Professional Documents
Culture Documents
cpg20141120 PDF
cpg20141120 PDF
ISBN 978-616-7859-15-6
1
20,000
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
.
457/6-7 10200
. 0 2282 6033-4 0 2280 2187
E-mail : info@aroonkarnpim.co.th www.aroonkarnpim.co.th
.. 2557
2552
(Chronic Care Model)
/
/
2557
2557
( )
2557
.. 2557
..2557
( )
.. 2557
2557
.. 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.
.. 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
1
1 1
2 3
3 13
2
4 21
5 29
6 37
7 47
3
8 51
9 63
10 73
11 79
.. 2557
4
12 89
13 103
14 109
5
15 115
16 121
17 125
6
1 131
2 (Oral Glucose Tolerance Test) 133
3 135
4 141
5 145
6 147
7 151
8 153
9 161
10 diabetic ketoacidosis (DKA) 165
11 173
1
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)
2 .. 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.
2
15 4
.. 2551-2552
1
(screening test)
(high risk screening strategy)
1 2
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
23 ./.2 0
23 27.5 /.2 3
27.5 ./.2 5
90 . 80 . 0
90 . , 80 . 2
0
2
( )
0
4
0-17
2
5
2. 2
12
1/20 -
2 5 -
-
- 3
3-5 5-10 1/12 -
-
-
- 1-3
6-8 11-20 1/7 -
-
-
-
- 1-3
8 1/ - 1/ -
4 3
20 -
-
-
- 1
( 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)
8
(waist circumference) 90
80 0.5
1. 2 10
2.
3.
4.
7
fasting plasma
fasting plasma glucose
glucose < 100 ./.
fasting plasma glucose
Impaired fasting glucose
100-125 ./.
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. ()
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 ./.
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
9
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, HbA 1c, total
cholesterol, triglyceride, HDL-cholesterol, ( LDL-cholesterol LDL-
cholesterol), 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.
3
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
2
( 4)
HbA1c HbA1c * HbA1c
HbA1c < 7.0% 7.0 - 7.5% 8.5% 3-6
/
* ()
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
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) 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
( ++)
ratio 1 12
1 2 (1 45 .
120 . 330 .)
()
19
. , .
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.
2
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
26 .. 2557
1.
2.
3.
4.
5.
6.
2
1.
1.1
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 manage-
ment 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.
5
(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
2.
150 / 30-50
3-5 2-3
75 / 3 /
2 ( ++)13
7 (
+)13
1 2
/
12,13,16
/ / /
( ++)
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)
(non-weight bearing exercise)
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
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
(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*
0.5-2%
/
Metformin 1-2%
serum creatinine 1.5 ./.
estimated GFR 30 .//1.73 .2
Sulfonylurea 1-2%
glibenclamide
serum creatinine 1.5 ./.
estimated GFR 30 .//1.73 .2 ( glipizide
)
Glinide 1-1.5%
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
GLP-1Analog 1%
medullary thyroid
carcinoma
Insulin 1.5-3.5%
()
*
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)
2 Sulfonylurea
>300 1. Thiazolidinedione
./. HbA1c > 11% 2. DPP-4 inhibitor
3. glucosidase inhibitor
4. Repaglinide
5. Basal insulin
> 300 ./.
HbA1c > 11%
NPH (21.00
23.00 .) LAA
premixed human insulin
premixed insulin analog 3
1-2
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
1
*
( ) RI-RI-RI-NPH or LAA RAA-RAA-RAA-NPH or LAA
(LAA )
3 RAA RI
3
RI/NPH-0-RI-NPH
4
2
RAA = Rapid Acting Insulin Analog RI/NPH-0-RI/NPH-0
RI = Regular Human Insulin
NPH = Neutral Protamine Hegadon Insulin 3 4
LAA = Long Acting Insulin Analog
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
1. 1
2. (diabetic ketoacidosis)
(hyperglycemic hypersmolar nonketotic
syndrome)
3. 2
2-3
(malnutrition)
4.
45
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
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
1,2
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 (mono-
therapy) -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. point-
of-care-device () 15-20
3. 15 < 70 ./.
4. > 80 ./.
1
(snack) 15
55
5. point-
of-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 . () 1 .
180 . 3 1 :
1
15 50% 10-20 .
15 50%
< 70 ./. 50 . ( 50%
< 70
> 80 ./. ./.) 10%
1 2 ./ 1 ./
1 15
1 1 > 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 func-
tion during hypoglycemia in intensively treated patients with short-term IDDM. Diabe-
tes 1993; 42: 16839.
9
/
(diabetic retinopathy) (diabetic nephropathy)1-3
4
(diabetic retinopathy)
1. Non-proliferative diabetic retinopathy (NPDR) 3 (mild)
(moderate) (severe)
2. Proliferative diabetic retinopathy (PDR)
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
12
1 2
5 12
1 6 - 12 3 - 6
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
()
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
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
( ++)
140/80
( ++)
(Rennin-Angiotensin
albuminuria ( ++)
140/80 ( ++)
(Rennin-Angiotensin
aminoglycoside
diabetic retinopathy
3. albuminuria 300 ./
140/80
(
++)
(Rennin-Angiotensin
60 //1.73 .
2
( ++)
0.8-1.0 1 .
( ++)
4. (end stage renal disease)
30 /
( ++)
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.
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.
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
statin2,8,9 ( 1, ++)
HDL-C triglyceride8
triglyceride
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,
++)
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 ./
( 2, ++)
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 preven-
tion 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.
11
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 3
6
*
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
2 (
8)
(neuropathic ulcer)
( ++)
(sterile normal saline) 2
hydrocolloid hydrogel
2 ( 4, +/-)
( ++)
( ++)
(neuropathic ulcer)2
( 2, ++)
(ischemic ulcer)
2
( 2, ++)
surgical debridement (dry gangrene)
( 2, --)
(infected ulcer)
2,18
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
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.
4
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
10
1. ( 120)
2. 2 3
2.1
2.2 (BP > 130/85 .)
2.3 acanthosis nigricans
5-10
Random capillary blood
glucose > 110 ./.
1
1.
1.
2. 2.
3. 1
Biguanide
Sulfonyluea
4. : 15
1. 2 ( 10 )
91
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%
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 ./.
(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 / 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 ./.
DKA DKA
1.
2.
: 15
4 /
3. 1-3 HbA1c 3
2. 1
94 .. 2557
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
- 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.
3-6 1
HbA1c
* 1
(microalbuminuria) 10
5
2
1
10
5
2
**
freeT4 TSH 1
1-2
* 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
(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.
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)
pregestational diabetes
1
114 .. 2557
105 ./.
95 ./. 1 .
2 . 140 120 ./.
1-2
( 1, ++)
glibenclamide metformin
metformin ( 3,
+)
7.4 5 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.
5
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
( )
1
/
117
1
*
8
(Process)
HbA
1c
lipid profile
albuminuria
118 .. 2557
()
/ /
(..)
(Outcome)
(Prevalence) (Incidence)
HbA
1c
< 140/80 mmHg
diabetic retinopathy
diabetic nephropathy
myocardial infarction
cerebral infarction
119
(..)
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
6
/
(medication error)
:
(drug interaction) -
- - -/
/
(
: )
(non-compliance)
1 ()
CBG > 130 ./.
3
6
(CBG < 130 ./.)
1.
128 .. 2557
13.
14.
15.
16.
3
1. (non-compliance)
2.
3.
129
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
()
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 = Interna-
tional Diabetes Federation, IADPSG = International Association of Diabetes Pregnancy Study
Group
3
SMBG
SMBG
1 2
SMBG
SMBG1 meta-analysis stratified
SMBG SMBG
1. SMBG HbA1c
2. SMBG (real time)
3.
4. 2 SMBG
HbA
1c
136 .. 2557
/
( )
2-4
:
(finger prick device) 70%
:
10-15
25
(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
5 5
2 . 2 . 2 .
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
5
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. 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.
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.
4
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.
5
1
2
, , ,
( )
( )
velcro
146 .. 2557
1
(
)
( )
1. , . :
, , . Diabetes Mellitus. 1.
: ; 2548: 583-608.
6
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
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-con-
tained workshop curriculum and materials. American Coffee of Physicians Clinical Skills
Workshop Series, 2007.
7
metatarsophalangeal 1
(
) 3/8 1/2
(forefoot) metatarso-
phalangeal 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
8
(hemorrhagic callus)
(
)
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)
3,12
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
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*
Streptococcus spp Cephalexin*
Dicloxacillin
Clindamycin
Methicillin-resistant S. aureus Linezolid*
(MRSA) Trimethoprim/sulfamethoxazole (
)
MODERATE (P.O. or initial Staphylococcus aureus (MSSA), Ampicillin-sulbactam*
I.V.) Streptococcus spp, Ertapenem*
Enterobacteriaceae, Imipenem-cilastatin*
obligate anaerobes Levofloxacin
Cefoxitin
Ceftriaxone
Moxifloxacin
Tigecycline
Levofloxacin or ciprofloxacin with
clindamycin
SEVERE (usually I.V.) Methicillin-resistant S. aureus Vancomycin*
(MRSA) Linezolid
Daptomycin
Pseudomonas aeruginosa Piperacillin-tazobactam*
Methicillin-resistant S. aureus Vancomycin, ceftazidime, cefepime,
(MRSA), Enterobacteriacae, piperacillin-tazobactam, carbapenem
Pseudomonas,
and obligate anaerobes
P.O. = ; I.V. = ; * =
159
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
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
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. Off-
loading 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 Edi-
torial 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
9
()
( ++)
4 /
1 2 / 2
G 32
0.5 . 1.0 . 2
4
( ++)
/
162 .. 2557
( ++)
(networking)
(PCU)
call
center hotline
1-3
12
()
(regular insulin, RI)
- (Actrapid HM, Humulin R, Gensulin R, Insugen R, Insuman Rapid) 30-45 2-3 4-8
(Insulin Isophane Suspension, NPH)
- (Insulatard HM, Humulin N, Gensulin N, Insugen N, Insuman Basal) 2-4 4-8 10-16
- 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
I.
DKA (Kussmaul
breathing metabolic acidosis) acetone
(dehydration)
DKA
1. : (plasma glucose) > 200 ./.
(> 11 /)
2. (acidosis): HCO3 < 15 /. venous pH < 7.3
3.
DKA
DKA
Venous pH 7.20-7.29 7.10-7.19 < 7.10
Serum bicarbonate (/) 10.0-14.9 5.0-9.9 <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. 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
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
decreased sensorium,
,
disorientation, agitation, pupillary change, ophthalmoplegia, papilledema,
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) ( rapid-
acting 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 somato-
mammotropin (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)
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.