Professional Documents
Culture Documents
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f
a
2014
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.. 2557
ISBN
50 10 2 47
10310
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0 2716 5412 0 2716 5411
www.diabassocthai.org
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50 10 2 47
10310
a
0 2716 6337 0 2716 6338
www.thaiendocrine.org
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11000
0 2590 6395 0 2965 9844
d
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
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2552
(Chronic Care Model)
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( )
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(Quality of Evidence)
1
1. (systematic review) -
(randomized -controlled clinical trial)
2. -
1 (well-designed
randomized-controlled clinical trial)
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2
1. (non-randomized
controlled clinical trial)
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2. (well-designed non-randomized
controlled clinical trial)
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3. (cohort)
(case control analytic studies)
/
r
.. 2480
3
1. (descriptive studies)
2. (fair-designed controlled clinical trial)
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4
1. (consensus)
2.
2
(anecdotal report)
(Strength of Recommendation)
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+ +
(cost effective)
+
f
+/-
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-
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- -
.. 2557
2557
1.
t
1. 1
2. 3
3.
2.
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13
a
4. 21
5. 29
6. 37
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7. 47
3.
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8. 51
9. 63
10. 73
11. 79
.. 2557
4.
12. 89
13. 103
14. 109
5.
15. 115
16. 121
17. 125
t
6.
1. 131
f
2. (Oral Glucose Tolerance Test)
3.
4.
133
135
141
a
5. 145
6. 147
r
7. 151
8. 153
9. 161
d
4
1. 1 (type 1 diabetes mellitus, T1DM)
2. 2 (type 2 diabetes mellitus, T2DM)
3. (other specific types)
t
4. (gestational diabetes mellitus, GDM)
f
(provisional diagnosis)
/
a
1
30
()
r
(ketoacidosis)
ketoacidosis
-
d
(C-peptide) /
Anti-GAD, islet cell autoantibody, IA-2
2 95
30
2
( 1)
MODY (Maturity-Onset Diabetes of the Young)
2 .. 2557
glucose tolerance test
1. : ,
, . Diabetes Mellitus. 1. :
t
2548; 1-19.
2. American Diabetes Association. Diagnosis and classification of diabetes mellitus.
Diabetes Care 2014; 37 Suppl 1: S81-90.
f
a
r
d
2
t
15 4
.. 2551-2552
1
f
(screening test)
a
(high risk screening strategy)
1 2
r
cohort study2
1
(risk score)
( 12 )
( ++)
4 .. 2557
1. 2 2
Diabetes risk score
34 39 0
40 44 0
45 49 1
50 2
0
2
t
23 ./.2 0
23 27.5 /.2 3
27.5 ./2
90 . 80 .
f 5
0
a
90 . , 80 . 2
0
2
r
( )
0
4
d
0-17
2
5
2. 2
12
1/20 -
2 5 -
-
- 3
3-5 5-10 1/12 -
-
t
-
- 1-3
6-8 11-20 1/7 -
f -
-
-
a
- 1-3
8 1/ - 1/ -
4 3
20 -
-
r
-
- 1
d
( 1)
3 ( 2, ++)
6 .. 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)
t
8
f
(waist circumference) 90
80 0.5
a
1. 2 10
r
2.
3.
d
4.
7
fasting plasma
t
fasting plasma glucose
glucose < 100 ./.
fasting plasma glucose
100-125 ./.
1. 35
d
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. ()
8 .. 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 ./.
t
FPG4 capillary blood glucose
capillary blood glucose 110 ./.
f
3 ( 2,
++)
a
4
1.
r
200 ./.
2. 8 (FPG)
d
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
(./.)
t
HbA1c
standardization quality control HbA1c
f
HbA1c 6.0-6.4%
25-50%5
a
6,7
( 1, ++)
r
glucocorticoid
d
(
)
( 4)
()
(carotid bruit)
(diabetic retinopathy) (diabetic nephropathy)
(diabetic neuropathy)
10 .. 2557
4.
( )
t
f
a
HbA1c
Lipid profiles (total choleseterol, HDL-cholesterol, triglycerides)
Liver function tests
r
serum creatinine
urine exam proteinuria microalbuminuria
d
11
1 5
FPG, HbA1c, total
cholesterol, triglyceride, HDL-cholesterol, ( LDL-cholesterol LDL-
cholesterol), serum creatinine, (urinalysis)
albuminuria
(ECG) /
1. ().
; 2553. f
4 .. 2551-2552. : /
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
t
3
1.
2.
t
3.
4.
5.
f
a
1,2
r
1. 1,2
HbA1c
< 6.5% ( 1)
d
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)
t
HbA1c 7.0-8.0%
f
3.3.1 (fraility)
HbA1c 8.5%
3.3.2 (dementia)
a
HbA1c 8.5%
4. 1 (life expectancy < 1 )
()
r
(
d
2. 3
HbA1c
<7%
7.0 - 7.5 %
8.5 %
8.5 %
15
1-3 ( 3)
3. 1,2
/
* < 100 ./.
< 150 ./.
t
: > 40 ./.
> 50 ./.
**
(systolic BP)
(diastolic BP)
f < 140 .
< 80 .
a
18.5-22.9 ./.
: < 90 .
< 80 .
r
() 2 ***
d
* 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
t
(lipid profiles) 1
1
2
f
a
( 4)
r
* ()
1.
17
4. //
/ / /
* * **
HbA1c < 7% HbA1c 7.0-7.9% 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
t
m2/yr. ml/min/1.73 m2/yr.
< 7 ml/min/ 1.73 m2/yr.
retinopathy mild NPDR moderate NPDR severe NPDR, PDR
Protective
peripheral
sensation neuropathy,
f
VA
macular edema
rest pain
previous amputation gangrene
a
peripheral pulse peripheral pulse intermittent claudication
hypertension hypertension / hypertension angina pectoris
dyslipidemia dyslipidemia / dyslipidemia CAD myocardial
r
infarction
CABG CVA heart
failure
d
*
**
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) eGFR = 144 (SCr/0.7)-0.329 (0.993)Age
serum creatinine > 0.7 (mg/dl) eGFR = 144 (SCr/0.7)-1.209 (0.993)Age
serum creatinine < 0.9 (mg/dl) eGFR = 141 (SCr/0.7)-0.411 (0.993)Age
serum creatinine > 0.9 (mg/dl) eGFR = 141 (SCr/0.7)-1.209 (0.993)Age
18 .. 2557
1,2,9-14
4
( ++)
t
1
ratio 1 12
f
albuminuria (microalbuminuria) urine albumin/creatinine
a
1 2 (1 45 .
120 . 330 .)
r
()
19
t
glycemic control and cardiovascular outcomes in diabetes. A cohort study. Ann Intern
Med 2009; 151: 854-60.
f
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
a
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
r
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
d
. , .
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
t
f 2
a
r
d
d
r
a
f
t
4
f
a
1-4
r
(empowerment)
d
4-9
10
22 .. 2557
5
1.
11
2.
3.
4.
t
f
5.
a
11
r
1.
2.
3.
d
4.
5.
6.
7.
8.
9.
10.
1
(Self monitoring of blood glucose, SMBG)
23
(
)
f
a
24 .. 2557
GLP-1 agonist
f
a
26 .. 2557
1.
2.
3.
4.
5.
6.
t
2
1.
2.
f
1.
a
:
r
2.
27
1. Norris SC, Lau J, Smita SJ, Schmid CH, Engelgau MM. Self-management education for
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 empower-
ment-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
t
ethnically diverse underserved populations. Popu Health Manag 2011; 14: 11-20.
12. . , ,
f
, , .
2553.
a
r
d
5
(Lifestyle modification)
(Lifestyle modification)
t
1
f
1 2
1-3
a
2
r
( 1, ++)
4,5 7
( ++) 5
5
30 .. 2557
1 ( ++)
(maintenance of weight loss) (
+)
/
( +)
t
HbA1c 0.3-1% 1 0.5-2%
f
21,2 (medical nutrition therapy)
1
a
1. 2,3,5,6
r
2 50
3,5,6
( 2, ++)
d
< 130 / ( -)
( ++)
glycemic index
glycemic load ( +)
5 6 ( 3-6 ) 2-3
( +)
31
(
++)
14 1000 (
++)
sorbitol, xylitol mannitol
( ++)
7
- 50 . 1 .
- 15 . 1 .
t
- 5 . 1 .
- 5 . 1 .
f
30-35
7 10
a
( ++)
300 ./ ( ++)
1
( ++)
r
15-20 ( +)
4 2 / 3
d
( ++)
(
++)
( -)
1 / 2 /
2 ( +) 1 ( 12-15 )
45 . 330 . 120 .
( +)
32 .. 2557
( ++)
(
-)
( -)
1 1
t
( +)
( +)
f
( +)
a
( 11)
( ++)
ketosis
( +)
r
( +)
( ++)
d
( +)
( +)
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 ./
t
( ++) 1 1160-1420 . 1
960-1420 . 1 492 . 1
2000 .7
f
( +)
3, 12-15
a
10
r
50
( = 220 )
50-70
( 70 )
(talk test)
( 2)
(resistance) 2
8-10 ()
34 .. 2557
2.
150 / 30-50
3-5 2-3
75 / 3 /
2 ( ++)13
7 (
t
+)13
f
1 2
/
a
12,13,16
r
/ / /
( ++)
d
3,13
3
16
16 17
( ++)
35
3.
( 250
ketosis
./. 1
ketosis
300 ./. 2)
< 100 ./.
proliferative diabetic retinopathy (PDR) severe NPDR
resistance exercise
(peripheral neuropathy)
t
(non-weight bearing exercise)
f
a
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
r
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
d
t
11. Bow Y, Han J, Hu FB, et al. Association of nut consumption with total and cause-
specific mortality. N Engl J Med 2013; 369: 2001-11.
f
12. . :
. , .
2555.
a
13. Colberg SR, Rubin RR, Sigal RJ, et al. Exercise and type 2 diabetes. The American Col-
lege of Sports Medicine and the American Diabetes Association: joint position state-
ment. Diabetes Care 2010; 33: e147-e167.
r
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
d
3 GLP-1 analog 1
2
t
1-4
f
3 ( 1)
a
1. (insulin secretagogue)
(sulfonylurea) (non-sulfonylurea glinide)
glucagon like peptide-1 (GLP-1) DPP-4 inhibitor (
r
gliptin)
2. biguanide thiazolidinedione glitazone
3. alpha-glucosidase (alpha-glucosidase inhibitor)
d
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
(premixed insulin)
100
RI, NPH
GLP-1 Analog
t
GLP-1
f
exenatide, liraglutide
a
1. 2
1
r
2.
2.1 HbA1c ()
d
2.2 ()
2.3
3. 1-4
HbA1c
2-6 3 ( 2, ++)
4. 2 ( 1) metformin
( 2, ++)
2 (combination therapy)
39
1.
HbA1c*
0.5-2%
/
Metformin 1-2%
t
serum creatinine 1.5 ./.
estimated GFR 30 .//1.73 .2
Sulfonylurea 1-2%
f
glibenclamide
a
serum creatinine 1.5 ./.
estimated GFR 30 .//1.73 .2 ( glipizide
)
r
Glinide 1-1.5%
d
Thiazolidinedione 0.5-1.4%
metformin
2-4
congestive heart failure
40 .. 2557
1. ()
HbA1c*
Alpha-glucosidase 0.5-0.8%
Inhibitor (-Gl)
DPP-4 inhibitor 0.8%
metformin thiazolidinedione
t
GLP-1Analog 1%
f
medullary thyroid
carcinoma
a
Insulin 1.5-3.5%
r
()
*
d
2
metformin 2 sulfonylurea6
( glibenclamide )
sulfonylurea > 220
./. HbA1c > 9% 2 ( +)
5. 3 3
2 ( 1) 2 3
5.1 Thiazolidinedione: 2 metformin
( 2, +) 3
41
< 180 ./. HbA1c < 8.0 %5
1-3
metformin
180 ./. HbA1c > 8 %5 : Sulfonylurea Glitazone
DPP-4 inhibitor
- glucosidase inhibitor Repaglinide
> 220 ./. HbA1c > 9%5
2 2 ( metformin)
t
2 Sulfonylurea
>300 1. Thiazolidinedione
2. DPP-4 inhibitor
./. HbA1c > 11%
f
3. glucosidase inhibitor
4. Repaglinide
5. Basal insulin
a
> 300 ./.
HbA1c > 11%
NPH (21.00
23.00 .) LAA
r
RAA = Rapid Acting Insulin Analog NPH LAA
RI = Regular Human Insulin RI
NPH = Neutral Protamine Hagedorn Insulin RAA
LAA = Long Acting Insulin Analog
1. 2 ( metformin )
42 .. 2557
t
2, +/-)
6. 2 basal insulin
f
( 2, ++)
6.1 basal insulin ( 9)
Intermediate acting insulin NPH 21.00-23.00 .
a
Long acting insulin analog (LAA) insulin glargine insulin detemir
insulin glargine
6.2 basal insulin NPH 0.1 - 0.2 /./
r
2-4
3-7
d
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 )
3 RAA RI
t
3
f RI/NPH-0-RI-NPH
4
a
2
RAA = Rapid Acting Insulin Analog RI/NPH-0-RI/NPH-0
r
0 = None
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
t
1. 1
2. (diabetic ketoacidosis)
syndrome)
3. 2
f
(hyperglycemic hypersmolar nonketotic
a
2-3
r
(malnutrition)
d
4.
45
t
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>
6. Zhang Y, McCoy RG, Mason JE, Smith SA, Shah ND, Denton BT. Second-line Agents for
a
glycemic control for type 2 diabetes: Are newer agents better? Diabetes Care 2014.
DOI: 10.2337/dc13-1901.
r
d
d
r
a
f
t
7
t
(blood glucose meter) SMBG
SMBG
SMBG
a
SMBG1-5
1. SMBG
1.1 (pre-gestational
r
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
t
SMBG
SMBG
1. SMBG 1-2
a
3 ( 7 )
2. 3 SMBG 3
SMBG 2 .
r
02.00-04.00 .
3. SMBG
4. SMBG
49
8. 2 SMBG
3 / SMBG
HbA1c
2 SMBG
(structural) 7 3
3 HbA1c 0.3%6
SMBG
SMBG SMBG (
3) / (
t
)
SMBG
f
SMBG
SMBG
a
SMBG
SMBG
d
whole blood (
) whole blood 1.1 x
( ./.)
50 .. 2557
t
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.
f
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
a
diabetes: results from the Structured Testing Program study. Diabetes Care 2011; 34:
262267.
r
d
t
f 3
a
r
d
d
r
a
f
t
8
1,2
t
1.
f
2.
a
3.
3 (Whipple
triad) 70 ./.
r
1,2
d
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
t
2. Documented symptomatic hypoglycemia
f
70 ./.
3. Asymptomatic hypoglycemia
< 70 ./.
a
4. Probable symptomatic hypoglycemia
5. Pseudo-hypoglycemia relative hypoglycemia
r
> 70 ./.
70 ./.
d
3
1,5
1. (mild hypoglycemia)
2. (moderate hypoglycemia)
53
3. (severe hypoglycemia)
1
6-10 ( 4)
(insulin secretagogue)
glinide1,5
a
metformin, thiazolidinedione, dipeptidyl peptidase-IV
inhibitor glucagon-like peptide-1 receptor agonist (mono-
therapy) -glucosidase inhibitor
r
(combination
therapy)
1,2,5
d
1,2
1.
2.
/
3. (glucose utilization)
4. (endogenous hepatic glucose production)
54 .. 2557
5. (insulin sensitivity)
6. /
7.
8. HbA1c /
9.
10.
t
2
f
11 2
1
a
1,5,12
( 1)
1. 15
d
30 12 15 3 180 .
180 . 3 1 240 . 2
1 15-20
2. point-
of-care-device () 15-20
3. 15 < 70 ./.
4. > 80 ./.
1
(snack) 15
55
5. point-
of-care-device
6.
( )
(complex carbohydrate)
.
f
-
a
1. 1 .
2.
r
.
-
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 .
f
2 50% 30-40 .
50% 50 .
a
6. 50%
50%
r
7.
50% 50 .
()
d
10% (10%D) 2 ./ 1 ./ ( 60 ./
50 .) 80 ./.
180 ./.
6
8. 10%D
9. 10%D
15-30
57
70 ./.
() ()
cognitive
f
a
15 :
3 180 . () 1 . (
180 . 3 1 < 5 0.5 .)
1 :
r
15
15 50% 10-20 .
< 70 ./. 50%
d
50 . ( 50%
> 80 ./. < 70
1 ./.) 10%
1 2 ./ 1 ./
1 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 5%D ) f
10%D (
13.
a
14. 15-30
> 80 ./. 3
r
dexamethasone 5 . 6 / 20%
mannitol 300 .
1,2
< 70 ./. (
2, +)
(
59
1, ++)
(microvascular
complication) ( 1,
++)1
( 2, ++)
(diabetes care
team)
t
( 1, ++)
(
1, ++)
f
1.
(regimen)
a
glinide
2.
3. (self-monitoring of blood
r
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%
t
( 1, +)
f
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
a
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
r
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
d
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.
t
Diabetes Care. 2010; 33: 1389-94.
11. UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes:
f
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
a
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.
r
d
d
r
a
f
t
9
/
(diabetic retinopathy) (diabetic nephropathy)1-3
4
(diabetic retinopathy)
a
1. Non-proliferative diabetic retinopathy (NPDR) 3 (mild)
(moderate) (severe)
r
NPDR
HbA1c
PDR macula edema
64 .. 2557
5,6
( 1)
visual acuity
( 2 ++)
(Fundus photography)
digital camera
( 4 ++)
1 5 12
t
1 ( ++)
2
f
1 ( ++)
a
> 126
./.
r
2,7 ( 1 ++)
HbA1c
8 ( ++)
( +)
severe NPDR PDR macular edema
( ++)
9,10 ( ++)
65
12
t
1 2
f
a
5 12
r
1 6 - 12 3 - 6
1.
66 .. 2557
( ++)
( ++)
t
( ++)
( +)
f
3
a
( ++)
(diabetic nephropathy)
r
diabetic nephropathy
13,14 ( 1)
(albuminuria)
d
30 . 30 . dipstick
300 . 300 .
dipstick
15,16
( 2)
1 5 2
1 ( 2, ++)
67
12
urine protein
()
Alb/Cr < 30 mg/g Alb/Cr 30-299 mg/g Alb/Cr > 300 mg/g
f
a
1-2 6
2 3
r
eGFR < 60 ml/min/1.73 m2
d
albuminuria
albuminuria urinary albumin
creatinine ratio (Alb/Cr) Alb/Cr 30-299 ./ 1-2 3-6
2 albuminuria
(estimated GFR, eGFR)
16
diabetic nephropathy
14-16
1. albuminuria
t
( ++)
f
140/80
( ++)
a
(Rennin-Angiotensin
System inhibition) angiotensin converting enzyme inhibitor (ACEI) angiotensin II
receptor blocker (ARB) albuminuria 17,18 (
r
++)
2. albuminuria 30-299 ./
d
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
t
System inhibition) angiotensin converting enzyme inhibitor (ACEI) angiotensin II
receptor blocker (ARB)
f
( ++)
diabetic retinopathy
60 //1.73 .2
a
( ++)
0.8-1.0 1 .
( ++)
r
0.8 1 .
( ++)
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.
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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
t
microvascular complications of type 2 diabetes (UKPDS 35): prospective observational
study. BMJ 2000; 321: 405412.
f
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.
a
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
r
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
d
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
t
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
f
losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and
nephropathy. N Engl J Med 2001; 345: 8619.
a
r
d
d
r
a
f
t
10
t
1,2
f
(Cardioroscular dissases)
a
2 silent myocardial
r
ischemia 3
4 ( 1, ++)
d
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
t
Beta-blocker
ACEI diabetic nephropathy ARB
f
ACEI ACEI ARB serum potassium
serum creatinine ( 1, ++)
ACEI ARB ARB
a
ACEI
Calcium-channel blocker
Beta-blocker tachyarrhythmias
1
macrovascular events7
d
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, ++)
2,8,9
HDL-C triglyceride8
triglyceride
niacin ( 2, ++)
triglyceride 500 ./. fibrate
niacin statin
statin
t
9,10 ( 2, ++)
HbA 7.0%
1c
6.5%
f
HbA
HbA 7% 8.5%
1c
a
1c
r
1, ++)
antiplatelet
antiplatelet 50
60 4,8
albuminuria ( 4, +)
antiplatelet aspirin 75-162 ./ ( 1,
++)
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
f
antiplatelet aspirin 75-162 ./
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 dia-
betes 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.
t
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
f
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.
a
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.
r
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.
d
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
t
11
2,4,5
f
a
( 1, ++)6
1-6 7
r
( 1, ++)
monofilament 10 7
d
( 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)
HbA ( 2)
1c
( 2)
f
( 2)
a
( 2)
( 2)
( 2)
r
2
d
//
/
/ /
ABI < 0.9
//
81
- : //
- :
- : 10 g - monofilament 4
- : claudication ABI
t
// //
//
/
f
*
a
ABI > 0.9 ABI < 0.9
ABI < 0.9 3
6
*
1.
82 .. 2557
2,3
( 1)
( ++)
(self foot-care)
( ++)
5
( ++)
( ++)
t
( ++)
f
1 ( ++)
( ++)
a
ABI < 0.9
( ++)
( ++)
r
( ++)
( ++)
d
6 ( ++)
( ++) /
12 (
1, ++)
( ++)
( ++)
3 ( ++)
83
( ) (
++)
( ) ( gangrene)
(callus) ( ++)
(ingrown toenail)
( ) (
++)
(deformity) neuropathy
hallux valgus, hallux varus, claw toe, hammer toe, (bony prominence)
t
Charcot foot (gait)
(mobility) ( ++)
f
neuropathy
(claudication)
/
( +) ABI 0.9
( ++)
2 (
8)
(neuropathic ulcer)
( ++)
(sterile normal saline) 2
hydrocolloid hydrogel
2 ( 4, +/-)
( ++)
( ++)
(neuropathic ulcer)2
( 2, ++)
(ischemic ulcer)
2
f
( 2, ++)
surgical debridement (dry gangrene)
a
( 2, --)
(infected ulcer)
2,18
debridement ( 2,
++)
(severe infection)
d
(moderate infection)
( 3, ++)
( 3,
++) biopsy, aspiration curettage
debridement swab
( 2, ++)
85
(osteomylelitis)
/ (probe-to-bone test )
(bony prominence) ( 2, ++)
2
( 2, ++)
19
f
a
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. .
r
. 1.
2556. www.dms.moph.go.th/imrta
3. Mclntosch A, Peters JR, Young RJ, et al. Prevention and management of foot problems
d
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
t
574-600.
11. Sriussadaporn S, Ploybutr S, Nitiyanant W, Vannasaeng S, Vichayanrat A. Behavior in
12. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot re-ulceration
a
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;
r
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
d
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.
t
f
a
r
d
d
r
a
f
t
t
f 4
a
r
d
d
r
a
f
t
12
1 2
10 2 3
t
1.
2. (BP > 130/85 .)
3. acanthosis nigricans
f
1 ( ++)
1
a
2 > 200 ./.
(diabetic ketoacidosis, DKA)
r
OGTT
d
( 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
t
f
4,5 (
a
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
Random capillary blood
glucose > 110 ./.
t
1
1.
1.
2. 2.
d
3. 1
Biguanide
Sulfonyluea
4. : 15
1. 2 ( 10 )
92 .. 2557
1. 1
0-6 100 - 180 ./.
110 - 200 ./.
(HbA1c) 7.5 - 8.5%
6-12 90 - 180 ./.
100 - 180 ./.
(HbA1c) < 8%
13 - 19 90 - 130 ./.
90 - 150 ./.
t
(HbA1c) < 7.5%
1. 1 ( 2)
1.1 f
1.2
a
(
12 )
1.3 2
r
1.4 4
1.4.1 4 / basal-
bolus 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)
, ,
RCBG < 110 ./.
t
RCBG 110-199 ./.
plasma glucose
f
> 200 ./.
> 126 ./. 2
a
DKA
DKA
10
r
DKA DKA
1.
2.
d
: 15
4 /
3. 1-3 HbA1c 3
2. 1
94 .. 2557
t
(+) Premixed insulin
3 ( ++)
f
1.4.4
(insulin pump)
Diabetes self
a
management education (DSME)
(SMBG) 3
r
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
t
portion)
( ++)
f
-
3 2-3 basal-bolus insulin
a
3-4
1
1. (carbohydrate portion)
r
( ++)
2.
1
d
2 4 1 ( ++)
3. (healthy eating
principle)
4.
(cognitive) psychosocial
3
5.
96 .. 2557
- 3-4
250 ./.
a
-
-
r
-
-
-
d
1.7
(psycho-social adjustment and family support)
-
-
-
97
-
-
-
1.8 1
3
3-6
3 ( ++)
t
1.
centered)
f
2. (learner
3.
a
/
4.
r
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
t
4 6 1
( 96)
f
2.6
2.7 (DSME)
a
7-10
2
r
2.8
(psycho-social adjustment and family support)
1
3
1,2,6
99
3.
3-6 1
HbA1c
* 1
t
(microalbuminuria) 10
5
2
f
1
10
a
5
2
**
r
freeT4 TSH 1
d
1-2
* 2
**
- 2 > 10
-
100 .. 2557
3 4 6-12
1. (medical outcome)
HbA1c
HbA1c DKA
1
2. (psychosocial evaluation)
t
f
3. (behavioral evaluation)
a
(self monitoring of blood glucose)
r
5,10
1. HbA1c 8.5% 1 7% 2
d
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
t
book Authors. Type 1 diabetes through the life span: a Position Statement of the
American Diabetes Association. Diabetes Care 2014; 37: 2034-54 Published online
f
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.
a
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
r
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
d
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.
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131: e648-64.
d
r
a
f
t
13
(hypoglycemia) (moderate hyperglycemia)
(diabetic ketoacidosis, DKA)
(hypoglycemia)
f
a
I. 1,2
r
(autonomic symptom) (neuroglycopenic symptom)
d
104 .. 2557
II.
1 2
2
/
1,2
1
1. (mild hypoglycemia)
1.1 70 ./.
( )
( 10 )
t
20-30
f
1.2 70 ./.
20-30 5-10
a
10-15
10
r
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)
t
3.1 ()
0.5 < 5 1 > 5
3.2
a
() 0.5 < 5 1 > 5
50%
50% 1-2 ./ 1 .
r
10%D
2-3 ././. 6-12
2
1
106 .. 2557
III.
t
DKA (ketone)
1.
f
1.1
a
250 ./.
r
5 -10
1.2
/
d
2-4 2
10-20
4-6
180 ./.
8
107
2.
2.1
4
(2-4 4 )
1
2.2
2.2.1
DKA
/
t
2-4 2
regular insulin 0.1-0.25 / 1 .
)
2-4
f
4-6 NPH regular insulin (
a
4-6
8-24
r
24
2.2.2 DKA
d
acetone
( 10 Diabetic
ketoacidosis )
108 .. 2557
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of hypoglycemia in children and adolescents with diabetes: ISPAD Clinical Practice
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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
t
adolescents with diabetes: ISPAD Clinical Practice Consensus Guideline 2009. Pediatric
Diabetes 2009; 10 (Suppl 12): 118-33.
f
5. . (Management for
diabetic ketoacidosis). 2545: 41 (1): 115-22.
a
r
d
14
2
(pre-gestational diabetes) (gestational
diabetes, GDM)1,2
t
(tight
f
control) ( 11)
(conception) 2-3
2 ( 1, ++)
a
2-3
HbA1c 6.5%
2
d
( 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 ./.
t
(simple sugar) 32
(ideal body weight) 38
f
2 3
50-55 20 25-30
200 2 accelerated
a
starvation ketosis
(
1, ++)
r
arm
ergometry
d
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
t
10-12
f
8 2
( 2, ++)
a
2.
(./2) (.)
< 18.5 12.5 - 18.0
r
HbA1c HbA1c
(organogenesis)
112 .. 2557
HbA1c
HbA1c 6.0% 6.5%
2 3 fructosamine HbA1c
2 fructosamine 280 ./. (
2, +)
1
180 ./. ( 2, +)
t
70-120 ./.
f
ketosis
5%
100-120 ./ 1-2
a
(normal saline)
1-2 /
(caesarian section)
r
5% 100-120 ./
1-2 5%
d
(Gestational diabetes)
(glucose intolerance)
1-14 ( 2)
( 11)
t
25
f
24-28
( 2)
a
2 Carpenter Coustan International Diabetes
Federation (IDF) Carpenter Coustan
100 4 IDF
r
75 3 Carpenter
Coustan 50
(50 g glucose challenge test) 1
d
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,
+)
t
5
f
7.4 6
75 (75 g oral glucose tolerance test, OGTT) (
9) 1
a
( 1, ++)
r
1. . . : 2550.
, , , .
d
. 2550
2. IDF Clinical Guidelines Task Force. Global Guideline on Pregnancy and Diabetes.
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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 5
a
r
d
d
r
a
f
t
15
Wagners Chronic Care Model (CCM) WHOs Chronic Care
t
Model1,2
1.
2.
f
3.
4.
a
5. (Self management support)
6.
r
6
d
3-7
116 .. 2557
()
(
)
1
t
( )
f
a
r
1
/
117
1
*
f
a
/
8
(Process)
d
impaired fasting glucose (IFG)
HbA
1c
lipid profile
albuminuria
118 .. 2557
()
/ /
(..)
(Outcome)
(Prevalence) (Incidence)
HbA
1c
f
< 140/80 mmHg
diabetic retinopathy
diabetic nephropathy
d
myocardial infarction
cerebral infarction
119
t
4. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes
Care 2014; 37 (Suppl 1): S14-S80.
f
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>
a
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
r
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
d
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
r
a
f
t
16
(..)
f
a
1.
r
1. ..
d
(
)
/
/
122 .. 2557
..
1.
1.1 .. .
15
(
)
1.2 (
)
1.3
1.4
t
1.5 Data center
2.
f
2.1
2.2
a
/
r
2.3
2.4
d
2.5
2.6
3.
3.1
123
3.2 /
1 ( 2)
3.3
3.4
2.
/ 1
t
-
- (albuminuria, )
- /
f
- /
- / (
a
)
- 1-3
- / /
r
-
6-12
-
d
3-6
-
-
- /
- /
124 .. 2557
4.
4.1
4.2
4.3 /
4.4
4.5
5.
5.1
5.2
t
5.3
5.4
f
5.5
5.6
a
1.
r
. . 1. 2555, 31-35
d
17
1-3
1.
2.
t
3.
f
a
(
) (capillary blood
r
126 .. 2557
1
70-130 ./.
6 ( 1)
()
f
a
1. CBG < 70 ./.
2.
r
6.
7.
8. ( > 100 /) / orthostatic hypotension
9. /
10. 180/110 .
systolic BP > 140 . / diastolic BP > 80
. 3
11.
12.
127
5
CBG > 130 ./. 3
6
/
t
(medication error)
:
f
(drug interaction) -
- - -/
a
/
(
: )
r
(non-compliance)
d
1 ()
CBG > 130 ./.
3
6
(CBG < 130 ./.)
1.
128 .. 2557
13.
14.
15.
16.
t
3
f
1. (non-compliance)
a
2.
r
3.
129
t
November 11, 2006
2. Stacy AM, Kim RK, Warren AN. Identifying at-risk patient through community pharmacy-based
f
hypertension and stroke prevention screening projects. J AM Pharm Assoc 2003;
43: 50-5
a
r
d
d
r
a
f
t
t
f
a
r
d
d
r
a
f
t
1
1. 1 (type 1 diabetes mellitus, T1DM)
1.1. Immune mediated
1.2. Idiopathic
2. 2 (type 2 diabetes mellitus, T2DM)
t
2.1 Predominant insulin resistance with relative insulin deficiency
2.2 Predominant insulin secretory defect with insulin resistance
3. (other specific types)
f
3.1
Maturity-onset diabetes in the young (MODY)
a
Mitochondrial DNA
MODY 3 Chromosome 12 HNF-1
MODY 2 Chromosome 7 glucokinase
MODY 1 Chromosome 20 HNF-4
r
t
f
a
r
d
2
(Oral Glucose Tolerance Test)
()
1.
150 3
2.
,
f
3. 10-16
10 FPG
16
a
4. FPG
75 250-300 . 5
2
r
30
5. 6 .
1 .,
d
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
t
Pregnancy Study Group)
75 OGTT
f
92, 180 153 ./.
1 2
a
(./.) () GDM
1 2 3
r
NDDG 100 > 105 > 190 > 165 > 145 > 2
Carpenter & Couston 100 > 95 > 180 > 155 > 140 > 2
WHO 75 - - > 140 - 2
d
SMBG
SMBG
1 2
SMBG
SMBG1 meta-analysis stratified
t
SMBG SMBG
1. SMBG HbA1c
2. SMBG (real time)
f
a
3.
r
4. 2 SMBG
HbA1c
136 .. 2557
/
( )
2-4
:
(finger prick device) 70%
:
10-15
f
25
a
(forearm) (thigh) (palm)
( )
4 :
10-40 (
40 )
( 10-90)
(photometer)
137
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
t
5 5
2 . f
2 . 2 .
a
X X X X X
X X X X X
X X X X X
1
2 . 2 . 2 .
X X
X X
X X
X X
X X
X X
X X
138 .. 2557
5
2 . 2 . 2 .
X X
X X
X X X
t
5
2 . f
2 . 2 .
a
X
X
X
X
r
X
X
d
SMBG2-3
1.
2.
139
3.
2
1
4.
(photometric method)
(color intensity) (strip)
f
electrochemical technology
biosensor glucose oxidase (GO) glucose dehydrogenase (GD)
GD GO
a
oxygen GD
GD
5.
r
polycythemia
d
biosensor (glucose
oxidase)
(PaO2) PaO2 150 .
4 The International Organization for Standardization (ISO)
140 .. 2557
< 75 ./. ()
15 ./. > 75 ./. 20
() 95 6
t
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f
taking insulin: A meta-analysis. Am J Manag Care 2008; 14: 468-75.
2. , , .
: 1. ,
a
, . , 2548: 81-106.
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4
1,2
< 70 ./.
< 50 ./.
< 70 ./. (glucose alert level)
t
(glucose counter-regulatory system)
glucose counter-regulatory hormone , ,
(autonomic
f
neuro-transmitter) (autonomic
nervous system)
a
(accuracy)
2
r
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
t
portable glucose meter) (monitor-based glucose measurement)
(self monitoring of blood glucose, SMBG)
f
(point-of-care testing of blood glucose)
2
3. (plasma glucose)
a
(whole blood glucose)
r
) 95 2
5. (HbA1c)
13,14
2
1. Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest 2007;
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f
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a
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
r
8. Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with
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insulin-dependent diabetes mellitus. Recent antecedent hypoglycemia reduces
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J Clin Invest 1993; 91: 819-28.
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t
and type II diabetes. Diabetologia 2002; 45: 937-48.
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a
1573-6.
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r
Control and Complications Trial Research Group. N Engl J Med 1993; 329: 977-86.
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d
(UKPDS33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352: 837-53.
5
1
2
t
, , ,
( )
a
( )
velcro
146 .. 2557
1
(
)
( )
f
1. , . :
d
, , . Diabetes Mellitus. 1.
: ; 2548: 583-608.
6
Semmes-Weinstein monofilament
( 5.07 10 )
Semmes-Weinstein monofilament
light touch deep pressure. Semmes-Weinstein monofilament
() monofilament
t
monofilament monofilament
monofilament monofilament
5.07 10
f
(protective sensation)
a
(reproducibility) 1
monofilament
1. monofilament 2 (reusable)
r
(disposable) monofilament
monofilament
d
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
t
2. callus
monofilament 5.07 10
f
The American College of Physicians 20072
a
1.
2.
r
monofilament (forearm)
monofilament 1-1.5
d
3.
4.
5. monofilament
monofilament 1-1.5 () monofilament
monofilament
monofilament
149
3 (real application) monofilament
2 (sham application) monofilament
t
monofilament ? 1
f
6. 2 3 (
1 5) protective sense
7. 1 3 (
a
1 5) 5
8. 1 3
r
9. 4 2
2
d
10.
protective sensation (insensate foot)
11. 1
3.
4.
5. distal interphalangeal joint 2
6.
?
7.
?
f
1 2
a
8. 7 1 2
4
9. 2 1
r
10. 7-9 1 2 2 8
11. 5
d
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
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tained workshop curriculum and materials. American Coffee of Physicians Clinical Skills
Workshop Series, 2007.
7
t
metatarsophalangeal 1
(
) 3/8 1/2
f
(forefoot) metatarso-
phalangeal joints
a
(claw hammer toe)
(velcro)
r
2
(foot-orthoses) (ankle-foot-orthoses)
152 .. 2557
1.
1.1
1.2
1.3
3/8 1/2
1.4
2.
2.1
f
2.2
2.3
2.4
a
3.
(ankle-foot-or-
r
thoses)
d
1. , . :
, , . Diabetes Mellitus. 1.
: 2548: 583-608
2. .
. 1.
2556
8
f
/
(hemorrhagic callus)
a
(
r
2
d
callus
granulation
(claw hammer toe)
154 .. 2557
(intermittent claudication)
(rest pain)
dorsalis pedis
posterior tibial
( )
t
4
f
1. (off loading, pressure reduction)4-7
80-90
a
off-loading8 total contact cast (TCC)
non-weight bearing
TCC
r
TCC
2. debridement4-7,9,10
d
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
t
surgical debridement
(infected ulcer)3
f
a
r
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
t
3. (severe)
acidosis azotemia
(necrosis) (bleb)
f
a
(loss of plantar arch)
r
3,12
d
1.
amoxicillin-clavulanate cephalexin
amoxicillin-clavulanate
cephalexin dicloxacillin
cephalexin ( 1) beta-
lactam 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
t
metronidazole cephalexin, dicloxacillin roxithromycin
2
f
(National Antimicrobial Resistance Surveillance
Center)13 tetracyclines Staphylococcus aureus
methicillin
a
tetracyclines
2.
amoxicillin-clavulanate 1.2 8 .
r
3-7
clindamycin 600 6-8 .
ceftriaxone 2
d
1. 12, 13
MILD (usually P.O.) Staphylococcus aureus (MSSA), Amoxicillin-clavulanate*
Streptococcusspp Cephalexin*
Dicloxacillin
Clindamycin
Methicillin-resistant S. aureus Linezolid*
(MRSA) Trimethoprim/sulfamethoxazole (
)
MODERATE (P.O. or initial Staphylococcus aureus (MSSA), Ampicillin-sulbactam*
t
I.V.) Streptococcus spp, Ertapenem*
Enterobacteriaceae, Imipenem-cilastatin*
obligate anaerobes Levofloxacin
f
Cefoxitin
Ceftriaxone
Moxifloxacin
a
Tigecycline
Levofloxacin or ciprofloxacin with
clindamycin
SEVERE (usually I.V.) Methicillin-resistant S. aureus Vancomycin*
r
(MRSA) Linezolid
Daptomycin
Pseudomonas aeruginosa Piperacillin-tazobactam*
d
2. 12
SOFT TISSUE ONLY
Mild T.C. / P.O. OPD 1-2
4
Moderate P.O. ( I.V.) IPD/OPD 1-3
Severe I.V. P.O. IPD OPD 2-4
BONE OR JOINT
No residual infected tissues e.g. I.V. / P.O. IPD OPD 2-5
post amputation
t
Residual soft tissues (not bone) I.V. / P.O. IPD OPD 1-3
Residual infected viable bone I.V. P.O. IPD OPD 4-6
Residual dead bone / No surgery I.V. P.O. IPD OPD 3
f
T.C. = , P.O. = , I.V. = , IPD = inpatient department,
OPD = outpatient department
a
1. , . :
, , . Diabetes Mellitus. 1.
r
: ; 2548:583-608.
2. . . : , , .
Diabetes Mellitus. 1. : 2548:
d
563-82.
3. .
. 1.
2556.
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t
9. McIntosh C. Diabetic foot ulcers: what is best practice in the UK?. Wound Essentials
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f
10. Bakker K, Apelqvist J, Schaper NC, International Working Group on Diabetic Foot Edi-
torial B. Practical guidelines on the management and prevention of the diabetic foot
a
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.
r
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
d
()
t
( ++)
f
4 /
1 2 / 2
a
G 32
0.5 . 1.0 . 2
4
r
( ++)
d
162 .. 2557
/
d
( ++)
(networking)
(PCU)
call
center hotline
1-3
12
()
- Premixed 30% RI + 70% NPH (Mixtard 30 HM, Humulin 70/30, 30-60 2 8 12-20
Gensulin M30, Insugen 30/70, Insuman Combo30)
- Premixed 50% RI + 50% NPH (Gensulin M50) 30-60 2 8 12-20
d
I.
DKA (Kussmaul
breathing metabolic acidosis) acetone
t
(dehydration)
DKA
1. : (plasma glucose) > 200 ./.
(> 11 /)
f
2. (acidosis): HCO3 < 15 /. venous pH < 7.3
3.
a
DKA
DKA
r
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
t
24 1.5-2.0 maintenance
( 4 //)
f
ideal weight for height
( osmotic diuresis)
a
1.5 KCl initial rehydration
/ hyperkalemia (serum K > 6 /) KCl 3
1.6 fluid balance
r
2-3
1.7 moderate severe DKA
( mild DKA )
d
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%
t
dextrose 5% dextrose in 0.45% NaCl
5. Insulin infusion acidosis ketonemia
f
dextrose
150-250 ./. ( 150 ./.)
RI ( 0.05 /./.)
a
dextrose 7.5-12.5% ketonemia acidosis RI
RI 0.05 /./.
6. 70 ./. 10% glucose 2 ./.
r
glucose
1. insulin infusion RI
d
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
t
KCl K 0.5 /./.
4. (sodium, Na)
f
DKA
corrected serum sodium
a
Corrected Na = Na (mmol/L) + [Plasma glucose (mg/dL)100] x 1.6
100
r
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
t
5.2 bicarbonate cerebral edema,
paradoxical cerebral acidosis, shift to the left of oxyhemoglobin dissociation curve
f
peripheral oxygen availability severe hypokalemia
K EKG
6. (phosphate, PO4)
a
DKA
acidosis RI
DKA
r
(hypocalcemia)
1 ./.
K2HPO4 20-30 /.
d
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
t
9.1 Hypoglycemia continuous insulin infusion
f
9.2 Persistent acidosis HCO3 < 10 /
8-10 hyperglycemia
RI RI RI
a
intravenous infusion
r
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,
t
30 2
mannitol hypertonic saline (3% NaCl)
5-10 ./. 30
f
Intubation coma aggressive
hyperventilation PCO2 < 22 mmHg
a
Monitor neurological signs CT brain
stabilize
r
DKA
1. 12-24 (
) metabolic blood
d
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) ( rapid-
acting insulin 15-20% TDD)
2 24 . (TDD)
RI intermediate acting insulin (NPH) 2 3 TDD
t
( NPH : RI 2 : 1) 1 3
( NPH : RI 1 : 1)
f
1. diabetic ketoacidosis (
a
.. 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
r
(Pre-gestational diabetes)
1.
t
2 human chorionic somato-
mammotropin
(post-prandial hyperglycemia)
f
2. diabetic retinopathy
(tight control)
a
diabetic retinopathy
proliferative diabetic retinopathy
diabetic retinopathy
r
(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
t
(intrauterine fetal death)
f
lactate
metabolic acidosis
respiratory distress syndrome
a
hyperinsulinemia
(hypocalcemia
hypomagnesemia)
r
(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.
t
f
a
r
d