CPG TYPE 2 DM Fourth Edition - 2009, CPG INSULIN THERAPY

Issues:
1) Hypoglycemia secondary to dilutional hypeglycemia
2) Tight Glycemic control in MI patients
3) Initiation of treatment in newly dx type 2 DM - OHA and Insulin
4) Insulin dose adjustment

A 50 years old gentleman presented to ED HSB with sudden onset of central chest discomfort radiated to the back, shoulder and left arm associated with sweating. pain relieved post Streptokinase

RF:
Smoker 15-20/ day for 30 years
HPT
Strong FHx
newly dx Type II DM

Background Hx:
HPT on T Atenolol 50mg BD
Staghorn calculus with renal impairment in 2008
Gout on NSAIDS

In the ward:
T lovastatin 20mg ON
T isordil 10mg TDS
T aspirin 150mg OD
T plavix 75mg OD
T carvidelol 3.125mg BD
Sc insulatard 10u ON
T metformin 500mg BD

Blood Ix: 18/7/2011
CK 317 (30-200)
LDH 467 (125-220)
AST 48 (5-34)

FBC: wcc 10.67 (4-11) hb 15.4 (13-17) plt 109 (110-450)
Lipid (mmol/l)
TG 14.06 (Lipaemic sample)
LDL 7.74
HDL 0.7
Tot Chol 14.84

HbA1c 11.9%

RP
Ur 6 (3.2 - 7.4)
Cr 144.9 (62 - 115)
Na 126 (136-145)
K 3 (3.5-5.1)

LFT
TP 67 (64 - 83)
Albumin/ Globulin ratio  0.76
Bili 14 (3.4 - 20.5)
ALT (42)
Albumin 29 (35-50)
ALP 80 (40-150)
Cl 92 (98-107)

RP 19/7/2011
Ur 5.9 (3.2 - 7.4)
Cr 154 (62 - 115)
Na 131 (136-145)
K 3.3 (3.5-5.1)
Cl 93

RP  21/7/2011
Ur 6.4 (3.2 - 7.4)
Cr 156 (62 - 115)
Na 131 (136-145)
K 3.3 (3.5-5.1)

Albumin 30
GGT 133.9 (5-85)
-------------
Baseline RP:
Feb 2009 ur 11.5  Cr 328  UA 695
(presented to uro with Left staghorn calculi)
RP within x1/52:  ur 7.5  Cr 155

CXR @20/7/2011
Mild cardiomegaly

ECHO @ 21/7/2011

ADJUSTING/ TITRATING INSULIN DOSE
http://www.mems.my/file_dir/8744697374dc0e0db6586e.pdf
Insulin Therapy - adjusting the dosage
http://www.fpnotebook.com/Endo/Pharm/InslnDsng.htm
http://tde.sagepub.com/content/32/1/19S.full
blood glucose conversion table
http://www.bcchildrens.ca/NR/rdonlyres/841862E6-5AE1-4938-A479-E6C38D615EA3/20417/glucoseunits.pdf
diabetes mx in ramadhan
http://www.medscape.com/viewarticle/412367
http://www.diabetes.org.my/article.php?aid=636
dm in children
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5189
pt information
http://www.uptodate.com/contents/patient-information-diabetes-mellitus-type-2-insulin-treatment
initiating treatment
http://care.diabetesjournals.org/content/32/1/193.full
practice guideline for type 2 dm
http://www.diabetes.org.my/file_dir/138985421945a7495312db5.pdf
titrating insulin
http://clinical.diabetesjournals.org/content/27/2/72.full
http://clinical.diabetesjournals.org/content/23/2/78.full
Dilutional effect of hyperglycemia