. 2553)
2. Wolfsdort J, Craig ME, Daneman D, et al. Diabetes ketoacidosis in children and
adolescents with diabetes: ISPAD clinical practice consensus guideline 2009. Pediatric
Diabetes 2009: 10 (Suppl 12): 118-33.
3. Sperling MA, Weinzimer SA, Tamborlane WV. Diabetes mellitus. In: Sperling MA, ed.
Pediatric Endocrinology, 3rd edition. Philadelphia: Saunders Elsevier 2008; 374-421

 11

(Pre-gestational diabetes)

1.

2 human chorionic somatomammotropin
(post-prandial hyperglycemia)

2. diabetic retinopathy
(tight control)

diabetic retinopathy
proliferative diabetic retinopathy
diabetic retinopathy

3. diabetic nephropathy proteinuria

70 diabetic nephropathy proteinuria
(creatinine clearance)
proteinuria serum
creatinine 3 ./

(toxemia of pregnancy) (pyelonephritis)
(polyhydramnios) (caesarian section)

174

.. 2557

(spontaneous abortion)
(congenital malformation) 9
HbA1c 9

Macrosomia
hyperinsulinemia

(micro-angiopathy) (intrauterine growth
retardation, IUGR) uteroplacental insufficiency
(intrauterine fetal death)

lactate
metabolic acidosis
respiratory distress syndrome
hyperinsulinemia
(hypocalcemia
hypomagnesemia)

(Gestational diabetes mellitus)

perinatal loss
(macrosomia,
4 ) hypoglycemia, hypocalcemia, polycythemia
hyperbilirubinemia macrosomia
(obesity)

(organogenesis)

175

1. The HAPO study cooperative research group. Hyperglycemia and adverse pregnancy
outcomes. New Engl J Med 2008; 358: 1991-202.
2. Bellamy L, Casas JP, Hingoranai AB, Williams D. Type 2 diabetes mellitus after
gestational diabetes: a systemic review and meta-analysis. Lancet 2009; 373: 1273-9.